Does my STP look big in this?

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We published results of our latest CCG Barometer survey this week, which gave some useful views on the early stages of the sustainability and transformation planning process. Thank you to the chairs and accountable officers who filled it in.

After an early start and delayed guidance on STPs, they are now the subject of substantial head-scratching for execs in most CCGs and many provider trusts.

While some areas appear to have settled their patches and nominated the responsible “named person” fairly quickly, there are plenty still agonising over at least one of these decisions.

Thanks to the history of stalled NHS national strategy processes, there are also plenty of senior figures with major reservations about whether STPs can make much difference.

But they are the main policy we have for moving services to a sustainable footing and implementing big parts of the Five Year Forward View, and for some areas they will work. Underpinning the STP idea are radical breaks in policy which could make for quite an upheaval: single individuals running whole areas; crossing the purchaser/provider split; withholding growth funding from areas where leaders won’t get on.

So I plan to watch them quite closely.

STP rules and arrangements are developing quickly, and a lot of confusion remains. The national guidance issued last week has a permissive flavour but has also left people wondering exactly what STPs are for - and therefore who should lead them. It might well be that officials are still expecting Simon Stevens to give some further direction.

Here are some early observations and dilemmas that have surfaced in the CCG Barometer answers and other conversations I’ve had:

1. Achieving the necessary change will require grabbing provider trusts’ attention

This is part of the justification for the movement (likely to be taken forward in lots of STPs) to hand commissioner responsibilities over to providers: to get them to take population health and preventative care seriously. Some see this as a reason to pick trust chief execs to lead STPs. Putting providers in charge may encourage them to put their capacity behind transformation and take it seriously even when it means their organisation taking a hit.

One dilemma for commissioners is the risk of ceding control to traditional NHS providers, which have rarely demonstrated they can move beyond their normal business and take population health seriously.

There were a couple of interesting comments from chief officers and chairs responding to our Barometer survey on this theme:

• “The collective huddle proposed does not reconcile with choice and competition and will require the relinquishing of autonomy before the implications are clear.”
• “Smaller CCGs will really struggle with the wider STP footprints. It is clear that most of our transformation and future commissioning will be at scale and possible centred around major providers, so the CCG boundaries will become very blurred.”

2. STP shoe size

It appears there will be just under 45 STP footprints. This is much reduced from the 2013 round of planning units (about 120) but more than 37 suggested in work published by Monitor over Christmas.

Quite a few areas have been pressured from above (or by neighbours) to form larger patches than they would have wanted. Some have pushed back successfully and others haven’t. The result is likely to be a lot of variation in patch size, but plenty of very big (by traditional NHS standards) footprints. Some will be bigger than the 2011-13 era PCT clusters.

There are many who believe that NHS statutory footprints have long been too small for strategic planning/commissioning.

However, the bigger scale brings risks and problems. Some examples:

• Many will be working with organisations and leaders which they are not used to, do not want to work with, and may feel are irrelevant to them. Some will feel that being forced into big patches undermines the hard work they’ve already done on things like service redesign and system working in their locality. It will be important to make sure that where good work is going on in smaller constituent patches, it isn’t slowed down or damaged; while at the same time using STPs to tackle those where it isn’t happening. If one or two areas have a good case, they should be allowed to change their mind and move to slightly smaller patches.
• This will also compound the lack of time to write the STPs. This major undertaking - as much about relationships than doing sums - will now involve NHS leaders who have so far done little substantial work together. It will be very tempting for some to keep their ambitions strictly limited for a plan by the end of June.
• It means STPs span many established community and political boundaries - both local authorities and emerging city regions/devolution areas.
• It could mean some STPs work well for sorting out specialised services - such as the improvements that need to be made in cancer treatment - but that the critical business of building up out of hospital services and reinventing DGHs isn’t tackled. 

I’m planning another comprehensive piece on STPs in coming days, and there will be plenty of STP developments HSJ will cover in the next couple of weeks.  

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Dave West, senior bureau chief, HSJ

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