Central pressure forcing ‘far too many’ STPs to create unsellable plans

From the STP plans submitted last October, there are “far too many that are simply not realistic or deliverable” and were only created as a result of an intense financial pressure “placed on local systems from above to meet a frankly undeliverable 2020-21 target”, the outspoken boss of NHS Providers has argued.

Speaking at yesterday’s King’s Fund summit on STPs in Manchester, Chris Hopson laid bare the reality that some STPs around the country have been “forced by national leadership to come up with a bunch of proposals to close an impossible-to-close financial gap”.

The “somewhat understandable” reaction to that, he explained, was to come up with a “bunch of proposals that nobody either locally or nationally agrees is appropriate, sellable or is something that in people’s heart of hearts they really think ought to be done”.

Hopson was responding to an audience question during a panel debate that raised the point that in some areas of Greater Manchester – the country’s shining beacon of health and care integration – such as Wigan and Bolton, there are people actively campaigning against STPs, arguing that the plans are more about cuts than transformation.

“Just remember the strategic context,” the NHS Providers CEO replied. “Demand and cost in the NHS is going up by 5% a year. We’re now in an unprecedented 13-year period where demand funding is only going up by 1%, so the NHS is under huge pressure to basically close that gap.

“I would argue that what you’re seeing in STPs is we need to distinguish between apples and pears. There are some apples where there are some genuinely helpful and useful service reconfiguration and change proposals that are coming from the bottom up that are things that need to be done – where local clinicians, voluntary organisations and NHS managers are absolutely in favour of them and they need to happen, and we need to gain common support for them.

“And there are, I’m afraid to say, some STPs where the [footprint] has been forced by the national leadership to come up with a bunch of proposals to close an impossible-to-close financial gap.

“The problem is, we have apples and pears mixed up in the fruit bowl, and it’s very difficult to tell, at the moment, what are apples and what are pears. The problem is that the pears are polluting the fruit bowl, because effectively, they are preventing people who have a really good, sensible case from arguing it – because people are then saying ‘well, look over here, you know it’s mad to close these eight wards or to strip that level of acute beds or to close that A&E department’.

“And in their heart of hearts, the NHS managers that put forward those plans know that they’re probably not realistic. Therefore, where we need to get to is to distinguish between the apples and pears, and to be frank, take the pears out of the fruit bowl and get to sensible STP plans that we can all stand behind.”

Hopson also referred to news reported by NHE yesterday that a separate procedure, called the ‘capped expenditure process’, could see further closures of wards and services, extend waiting times and stop treatments in areas struggling to meet financial efficiency targets.

“The capped expenditure process is effectively trying to do in many senses similar things [to the STPs] in terms of trying to push through a bunch of really quite difficult service changes without any proper consultation or debate that, to be frank, a large number of NHS managers feel really rather uncomfortable with,” he added.

“So, if I may suggest, I think it’s important that we should all keep a really close eye on both of those processes to ensure that what’s being put forward is sensible and is subject to appropriate public scrutiny, as it should be.”

Having honest conversations

NHS Confederation boss Niall Dickson, another panellist in the debate, agreed with Hopson, arguing that the issue “at the moment is that the ‘S’ and the ‘T’ are colluding against one another”.

“The kind of pressures that individual STPs are under are pretty substantial, and then one gets polluted with the other,” said Dickson. “I think the answer is you have to go out and be absolutely honest. And that’s the trouble – I think sometimes, as a system, we go out and try to muddle it, use grand words, but we have to be absolutely honest if we’re having to say ‘actually, we’re under such pressure that we are having to make decisions, and these are the best ones we can come up with within this timeframe’.

“We also need to transform these services and change the way that they’re run, because if we don’t do that, then actually pouring more money in will be counterproductive, because it’s only by transforming those services that you’ll make them sustainable.”

Mark Doughty, patient and senior consultant of leadership and organisational development at the King’s Fund, emphasised that this was exactly one of the frustrations that patients in his local STP community have felt.

“There’s this aspiration that was noted in the Five Year Forward View and the expectation that we would be part of a collaboration and partnership in the conversations around the plan, and common sense dictated that this new relationship was about honesty, trust, openness and mutual understanding,” said Doughty.

“But unfortunately, I think a number of people haven’t experienced that. I totally understand why, because of the pressure the system is under, but for patients and a lot of community groups that’s not their concern as such. What they want is to be part of an honest discussion, and I think there’s a challenge for the system: are we prepared to be truly honest?”

Offering a Greater Manchester perspective, Warren Heppolette, executive lead of strategy and system development at the GM Health and Social Care Partnership, said there is a lot of “genuine anxiety about the nature of the service changes that are being described”, with a degree of myth and misinformation tied into conversations.

“There is some tension in those discussions because we are talking about radical service change,” argued Heppolette. “But the more we have those conversations, the more I would hope, and the more my experience has been, that we start to get people on the same page and understanding that actually, the intentions are good. The intentions are recognising that both in terms of us meeting the reality of the financial challenge but also shifting the way that services are delivered in ways that can actually tackle that fragmentation.

“Piece by piece, conversation by conversation, person by person, we have started to shift some of those misperceptions. But there’s miles more that we need to do about engagement and taking people with us. We made a couple of decent steps, but I absolutely acknowledge that we’re a long way from a genuinely aligned conversation.”


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