The Commissioner: STPs, busy being born or busy dying?

“STPs are dead” was the view a senior MP well acquainted with the NHS put to me in recent days. Many others are wondering the same thing, probably because the centre has been very quiet about sustainability and transformation partnerships since late last year – when controversy, political jitters, and their own shortcomings caught up with them.

Shortly STPs will be given public ratings for the first time, presumably not universally as “deceased”. Jeremy Hunt (with a history of enthusiasm for flawed ratings) will, with Simon Stevens, host a motivational get-together for STP leaders this week.

One source of confusion about STPs is that they have multiple identities – they are very different things to different people. And their character is changing. What fate is in store for five of their different identities?

1. A plan written in 2016 – often featuring potential major reconfiguration and expectations of reducing emergency care and key professional staff groups. As far as this goes, many STPs are dead. Some fledgling acute reconfiguration plans have been quashed or delayed – even more so now we have a precarious government. Details of activity, finance and workforce have been heavily revised as STPs became operational plans and contracts: far from an NHS first, to be fair. In particular in workforce, some have gone through the realisation that the main task must be recruitment, retention and motivation rather than relying on seismic changes in skill mix or working practices. Even so, some aspects of all STPs remain – often building on schemes already underway, and heavily refined since autumn – and people are trying to implement them.

2. The new unit of planning. Many STP teams have been coordinating operational planning, sometimes they have combined with shared commissioning teams. Lots have been staffing up and in some cases taking small teams from NHS England under their wing. Getting metrics and ratings – as STPs will imminently – is another mark of becoming the default planning unit.

On the other hand, some STPs are breaking apart. The first batch of accountable care systems (see below) shows that the cohesion needed for this next stage often won’t be found across a whole STP: Blackpool, Greater Nottingham, West Berkshire and Buckinghamshire are all sub-STP level. As are several “capped expenditure process” areas – see York and Scarborough, Cheshire, and Morecambe Bay. Many others would rush to peel off from their STPs if invited. STPs are also sharing the operational/planning limelight this year with the top-tier local authority level, at which there will be ranking and inspection on delayed transfers: an approach taking us back to the better care fund not STPs.

3. NHS England in sheep’s clothing/the new performance manager. Some STP leaders are worried this is quickly becoming their fate, stifling their other identities, particularly the one about locally driven transformation. It’s an extension of becoming a unit of planning, but for some a deeply unhelpful one. Some STPs had to take on the vexed CEP. In recent weeks STPs have been handed tight deadlines (ie: a couple of weeks) by NHS England to report against a whole bunch of delivery requirements, including an urgent and emergency care plan and the other Next Steps priorities. They are also expected to increasingly stage regulatory interventions in their system. All this means approaching constituent members like a strategic health authority or NHS England area team. Talking tough, asking for meaningless spreadsheets to be filled on absurd turnarounds. They may bear little relation to the local plans, or to reality, so sap STPs of valuable respect among members. With STP leaders relying on soft power and relationships internally, requiring them to play SHA is a big ask and for some could sour the project even further. It may be that a handful of STPs/ACSs can do this but the rest are best spared.

4. The path to “earned autonomy”. NHS England and Improvement say they are thinking about how to revive local autonomy in the NHS. NHS England has set out how ACSs (like the “devolution” areas) should be given back some of their own money (from the national “transformation” pot), and a bit of local agency, and create a path for others to follow. Jim Mackey has argued that new “earned autonomy” is needed for systems, not foundation trusts. He has raised the issue of what financial system should succeed the sustainability and transformation fund, which is one of most powerful mechanisms of central control currently. Reviving autonomy seems sensible. Several patches which are performing “OK” justifiably feel they could be thriving if they weren’t kept on the breadline by top-sliced funding. What do they have to do to earn ACS status?

At the moment, though, even for ACSs, “autonomy” is highly theoretical. Money has not passed back. They are still being driven hard on performance targets rather than population outcomes or transformation.

The biggest drags on local autonomy are the STF and CCG risk reserve systems – taking enormous top slices and putting them under national control. They still apply in full even to ACSs. These were instigated by the Treasury as the only guarantee of financial balance and, despite the improvement anticipated in the imminent 2016-17 accounts, will surely only disappear when financial risk has subsided a lot further.

5. The beginning of the “health system” coming first. This is where the big policy battle will be fought. NHS England’s mantra is NHS organisations and leaders must stick together or they will hang alone. The argument is that in the current circumstances the service will only survive by health systems working as one – not independent FTs with individualist agendas or multiple CCGs with pet projects or nimby interests. Nor by commissioner and provider sides working against each other. It remains the mantra, and the ACS project emphasises this – their defining feature seems to be that organisations/leaders are meant to get on and work together. It is the preferred delivery vehicle for new care model reforms and other improvements.

The suggestion is NHS England will support functional health systems where it thinks the basic ingredients, particularly the right leadership, exist. It will try to propagate the system first approach by seeking to get NHS Improvement teams on board, at all levels. ACSs are something of a fudge, but also highly contested. Why should any leader locally set aside what they think is best for their population and/or patients in deference to a vaguely defined, potentially poorly managed “whole system”?

The obstructions are everywhere: laws, regulations and incentives. Contrary beliefs and behaviours, which are particularly insoluble in some FTs and their overseers/champions in the regulators.