STPs are being hampered by confusion and indifference

Delivering the Forward View is the title of this year’s planning guidance, and its central proposal for making this happen is the development of five-year local sustainability and transformation plans.

Given the Forward View remains the NHS’s best plan for getting on to a sustainable footing, the apparent importance of STPs is substantial.

Time is also pressing: funding growth is frontloaded in 2016-17 and the NHS needs to show discernible progress on reform if it is to have any hope of negotiating a more viable deal with the Treasury later in this parliament.

Big footprints

With the stakes this high, the amount of confusion, uncertainty and indifference in the system surrounding STPs is disturbing.

HSJ understands the number of STP patches is currently set to land at 42. As well as confirming Simon Stevens does have the answer to life, the universe and everything, this gives them a mean population size of around 1.3 million – very large by NHS planning standards.

Many organisations feel they have been bounced into very big health system “footprints” without understanding exactly what they are for, while others have pushed back hard against this.

In the biggest patches, STPs risk an excessive focus on specialised services, while sapping energy from the critical business of reforming primary care, or redefining district general hospitals, that is being pursued at a more local level.

Some leaders have twigged that creating a single strategy across a whole health economy, under a single leader, has the makings of a comprehensive rewriting of the rule book – not so much blurring the purchaser-provider split, as trampling all over it. It could also alter national/local dynamics, potentially creating a set of de facto leaders of the service with whom national figures can deal directly.

Price of fish

But many are not convinced anything will change: jaded by a dozen other strategic planning processes, they expect the work will come to little but another form-filling exercise; at best a slight acceleration of service change plans already sitting with commissioners.

Cynicism is particularly prevalent among providers, with one acute trust chief executive, not known for naivety, telling us: “It has got nothing to do with the price of fish.”

This is a particular problem because there is a good case that, for many health systems, putting trust chiefs in the STP driving seat will offer their best chance of success – opening up the provider’s capacity and giving them skin in the game to make decisions that won’t benefit their home organisation.

‘With the stakes this high, the uncertainty and indifference surrounding STPs is disturbing’

Across swathes of the country, though, clinical commissioning group chiefs have been slotted into the STP lead roles by default because planning is seen as the sort of thing they do.

It is right the new system leaders will come from a mix of backgrounds. There are plenty of patches where no provider chief would be a good fit.

North Cumbria, for example, has a recently arrived interim hospital chief executive, shared with another provider and busy grappling with the day to day.

The natural choice there will be to ask success regime chair Sir Neil McKay, and his health authority experience should fit the bill.

There are areas where provider leaders aren’t trusted to prioritise the health of the population and the overall system, or none can give the near-full time commitment required.

But where there are credible trust chiefs who have shown they are up for population health and service transformation – Paul Mears at Somerset’s Yeovil District Hospital, for example – it is important they get all the encouragement needed to take on the STP roles.

To work, the STP process needs to step up a gear, and for the right chief execs to step forward and embrace the task.

• Read the Commissioner, our new weekly email briefing covering NHS commissioners, which this week discusses sustainability and transformation plans.