What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West.

This is the second of two The Commissioner newsletters on the next steps for sustainability and transformation plans. This one covers: moving towards Greater Manchester style delegation and resourcing; next steps for the other STPs; and implementation of the plans. Read last week’s for analysis of how some will be accelerated to new accountable care structures, and which places are involved in this. 

Towards Greater Manchester

What will the areas signing up for acceleration to becoming accountable care organisations or systems (see last week’s newsletter) get out of it? Some argue not enough, since with no legal changes it may be no easier to work in the new arrangements than the old.

There are though some sweeties on offer: NHS England and NHS Improvement will delegate some decision making, responsibilities and resources – and in this way the next steps are to move more STPs towards the Greater Manchester model, to become Greater Manchester-ish.

More control of specialised commissioning can be helpful, but I suspect the most attractive offer will be removing some of the huge assurance burden through NHSE and NHSI. Under the GM model assurance is hardly light (devo Manc boss Jon Rouse reports to NHSE finance chief Paul Baumann after all), but most of the responsibilities of NHSE local teams have been transferred into the GM agency. So a lot of the policing is internalised and most reporting runs through Mr Rouse straight to the centre.

Greater Manchester is also a model for the other offer to advanced STPs – to put them in control of more of the total management/admin resource of commissioners and NHSE. Lawrence Dunhill has written about how the patch is bringing together resources from across organisations, amounting to an annual running cost budget of £8m.

That might help STP leaders get their agenda moving, but is a double edged sword. STPs were set up to bring about transformation, which attracted many of their leaders, but they could find themselves doing lots of regional regulation and assurance, and employing lots of staff with that job description.

NHS England and colleagues will also try to give the leading STP areas control of a delegated transformation fund, like Greater Manchester, scraped together from various existing pots and allocation. Needless to say, don’t expect much.

What about the other STPs?

The powers that be have decided that despite the substantial difficulties with the programme, there is no plan B, and STPs are here to stay.

The majority won’t be fast tracked to become a new accountable care structure, but Simon Stevens and Jim Mackey will still do a few things to strengthen their hand.

There will be an appointment process for STP leaders. This is expected to take place in the first quarter of 2017-18. The main aim of this is to give the existing leaders more legitimacy – the appointments will involve an implicit deal whereby NHSE and NHSI agree that they and their local tentacles will do what they can to back that leader’s approach and plans. I don’t expect masses of leads to change but some will duck out or be replaced where things have gone badly, and there are one or two where the STP lead is already leaving.

As part of backing them, the centre is now also making explicit that if called upon it will help STP leaders overrule blockers to change – whether that be unpopular service change, shifts in funding, or bringing either clinical commissioning groups or providers together. Effectively STPs can escalate these issues up the line when they need to, and existing assurance regimes will be used to enforce the system line.

Implementation and funding

All STPs will have to move to implementation, though that means different things for different areas.

All areas have to make efficiencies, for the most part huge ones. Often they are using parts of their STPs to inform that.

But also, there are big gaps between original STP details and current operational reality – plenty of areas have already ditched original projections for activity, beds and staff, for example. Many still need to reconcile their plans with financial requirements in 2017-18, and there are still some big gaps. There are also the serious doubts about the general progress, deliverability and nous of many plans, which have been concerning central government as well as the health service.

The ethos on the ground is where possible to start getting on with changes that will make a difference quickly, but at the same time nearly all STPs have gone back to the drawing board to one extent or another.

They have been told to create “a credible implementation plan” which will deal with some of the issues. This will happen over the coming months but everyone will want to avoid another high profile, hostage-to-fortune submission deadline. An ad hoc approval process at regional team level seems more likely.

For major service reconfiguration, a small number of areas are moving ahead with consultation and beyond – see Dorset, Devon or Cumbria – and as ever these big changes won’t come quickly.

Capital and reconfiguration

The latest big news for STPs, from the budget, is about capital.

Most STPs have requested substantial capital and for many it’s a necessity for key parts of their plans. Capital availability is a really important consideration for STPs, not to mention for general maintenance of decent standards. Current spending plans fall far short.

The news from the budget is good and bad. Only a few pennies were actually allocated in the budget and these may just as likely go to local political pet projects, as to the most advanced STPs.

The chancellor has, however, indicated there is likely to be “capital programme” announced in the autumn budget – a positive signal and one that few anticipated. 

Accompanying this, though, we can expect a firm new message to STPs and other local NHS leaders in coming weeks. The Treasury and Number 10 feel that current STP capital proposals are not good enough.

With the centre of government seeking still more control, either the Treasury or Cabinet Office will have a role in a new prioritisation and approval process to decide on bids. It will be looking for more commercial nous in bids – land sales and housing developments for example – and will favour alternatives to the traditional hospital rebuilds which STPs are accused of falling back on. This creates new hoops to jump through, and it may be largely political games, but it does open a new window for STPs to bid with strong proposals.