Service Reconfiguration

Will STPs deliver long-term sustainability?

Amber Davenport, head of policy at NHS Providers, explains that if sustainability and transformation plans (STPs) are expected to be a silver bullet solution to the NHS’s problems then more time needs to be taken to properly support and enable their implementation.

The NHS is currently under the spotlight. Unsurprising as we head deeper into winter, A&E departments across the country become more and more crowded and the effects of a prolonged funding squeeze start to bite. Whilst managing these immediate challenges, NHS trusts across the country are working with local partners to transform health and care services to meet the changing needs of patients, and ensure they are sustainable in the long term.  

To really get underneath how trusts are responding to these challenges, we undertook a major survey of NHS trust chairs and chief executives at the end of last year. In it, 172 chairs and CEOs from 136 hospital, mental health, community and ambulance trusts responded, and we produced our flagship report, ‘State of the NHS Provider Sector’, as a result. Our hot topic for this survey was transformation – and more specifically how trusts are approaching STPs. 

Are plans truly locally-owned? 

There has been consistently strong support for the STP concept, which was reiterated by respondents to our survey who described the process as having “the potential to drive useful change with the capability to improve care”. However, concerns about unrealistic expectations of what can be achieved through this process were also raised by our members and is something we have previously voiced concern about, due to both a lack of clarity on their purpose and the pace at which they are expected to deliver. 

While initially described as locally developed delivery plans for the Five Year Forward View, which aims to prioritise more than just finance, most respondents felt that returning the local health economy to financial balance is the most important issue their STP is trying to address. And the majority of respondents (62%) felt that the STP process was predominantly a national, top-down process. This is definitely a cause for concern as we move into the implementation phase and local areas will be expected to deliver plans that are not necessarily locally-owned. 

Interestingly and worryingly though, only 11% of respondents were either confident or very confident that their plans will actually achieve long-term sustainability. 

Often cited as a potential barrier to change, our members feel that governance is a key enabler to transformation. Good governance can support the delivery of a plan and ensure that partners are properly involved in the process. However, 73% of respondents claimed they were worried or very worried about accountability and governance arrangements for their STPs, and was a particular concern of trust chairs. This must be addressed and NHS Providers has worked with Hempsons to produce a briefing document on STPs and governance, with a template memorandum of understanding that local areas can adapt. 

Public consultation concerns 

Public consultation has also been a major concern throughout the process, with STPs hitting the headlines before Christmas and described as ‘secret NHS cuts’. The pace of the process and mixed messages from the centre around sharing details of STPs in public did not lend itself to a meaningful engagement process. And when asked what national support they would like to deliver on their STPs, the most common ask was for time – time to plan robustly, to meaningfully engage with local communities, local partners and then implement plans in a safe and effective way. 

What also came out quite clearly through our survey was that STPs should not just concentrate on reconfiguring acute care. If transformation is really going to work for patients then it must address wider challenges in community care, mental health, primary care and social care as well. Engagement is key to addressing these issues and, again, engagement takes time. To date, only 35% of respondents felt that GPs or primary care were engaged and there was a mixed response about the level of engagement from local councils.

Overall, respondents to our survey cited the following enablers as key to making STPs a success: 

• Having strong and trusting relationships in place at a senior level and a commitment to place-based planning to deliver better outcomes for local residents is important
• Taking the time to build these relationships with local leaders from partner organisations
• Access to funding, both capital and revenue, was also mentioned by respondents, as well as investment in social care and primary care to alleviate pressures being felt across the whole system
• National alignment on priorities and how the centre holds the system to account was also called for by respondents to our survey. For example, one chief executive from an acute trust requested “regulatory arrangements to enable system accountability, rather than maintaining the independent accountability of individual organisations” 

STPs have recently been discussed at the Public Accounts Committee inquiry into the financial sustainability of the NHS as a potential solution to current and forthcoming challenges. If STPs are expected to be a silver bullet solution to the NHS problems then, as a sector, we need to take the time to reflect on how to properly support and enable their implementation.

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