Health Service Focus

Are we up for the challenge of the STPs?

Sustainability and transformation plans (STPs) have been all NHS and council leaders can talk about in recent months. But do they have what it takes to truly transform the health and social care system, and are organisations up for the challenge? Luana Salles reports.

One of the most memorable analogies made during this year’s NHS Confederation conference was that, much like Brunel’s Clifton Suspension Bridge, it is indeed possible to build the NHS without central support to sustain it. The only real question is how. 

STPs, formalised last year in NHS England’s five-year planning guidance, are one of the most promising answers to that. The plans, which create “ambitious local blueprints” for 44 national footprints based on a two-pronged process, were all the rage during this summer’s major health conferences. Regardless of whether you are a commissioner, provider or local government officer, it is unlikely you’ll have escaped the subject of STPs in the last few months.

Genuine optimism 

NHS England’s chief executive officer, Simon Stevens, laid out the three main headlines surrounding the STPs at NHS Confed: ‘horses for courses’, or the fact that not all plans will look the same and solutions should be bespoke; ‘if not now, when?’, or the fact that our backs are now against the wall and money is scarce; and ‘how big a team are we playing on?’, or the fact that we must think more broadly than individual institutions. 

“Now, let us just be frank about it: to some extent, these are work-arounds on a set of institutional arrangements, a set of governance structures, and set of incentives that are pulling people apart, when actually we need to hang together,” he told delegates. 

“And the reason that I’m optimistic about this, without being naive, is that I think that we have seen in some parts of the country some pretty rapid change over a relatively short period of time.” 

Stevens added that he would be touring the country with NHS Improvement CEO Jim Mackey in July to consult STPs, and emphasised he would not sign off plans all at once: instead, he expects to back the strongest plans in a first ‘tranche’ in September, whilst other plans may require more work. 

Many other healthcare leaders echoed Stevens’ genuine positivity around the plans, which have pushed providers and commissioners to come together in their designated footprints to truly embed integration and efficiency into their everyday operation. 

Local authority involvement 

NHS Confederation’s chair Stephen Dorrell, for example, who is also the independent chair of the Birmingham and Solihull STP board, said the plans could be used to “deliver a new vision” of integrated public services, with full council involvement. 

Former health secretary Dorrell also argued that local authority participation reduces the risk “of the STP simply talking to itself”, adding: “If the programme is to work, it seems to me it’s essential – it’s not an add-on, it’s something which needs to be top and centre – that the STP process is about embedding the national health service in a broader range of public services.”

He said his STP’s work was already showing that plans offer “an extraordinary opportunity to create a new civic agenda”, citing Sir Howard Bernstein’s leadership of Greater Manchester Combined Authority as another model for this. According to Dorrell, civic and council leaders are more authoritative in their areas and can hugely influence MPs – and, as Stevens said, could even end up taking more of a leadership role in health delivery in the future. 

STPs are also major game changers across the work of Vanguards, providing a “huge opportunity” to adapt their work and ultimately mainstream it, according to Jacob West, national lead for PACS in the New Care Models programme at NHS England .

Early red flags 

But are these plans all blue skies and plain sailing? The run-up to their first significant deadline on 30 June would suggest otherwise: NHS England was already worried at the end of May that, despite many good initiatives, few STPs were at the “degree of scale and pace” required to succeed. 

In a report published ahead of its board meeting at the time, the organisation said workforce was still a “key issue” in almost every footprint, adding:  “Some [areas] have strong relationships and a shared understanding of the problem and the solution; others have yet to agree what their base-line positon is as a system, what is driving cost and who needs to take what action when to drive cost out.” 

Similarly, board papers released by London Councils, which represents the capital’s boroughs, flagged “significant difficulties” in capacity and collaboration across regional STPs, including wide variation in the maturity of relationships built across the system – despite these being a “critical factor” to the programme. 

At that point, it also appeared the original expectations for the 30 June deadline had been softened by NHS England: instead of a firm cut-off in the development plans, the first milestone had been watered down to a “staging post” that would merely “form the basis for discussion”, according to life sciences minister George Freeman. 

And even after the deadline had passed, the Healthcare Financial Management Association’s NHS Financial Temperature Check revealed just 16% of finance directors were confident that their organisation could deliver a sustainable STP for the period up to March 2021, with many criticising the weak relationships between providers in their footprint as culprits. 

Insufficient central permission 

But these difficulties might not be just down to local areas. A major obstacle to the success of the plans, according to Dr Graham Jackson, chair of NHS Aylesbury Vale CCG and co-chair of NHS Clinical Commissioners, could be a lack of sufficient central permission in order to build strong local relationships and share the direction of travel. 

Arguing that there is currently a “permission issue” with STPs, Dr Jackson said that we’re still “in that mood” where STPs have “constituent components” rather than a collective drive because the process has moved very rapidly – meaning footprints had to focus on the technicalities of finalising plans rather than really strengthening relationships in their locality. 

“There are numerous STPs across the country that have been defined centrally, not based on local relationships,” he continued. “I think we need to understand that we need to allow them to grow. But we don’t have any time – that’s always an issue – we don’t have the time to do that. To me it’s all about permission, really: being allowed, centrally, the permission for STPs. If the central situation believes the STPs are the way forward, and I think there’s a very strong argument that it is, then give it some time and give some permission to let them grow.” 

Ambitious long-term goals 

The plans are a relatively new phenomenon and, as is the case with Vanguards, it is expected that many areas will stumble before they can firmly walk. But the goals for the longer term remain ambitious, according to NHS England’s director of strategy, Michael Macdonnell. 

Running through these goals, Macdonnell said communities and patients will get the chance to shape their own future, whilst leadership teams will bring healthcare and local government figures under one roof. Ideally, the future will look like place-based systems rather than siloed organisations, bringing forward “real service improvements that demonstrate we can keep the show on the road and do transformation”. 

But perhaps most importantly, the STPs will, fundamentally, give local areas significantly more control over their own destiny, creating services and designing workforces that suit the local needs of their population: proving, perhaps for the first time in the NHS’s history, that we do, in fact, have a lot in common with Brunel’s bridge.

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