Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by deputy editor Dave West.

“We have learned the lessons from the 2016 sustainability and transformation partnership process”. So goes the mantra of those involved in guiding and delivering the local NHS’s response to the long-term plan.

Exactly what lessons people believe have been learned - and whether they are all talking about the same lessons – will become clearer as those local plans are developed.

National implementation guidance, which should have been published weeks ago, is still not out – but is promised “very soon”. Local systems – both STPs and integrated care systems – are still expected to respond with their detailed plans by the autumn.

Too much specification

The draft implementation guidance runs to 200 plus pages – though it may well be slimmed down for publication.

The key debate driving the length and nature of the guidance is how much will be mandatory and what will be left to local discretion.

The NHS England leadership has been clear that, wherever possible, it wants STPs to get on with what they know needs to be done, and that their role is to encourage and incentivise.

Systems should be encouraged not to get bogged down in the countless long-term priorities available in the national plan, or make NHS targets the focus. This would be guaranteed to disengage the public and partners, especially local authorities.

One of the characteristics of the STPs which have matured most over the last three years is a shift to focus on practical “enablers”, and otherwise neglected areas, like workforce, technology, or housing.

Financial unreality

The process for the original STP plans was soured by forcing a financial obsession on the authors, who were required to focus on enormous fictional funding gaps five years away, and a pointless requirement (as it has proved) to plan to balance these to zero.

Repeating this misstep should be avoided. Doing so might involve exploding the myth that the government’s new funding settlement is going to mean deficits will quickly disappear.

In 2016 STPs had to make other absurd projections, influenced by financial projections, including that they would need fewer registered nurses. These predictions were disowned by the centre as soon as I revealed them, but later confirmed in official reports.

(See also: Raising expectations in government that the plans can solve its big NHS headaches.)

The credibility of STPs mark two will primarily lie in the realism of their visions.

Courting controversy

The highest profile controversy continuing to dog STPs is the idea that their plans are a cover for cost-cutting reconfiguration plans. Much effort went into repairing the damage done by rows over proposals in the original plans, and the NHS at national and local level will be on high alert to avoid it this time round. But if the lesson learned is to avoid clinically or economically sound reconfigurations or other controversial changes, it would be the wrong one.

The suspicion of a hidden agenda was heightened by allegations – some justified, others mischievous – of secrecy and lack of involvement of non-NHS partners. Soon STPs were christened “secret Tory plans” and many local authorities – not just Labour controlled-ones, took fright.

This “secrecy” was partially a result of having to work to a tight national timetable that gave no time to prepare the ground. That timescale seems to be being replicated and the national guidance should recognise the risk and offer practical ways for STPs to mitigate it.

If nothing else, there will be many fewer Tory-controlled councils this time round, as a result of local elections since 2016 including those this week.

Retreat to the local

Most STPs cut across local, and in some cases regional, boundaries and cover populations of more than a million. This takes NHS staff, politicians, and others out of their comfort zone. Many parts of the country are making bigger strides with integration on smaller patches – whether that be primary care networks or, in the jargon, “places” – which typically cover a single top-tier local authority and a smaller population. Integrated care provider or partnership models are being developed with some speed in this context.

There’s now an understandable temptation and opportunity to retreat into that space. But – though never made very clear – the main purpose of STPs is to recreate coherence and a strategy across a bigger patch. Scale is important if the desired changes to many clinical and non-clinical services are to be achieved.

From chaos comes…?

The big advantage many STP leaders have today compared to their 2016 counterparts is their systems have had three years to get to know each other. This means the majority of STPs are in a better place.

More than a few areas now have plans to build on and leadership that seems to be holding down the tough, and for some of them unfamiliar, job of corralling the system. More providers have come around to the benefits of system working. Some areas which were at the back of the pack in 2016, like Sussex or Bristol and surrounds, have made real progress. They have gone through much upheaval and chaos and it appears to have been worth it.

In contrast in some parts of the country, like Herefordshire and Worcestershire, or Shropshire and Telford, serious quality problems seem to have inhibited rather than animated system working. A few areas have made strides then fallen back – it looks like this may be the case in Devon – showing how fragile this can be; and there will be continued leadership churn in some places.

As a result, there is even more variation in preparedness and performance than in 2016 and there is a danger that some ‘left-behind’ areas will continue to pay lip service to system working.

How the national guidance approaches changing the course of the bottom quartile will be vital, if integrated care is to achieve national momentum.

Grey mush persists

Creating seven NHSE and NHSI regions has sent a signal that close system management is back. In the words of one chief executive it confirmed to trusts that “the post Lansley free-for-all is over”.

Yet whether the regional offices can recapture the supportive and prescient nature of the best health authorities, while resisting the temptation to control STPs and ICSs is, as yet, an unanswered question. The regions have the challenge of building their own operation out of the ongoing and painful NHSE/I ‘merger’ at the same time.

Indeed, half a decade on from the publication of the Five Year Forward View the exact purpose of the regions, STPs and ICSs is still – intentionally – left unclear. Some are convinced the latter should be a regulatory tier under the former and are developing them as such; others are vehement they will never be.

The ambiguity and confusion may be unavoidable but it will remain a real risk, especially where a system has leaders who can’t offer them much direction. The national guidance could do with offering some mitigation.