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

The “greater Bristol” health economy, as it presumably can’t be referred to locally, in the space of five days was labelled “needs most improvement” (the STP equivalent of inadequate), but also celebrated for University Hospitals Bristol’s double improvement to a CQC outstanding in Professor Sir Mike Richards’ retirement interviews.

I’ve spoken to a few people about Bristol, North Somerset and South Gloucestershire recently. It seems a bit of a straw in the wind, magnifying the experiences and dilemmas in plenty of other areas.

Until about a year ago, the area was not high on regulators’ worry list – but pressures have been mounting for some time and there were clear signs of stress in 2014.

Awkward borders and boundaries have long caused problems. BNSSG seemed particularly damaged by the 2013 reorganisation. It was left unable to hold together a coherent common strategy, with weak control and coordination of providers, just at a time of upheaval with North Bristol opening a major new hospital.

It has proved that a hospital can indeed be an island – sort of. As well as its outstanding rating, UHB recorded a surplus for 2016-17, while elsewhere things are a lot tougher.

North Bristol has some strong specialisms and a decent new hospital but is rated requires improvement and has a big budget gap, having just escaped financial special measures. There are more serious concerns about the small Weston General Hospital, mental health services have been subpar, and there is high reliance on acute care (more on that below). General practice is said to be good but underexploited.

There are no illusions on the patch that the last 18 months’ STP work has made much of a dent in its problems. It is now bottom of the class with the lowest STP rating overall and for leadership.

One of the things this period has achieved, at least at a surface level, is a seemingly shared and reassuringly specific description of problems. Acute usage and costs are higher than they should be, particularly because of long stays but also other factors associated with having three acute trusts: two of them quite large with substantial specialist services.

Long stays are associated with a confusion of different rules and services across six commissioners (three CCGs and three local authorities), three acute providers and three community providers, with substantial flows across these statutory borders and boundaries.

Eligibility and processes are so messy, it’s hard for patients to escape the gravitational pull of a hospital.

In the other direction, people are sucked in more often because services and protocols in primary/ambulatory care are insufficient, unclear and geographically variable, while specialist care is close at hand.

Although some vehemently disagree, in theory the region is well placed to benefit from the STP approach – to bind together decision making and establish rules and protocols across the bigger patch.

BNSSG can at least argue it has got its ducks in a row. Three CCGs have been melded together under a good shared chief officer and an experienced leader is in place as independent STP chair. This probably has a lot to do with a hardliner approach over the past year from the regulators, pressing for a single commissioner view and provider joint working. The two trusts have been working closer and North Bristol has shown financial improvement. 

Unsurprisingly, it won’t be all plain sailing on the Severn.

The best solution for Weston General (North Somerset’s small coastal DGH) is probably a major downgrade and organisational integration – a long running bugbear which will be contested.

University Hospitals Bristol (and arguably the Bristol CCG population) faces the likelihood that fighting for the health economy means giving up its current high ground – something already spotted and challenged by local politicians.

BNSSG is in the capped expenditure process and has areas of high elective usage (including private providers) – would choking this off do more damage than good?

Finally, there is the possibility the financial equation just can’t be balanced in the next few years; and urgent demands for cuts can eat up good will and time, knocking efforts to deal with the underlying issues off course.

Some say this is the story in nearby Devon, one of the first areas to receive a whole system kick up the backside, two years ago under the “success regime”. It seemed to be on a better track – reporting improved relationships and shared plans. This year though, with deficits persisting, regulatory intervention has stepped up and Angela Pedder, who was central to the system working, is stepping down.

There is a rosier picture for the time being in the other two success regime areas: Essex and Cumbria STPs were both given “advanced” ratings last week.