Sustainability and transformation planning has reached a highly precarious moment – but the STP project will be a long and difficult slog, not a big bang, writes Dave West.

It is a highly precarious time for the STP process.

Number 10 is receiving a stream of concerns from Conservative MPs fretting about their patch’s STP and the reconfiguration it is assumed to include.

It would be no surprise if the prime minister – new to the role, managing a small Commons majority and, some believe, still eyeing the possibility of a general election next year – had wondered whether she could be rid of this noisy and unpredictable programme.

The palpably sensitive situation is inciting increasingly irrational behaviour from officials. With ministers breathing down their necks, NHS England and NHS Improvement are advising local areas in ever more direct and panicked terms to delay publication of plans until they have been checked through centrally, following “full” STP submissions on Friday.

It is anticipated the checking process will be completed by mid-November. STP leaders are unclear whether, at that point, they are meant to publish their full plan, or only a summary version denuded of anything too radical.

This approach seems particularly absurd because of the involvement of local authorities, which cannot be gripped in the normal way. “Sharing with councils means sharing with elected members, and then the plan is effectively in the public domain anyway,” explains one lead, keen to publish before being leaked against. Yesterday the latest plans from two areas were released: Birmingham and Solihull (led by the city council chief executive), and North Central London (whose plan was effectively leaked by one of the councils in the STP).

So it is a jittery time for those developing STPs too. They are under concurrent pressure to publish their documents, keep them quiet, begin implementation and turn them into two year contracts before Christmas.

There is a fundamental nervousness about delivery. Are STPs – essentially models under which the NHS survives the next few years and stays within budget – any better than make believe? Will the actions agreed pull hospitals back from the brink? Can they prevent an NHS access crisis becoming a care quality crisis? Are the proposed service changes affordable, or worthwhile?

Our survey today confirms how widespread the doubts are among CCG leaders, many of whom are shaping STPs, and all of whose support will be required for successful implementation. It’s always wise to treat NHS activity plans with scepticism, but to find only one out of 99 willing to express “high” confidence their own STP will deliver on its aims next year is an extreme result.

Some CCG leaders report completely inadequate plans. “The STP is not even off first base and is unlikely to have any real impact,” says one. For a handful of areas this is true – they will likely be told to get through the current planning round then go back to the drawing board.

Much more prevalent are leaders believing their plans are the right ones, while harbouring deep doubts that they can meet the extreme requirements of the next couple of years.

Asked to identify barriers to STP success, only 29 per cent cite flawed plans while nearly three-quarters name capital funding and two-thirds point to lack of change capacity and capability.

The responses speak of an important message that needs to be heeded about the STP project: contrary to the impression created earlier in the year, success will not come from a single flawless, explosive master plan – it will be a long and difficult slog.

As a message for those with doubts over the next steps, “hold your nerve” is not the most comforting, but for all involved, from the prime minister down, it might be the best reassurance available.

In the arena of major service reconfiguration – a great source of fear for the government – it would never have made sense to launch 44 reconfiguration battles in a single violent moment, and this is not what will happen.

Many areas absolutely want to put forward centralisations of high profile clinical services, believing it necessary to shore up safety and release resources, though our survey also shows that more are planning less controversial expansions and developments.

But even leaving aside the madcap politics of trying to launch dozens of change consultations in the same month, many areas have not yet agreed on necessary details, been through the required sign offs or secured capital. This can be seen clearly in both the Birmingham and Solihull and North Central London STPs.

The centre’s evaluation of STPs over the past few months is that they broadly fall into three or four categories of readiness, ranging from a few patches poised to consult then implement right away (some already are), through to areas where local chief executives are still recovering from sitting in the same room for the first time, and most falling somewhere in the middle.

It means many of the plans published in the next few weeks will not detail the likely end point – one senior figure predicted “executive summaries without the answers in”.

Reconfigurations will be spread over a longer period, part of an unofficial pipeline. Jitters in Whitehall or SE1 will probably see some plans pushed back rather than accelerated.

The balancing act for national officials will be to carefully choreograph the controversial stuff, while remembering they usually do not themselves have the right answers – and could easily become a drag on change.

Exclusive: Survey reveals STPs' service change priorities