The NHS remains in a period of unprecedented change, combining massive post-2012 reorganisations, intense budget pressures, and spiralling service demand. One key new initiative – Sustainability and Transformation Plans (STPs) – has been dogged by controversy over their lack of transparency and public engagement. Here, the University of Manchester’s Dr Anna Coleman introduces STPs to a wider audience; argues that their creation has so far been undermined by a focus on debt reduction and budget cuts, and the truncated timetable for their implementation; and suggests practical steps to enable STPs to play the constructive role in the future development of healthcare services in England.

• STPs: designed to achieve collaboration and consensus in local health provision
• Focus on cuts and lack of transparency have eroded public support
• Ways to help STPs succeed – more time, more consultation, and stronger legal footing

So what are STPs and why all the secrecy?

Many members of the public and even staff working in the NHS and local authorities will probably not have heard of Sustainability and Transformation Plans (STPs). Current headlines about local councils rejecting the plans are therefore something of a mystery to many. STPs are five year plans drawn up by health and care leaders in 44 areas identified as a geographical “footprints” covering all of England. STPs, first set out in the NHS shared planning guidance 16/17 – 20/21, are being designed as part of the mechanisms to deliver the  Five Year Forward View (FYFV 2014), which aims for NHS bodies to make savings of £22bn by 2020, equivalent to 20% of spend over five years. Access to a £1.8 billion pot called the Sustainability and Transformation Fund (STF), part of £8bn allocated to the NHS in the Spending Review (2015), was promised to areas with the best plans. It should be noted however, that the vast bulk of the 2016/17 £1.8 billion STF – £1.6 billion – has been earmarked to fund the ‘sustainability’ side of STPs i.e. to cancel out NHS provider debts.

The STP policy requires collaboration between local organisations to reach consensus about changes to services under conditions of unprecedented financial constraint. However, the organisations involved continue to be regulated as individual organisations. STP areas have no legal powers and decisions can only be made in accordance with the delegations allowed to the chief executives involved in the STP process. Each STP area must designate a leader; most are from Foundation Trusts, NHS Trusts (both types of provider organisations) or Clinical Commissioning Groups (CCGs, commissioners of healthcare) with only 6 leads coming from Local Government. These leaders, appointed by NHS England, are responsible for overseeing regional planning across the health and care system, including the reconciliation of different , often competing,  interests of organisations to meet the needs of the local population. The 44 STPs range in population coverage from 300,000 (North, West and East Cumbria) to 2.8m (Greater Manchester), with an average population of 1.2m.

According to NHS England (FAQs page) “the boundaries used for STPs will not cover all planning eventualities” but instead there will be layers of plans sitting above (with neighbouring STPs, for planning specialised commissioning or ambulance services) and below (with individual CCGs) for example. Guidance for STPs focusses on NHS services. However they will also need to consider better joint work with local authority services as a wider local health and care system, to join up with public health, social care and other local authority services. The King’s Fund (2016) suggests that one of the biggest challenges for STPs is that they are being developed in a setting established to encourage competition not collaboration between local organisations, as set out in the Health and Social Care Act 2012 (HSCA12).

Too many cuts, too little time

At the outset STP plans were intended to look at the areas of improving quality and developing new models of care, improving health and wellbeing, and improving efficiency of services. NHS service leaders have warned that the STPs (submitted in September 2016) are in many cases overambitious and will not work. Witnesses at an evidence session of the Parliamentary Health Committee on 11 October raised several concerns about how the STP process had been dominated by financial saving expectations, crowding out opportunities to focus on quality and service improvements (O’Dowd 2016).

On submission, plans were sent for central scrutiny, with NHS England requesting that they be kept confidential until national checks and comparisons could be undertaken. However, many STP areas, wanting to be more transparent with the public if the plans were to proceed quickly in 2017, soon published them (CIPFA 2016). CIPFA’s recent report (19/11/16) analysed 9 of the 44 STP submissions concluding that, although they contained proposals for closing financial gaps, some failed to set out a credible case for delivery. By the end of November 37 of the 44 STPs had been published.

Examples of cost saving measures being considered in plans include:

• The closure or downgrading of some Accident and Emergency (A&E) units and other services deemed to be clinically and / or financially unsustainable
• Reductions in the number of hospital beds
• Supporting the NHS ‘financial reset’, including reducing growth in staffing costs and
• consolidating back office functions
• Reducing estate costs and disposing of surplus land.

At a Communities and Local Government Committee hearing on Monday 28th November, Mark Lloyd, the Chief Executive of the Local Government Association, said “where they’ve not worked are where plans have been introduced in secret,”  “where communities have not been engaged”,  “where politicians are not at the table” and, in some areas, as a result of these factors, he predicts “plans may well meet opposition as they’ve been made public”. This can already be seen happening where, following local news reports earlier in November, a meeting of the Wirral ‘people overview and scrutiny committee’ (28/11/16, item 7) was reported to have ‘rejected’ the Cheshire and Merseyside STP (details of decision awaited).  In the same week Liverpool Health and Wellbeing Board speaking for themselves and the local authority gave a clear rejection of the same STP, until a full consultation is undertaken. Two Shropshire councils have refused to endorse the region’s draft STP, saying that it is insufficiently developed (National Health Executive 29/11/16) and Hammersmith & Fulham Council threatened legal action over proposals contained in the North West London STP. This is just a snapshot from around the country.

In demanding that STP plans should be developed in such a short timespan, NHS England has given areas very little time to organise themselves and formulate realistic plans, let alone consult sufficiently with many local organisations (e.g. local authorities and primary care), their own staff and / or patients / the public who will ultimately to be affected by the proposed changes.  It was claimed back in May (Local Government Lawyer) that local authorities have not been fully included in the planning process, and that “genuine community engagement was suffering while they tried to catch up”.  John Coutts (National Health Executive, 2016) summarises this well in suggesting that “the drive from the centre to get things done, the lack of non-executive challenge, cautiousness over sharing early thinking more widely across local partners or the public, the homogeneity of the group and the pressure of not to be the one standing out against an agreement, STPs represent an almost perfect storm for ‘group think’”.

‘Selling tough choices’: the challenge ahead

It will be interesting to see how STPs are received and potentially challenged through formal (e.g. council overview and scrutiny committees, judicial challenges etc) and / or by less formal (local media, public meetings, and campaign groups) routes. Whilst many would argue that the current way of providing health and care services is not sustainable, selling tough choices to elected councillors, patients and the public as well as campaign groups was never going to be easy. A lack of time to develop plans and little transparency in the process has potentially conspired to make this task much more contentious and difficult.

So, practically what might help?

• Allowing organisations responsible for putting together such complicated plans, which require buy-in locally from other organisations, patients and the public for them to work, more time.
• Local (health) services command significant loyalty amongst local populations. Without adequate engagement and transparent decision making processes, local buy in for controversial decisions will be difficult to obtain, and plans are likely to be rejected.
• Consultation must be seen as real and meaningful. Local people will be rightly suspicious of consultations which appear to be ‘box-ticking’ or those where plans appear to be a fait accompli. There are many existing forums which could usefully be involved, such as Health and Wellbeing Boards, Local Authority Overview and Scrutiny Committees, Local Healthwatch etc.
• Individual organisations continue to be monitored and regulated separately, with targets to meet and budgets to balance. An STP, which has no statutory basis, is almost always going to be treated as less important by those making decisions. However, there is currently no appetite for more changes to legislation – this may need to be reconsidered as the process continues, as Jeremy Hunt has recently hinted.
• For those making policy at the national and local level, understanding the complicated interlinked issues of power, politics, history and representation will be key.