As part of the Five Year Forward View (5YFV), a wide-ranging strategy for the NHS in England, every health and care system in the country has been asked to create their own local place-based plan for the next five years. These are referred to as Sustainability and Transformation Plans (STP)s. These controversial plans are set to determine the future of England’s health service. Will it be the end for the NHS or the dawn of a new era?
STPs, in my view, are an aspiration. The British Medical Association (BMA) has found that £9.5 billion will be required to launch them. Following a series of Freedom of Information requests, the BMA discovered that NHS leaders are unlikely to have anything like the capital required to deliver the projects, with budgets under “significant pressure”. National staff are now sifting through the plans to work out which “small to medium scale” projects can be funded and implemented over the “next few years”. They are working with local areas to “review” and “refine” capital demands.
Essentially, STPs are driven by financial accountability, based on an unrealistic optimism about future savings. I’ve been visiting a lot of STPs and nobody I’ve spoken to is confident they can reduce the funding gap. NHS England seems to be in a hurry, running at least a five-year project in a year or two, with non-existent consultation with professionals and public.
It’s a marriage of two debts (health and social care) to deliver cuts and rationing, and opening doors for further privatisation of the NHS. To respond to a funding crisis by reorganisation is as at best foolhardy, at worst as grossly negligent.
The speed at which changes are being made will not allow any evaluation of their effects or, indeed, for them to be implemented properly. They will, however, provide a smokescreen to hide the rationing of healthcare and dismantling the NHS as we know it.
At most of the meetings I go to, I hear the CEOs starting their speech by talking of the integration of health and social care as the panacea to solve the crisis in the NHS. They emphasise the need to balance the books and to meet specific targets such as A&E access times. We need to move beyond the financial challenge to reach a point whereby the NHS gains from this experiment rather than loses everything dear to the health profession and the public.
The “top-down reorganisation” in the Health and Social Care Act presided over by Andrew Lansley was a health policy disaster and has led to endless workarounds to achieve progress. History is repeating itself. STPs are more fiction than reality. This is essentially a project by NHS England to supersede Lansley’s Act.
Why won’t STPs work? Because every small change has to be negotiated and agreed in detail with all stakeholders before it can get the green light. The clinical commissioning group (CCG), local authority and NHS foundation trust can veto any change. Any political interference can block change. Time after time, local managers are overruled by senior NHS staff to avoid political embarrassment.
And even if changes could be agreed locally, the funds and resources needed to deliver effective change is not available. So-called transformation money to fund STPs is spent plugging existing deficits. The iron rule of public service seems to have been lost: that you can spend the same money only once. NHS officials have come under intense pressure to produce plans that predict the undeliverable, and most have bowed to that pressure. The STP project is built on the least stable of foundations. These plans are fast becoming completely unworkable.
The NHS and local councils have formed partnerships in 44 “footprint areas covering all of England, to improve health and care. More than half of the STP footprint areas have told NHS England they would need more than £100 million of upfront funding to make changes – and a handful have quoted capital needs of more than £500 million, including Greater Manchester, Cambridgeshire and Peterborough and West Yorkshire.
It appears yet another reorganisation is inevitable – indeed CCGs are already being phased out. Changing health economies, integrated care organisations (ICOs) and the development of accountable care organisations (ACOs) are underway. My fear is this experiment, too, could end in tears. And in the process, universal healthcare, free at the point of delivery when you need it, will end.