Analysis: NHS told to stick together or hang separately

The first is not its contents, but its new and ambitious timetable: arriving three months earlier than usual; covering 24 months instead of 12; and requiring a breakneck pace to get contracts agreed covering this period – one of the most difficult the NHS has ever experienced – by early December.

Several reasons are given for this, but the most important effect is to emphasise the second big theme: a further leap down the road towards managing the NHS through whole systems, not separate organisations.

Your attitude to this collectivist approach will dictate what this planning guidance means to you

Your attitude to this collectivist approach, embodied by sustainability and transformation plans, will dictate what this planning guidance means to you.

A series of measures are taken to harden the role of the STP, including system control totals, STP level assurance, performance metrics for STP areas, and a system-wide risk pool. The message is clear: the centre would rather you stick together than hang on your own.

If you are comfortable in your STP, and your system’s influential figures are all more or less on the same page – whether through consensus or the right person taking charge – these measures offer welcome support and flexibility. STPs moving fast are also due to get the first transformation funding if they can show it will make a difference (although the sums on offer remain uncertain).

Expect many of these STPs to start building up their shared resources and staff. A few might change leader so they can move faster, some will take advantage of the new permission (with conditions) for clinical commissioning group mergers to get into a shape that will work better for them.

For systems that are not sticking together, these rules are your worst nightmare

The success of these motoring STPs is the single most important factor underpinning the health of the NHS as a whole, as they charge ahead with delivery, and, it is presumed, make huge efficiency savings in the process.

For systems that are not sticking together, conversely, these rules are your worst nightmare – they will make it virtually impossible to operate and mean you lose funds to the STP-level pot with no buy-in or control.

Problems will materialise extremely quickly as contracts are set. The guidance is baldly threatening to those who can’t agree contracts: You will be referred directly to messrs Stevens and Mackey, and providers refusing this process (as is their legal right) will be fined.

If it wasn’t already obvious, the new planning rules will shake out which health systems are not working as one. They will receive the latest incarnation of joint, up-close “assurance and support” from NHS England and NHS Improvement. In these areas leadership changes will not come as a surprise.

The guidance does make some concession to areas that can argue well that their STP is not the right size: there is a signal that, if it is deemed for the right reasons, they will be allowed to split – although a big shift away from the current 44 is unlikely.

Given the uniquely daunting task ahead, the guidance is relatively light on targets and terror. Building on the control totals regime, it seeks to extend tough measures for financial and performance failure, but tacitly it recognises the likelihood of widespread failure – by extending the £1.8bn sustainability fund to plug gaps, for example. But compared to July’s “NHS reset” document, the tone of this planning guidance is sweetness and light.

National leaders can therefore argue they are giving the health service what it has asked for – a whole system ethos, longer term planning, financial flexibility. Unpersuaded NHS chief executives could well counter that just saying so isn’t enough – organisational priorities and duties persist, as do outdated payment incentives. Plus, for some, there just isn’t the money to make it work.