Comment

STPs present novel case for change, but pace and scale are challenging

Professor Jane Dacre, president of the Royal College of Physicians (RCP), argues that if sustainability and transformation plans (STPs) are to be successful then clinical input must be at their core.

The need for wide-scale system change in the health and social care system is obvious and supported by the RCP. Physicians are committed to the NHS and can play a large part in its recovery. Their knowledge and experience gained from working directly with patients and the health system enables them to lead and support change. 

STPs offer a real opportunity to ensure that care is delivered in a joined-up way and that the needs of local populations are reflected in service delivery. However, this will be delivered against the backdrop of sustained financial pressure on the NHS and social care. 

STPs focus on trying to remedy the three ‘gaps’ identified in the NHS Five Year Forward View, namely the health and wellbeing gap, the care and quality gap and the finance and efficiency gap. Most of the plans lay out the need for change really well and say all the things the RCP made clear in the Future Hospital Commission report. The themes of improved public health, preventative medicine, care by community teams closer to home, improved specialist pathways, more use of technology and better workforce planning are welcome. 

Pace of change challenging 

STPs present well-evidenced cases for change, and propose novel and appropriate methodologies for achieving this. However, the pace of change required and the financial expectations are extremely challenging. Some STPs are more likely to succeed than others, based on financial risk, engagement, urgent and emergency care targets and the scale of change needed. Not all of the plans start from the same point and some are in far more financially challenged health and social care economies than others. Engagement with local authorities is great in many, but absent in others, and all rely on a large increase in the primary care workforce. 

The problems arise when the issue of meeting the funding gaps in health and social care are discussed. Most plans have, to put it mildly, aspirational plans for this as they rely on savings created by reductions in A&E attendances, bed numbers, non-elective admissions and outpatient appointments (often in the 10–20% region). 

In the past two decades the number of NHS beds has been reduced by 25%, and the only way we have been able to cope with increasing numbers of patients is by reducing length of stay. We cannot do that anymore – we cannot possibly reduce the number of beds by 30% over a few years without lengthening waiting lists for outpatient and inpatient procedures, and damaging patient care – unless there are enough beds provided elsewhere. I am pleased that Simon Stevens, CEO of NHS England, has made it clear that mass bed closures will not be permitted unless alternative arrangements for patients are put in place first.  

It is important that the transformation of the current care models towards the vision of care described for the future is done in an achievable way. The financial modelling requires change ‘at pace’ and ‘at scale’. It is difficult to see how monies required by the current system will be freed up to support the new systems without the current system collapsing. 

Clinical input must be at core of STPs 

The RCP believes STPs should be planned, implemented and delivered with clinical input at their core. To make a true success of joint working and collaboration, frontline staff, clinicians and their teams need be able to offer insight into how frontline services can be improved to ensure that the NHS delivers high-quality and sustainable care. 

All of the plans acknowledge the need for engagement with the public and the current system, although the evidence that clinicians in secondary care have been involved to this point is very thin. Most clinicians do not know what an STP is, and it is vital that STP leads engage with all parts of the healthcare workforce to produce locally created plans with buy-in. The RCP is happy to support this engagement with our members and fellows in any way that we can. 

If STPs are to be successful, they must involve physicians to effectively capture their expertise in delivering high-quality patient care. Each plan should reflect the particular needs of that locality. Physicians are best placed to comment and hold STPs to account. Accordingly, the RCP is encouraging physicians to get involved in their local STP – to assess their local plan and feedback to the STP leads.  

In addition, the RCP itself will be collating feedback from physicians to identify national trends, such as the appropriateness of the plan for the specific area in question, the level of clinical input and the likelihood of the proposals to improve patient care. We have a genuine opportunity to influence health service planning for the benefit of patients – health service managers should give staff the breathing space and ability to get involved – and clinicians should take up the challenge.

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