What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West
Here follow some early impressions from reading most of the “full” October sustainability and transformation plan submissions we have had so far and from discussions with those in the know in recent days and weeks.
Two important disclaimers: we have access to fewer than one in four STPs; and I will have missed things – we haven’t (yet) studied every word and the documents themselves won’t always do justice to all the work going on and the prospects of an STP patch.
Where are we at?
Ten “full” October STP submissions are public at the time of writing and we have access to a further two which we can’t publish yet.
Simon Stevens and Jim Mackey last week told chief executives at regional events to publish their plans as and when they want to (except for finance/operational details) – but people involved locally in several different areas insist they are still awaiting the national agencies’ processes and clearance.
The best guess is there will be a flurry more released this week and next, then a flow in late November to early December.
Overview – A little forward view, a little ‘reset’
The three main sub-headings and areas of focus in a typical STP, crudely speaking, are: 1) Overhauling community-based care; 2) reconfiguring/standardising secondary and tertiary care; and 3) providers coming together – mostly to cut costs in back office, clinical support and sometimes procurement.
Community based care proposals are generally pretty Five Year Forward View flavoured – there is a fair amount of talk of new care models, up-scaled primary care and multispecialty community providers. That said, STPs draw most heavily on less buzzy community based changes which have been the subject of NHS strategies for a long time: Neighbourhood/30,000-50,000 populations; multidisciplinary teams including social care; risk stratification and case management; primary care centres or networks with extended access; step-up/step-down care; overhauling outpatients. There are a few new acronyms for this concept (see south east London’s LCNs) in STPs but I’ve seen few convincing, dated commitments to full blown MCPs, PACS or ACOs. There is much more GP federation than super-practice or chain. There is often aspiration to set up hard capitated budgets, but generally it is pencilled in vaguely for 2019. Many will argue this is a good thing – what’s needed is more time chipping away at hard fought clinical service changes – but some will be looking for more easily recorded 5YFV wins.
In some STPs prevention is covered under the banner of community led population health, some detail it separately. There are lots of references to programmes to improve, spread and standardise good practice in primary and secondary prevention; often as per central forward view plans on cancer, mental health, diabetes, etc. But does this constitute a “radical upgrade in prevention and public health”? I’ve spotted no instances of an STP prominently playing the role of public health activist, perhaps stirring local/national government action on some big determinants of health – economics, planning, housing or empowerment – as was indicated in the Five Year Forward View. A whole one of only four chapters in the 5YFV was headed: “A new relationship with patients and communities.” Maybe it’s just hard to put on paper but I haven’t seen anything very persuasive on this.
The second of the big three themes is reconfiguration of secondary and tertiary care. This doesn’t get much attention at all in the forward view, though that document did tactfully note the need to convert our smaller hospitals into “viable smaller hospitals”. It is driven mainly by the realities (often pretty urgent) of clinical staff shortages, lack of cash, changes in practice, higher quality standards/expecations and transparency – whether via Care Quality Commission visits or the drive to “seven day” cover. Emergency care, maternity, paediatrics and stroke feature widely; as do acute/elective hot/cold site swaps (see Dorset); and more specialist services and small specialties get attention too.
Often the dilemma is what should a “viable local hospital” do; how little to be affordable and safe, how much gives a reasonable service to its community? Clinical and organisational networking between trusts perhaps features more heavily in STPs than in past similar exercises. The Tees+ STP speaks of its dilemma and approach over local hospitals.
Acute reconfiguration was given a strong push from the centre, behind the scenes, throughout the STP process; and it appears that despite political jitters, lack of capital and experts’ doubts about cost/benefit, some areas are still being egged on towards this.
What is critical, though, is that very few areas have firm proposals ready to go right now – instead they are eyeing consultation from spring/summer 2017. These could, presumably, be pushed beyond the hypothetical snap general election next year which some political pundits believe will come.
Finally, the third topic featuring widely and heavily in STPs is reorganisation of back office, clinical support and sometimes procurement functions. Often this accounts for the biggest chunk of forecast savings from the STP, or is a key part of the large efficiencies next to “business as usual cost improvement” – these are always larger than the numbers attached to containing activity through prevention or non-acute services.
There is a lot of variation in how far each STP area has got on this and how serious they appear to be (as in much else). Intriguingly north central London is proposing to pull commissioner and provider back office together too. Meanwhile, in some cases these plans are linked to more comprehensive linking of leadership or mergers between trusts – taking forward the general trend to collaboration and consolidation of trusts.
A STP in the right direction?
Another disclaimer: there are lots of themes in the STPs I haven’t covered, plus I’ve barely touched here on the implementation challenges and flaws. There is plenty more to come.
That said, the overall first impression reading STPs is many have made or agreed substantial steps towards some elements of the forward view agenda, and towards consolidation on the provider side – both clinical and non-clinical. But in most cases it looks like steps rather than leaps, and some parts of the national vision have got much less of a foothold than others.
Updated on 11 November to add a little bit to the analysis.