The 44 Sustainability and Transformation Plans (STPs) currently being developed across the country have the potential to make fundamental changes in the shape and nature of health and care services. However, the speed of the process to shape these plans has meant that they have so far not been very visible. Final versions are due in September but it is likely that further work to refine them will be required and there will then follow a dauntingly large implementation task.
We have been looking at some of the STPs and talking to those involved in leading them, including a workshop with leaders from 14 STPs held with the Healthcare Financial Management Association (HFMA). Here, we look at some of the ideas that emerged from this workshop about what STPs are doing and the process of developing plans. In a follow up blog, I will also explore some of the issues that are emerging about implementation.
At present most plans do not manage to meet the financial targets set by NHS England, except, as one STP lead put it, ‘on paper’. There are a lot of unanswered questions about the underpinning assumptions about the source and timing of savings. Providers will still be required to deliver historically high levels of efficiency improvements which are some way above what has been achieved in the past and some of the methods of doing this are no longer available.
In some cases the care of a large number of patients will be shifted into community settings to make room for growing demand; in others up to 20 per cent of beds may be closed. It is also likely that there will be changes in the number of A&E departments. For many of the sites we met in our workshop, it is workforce pressures that are forcing change, and this reflects a more general need across the NHS to rethink staffing models and workforce planning. There is a very mixed view of Health Education England’s role, however there is a common opinion that it is not providing the right level of support, thought leadership or imagination to meet this challenge.
The role of community hospitals is also being questioned. Some may close completely but more commonly some will have beds closed and their use will change to providing ambulatory care.
Mental health inpatient sites may also be rationalised. There is also a focus on reducing the large number of out-of-area placements.
There will be a need to get a grip on specialist services and make some decisions locally about the number and role of providers – particularly those seeing smaller numbers of patients. STP areas will be working with NHS England to work through a number of complex issues here.
Primary care and community services are important parts of plans but the community components of these perhaps need more development. Big changes in the models of general practice are also being planned but a more urgent approach to the crisis in general practice is needed. However, as our research shows, the evidence that scaled up models can deliver extended services is limited. There is no easy way to accelerate this.
Accountable Care Organisation (ACO) type models – which bring together a number of providers to provide integrated care for a defined population – are a key part of STP thinking, but the time these take to develop is an issue. These are part of wider strategies for demand management in both urgent and planned care. The principal driver for this is to ensure patients get to the right place first time to reduce duplication and prevent deterioration. There is a lot of interest in increasing standardisation across and within providers, rethinking outpatient models and looking at the thresholds for referring and treating patients.
Prevention receives a lot of attention although there is concern in some areas about the level of disinvestment from public health by local authorities. Making the case for a return on investment is proving difficult but there are a lot of ideas building on previous work with a strong focus on obesity, exercise, alcohol and early years.
The overall view is that an impressive amount of work has been done in a very short time. Filling in the detail beneath this will be the next step.
There are no magic bullets and while there may be opportunities to undertake more radical redesign of some services, most of the work is a detailed slog across a wide range of different activities. Some of the ideas being proposed are best described as 'plausible hypotheses' and there are some areas where the level of optimism about what can be achieved and the scale of effect is dubious. For example, many STP leads we spoke to thought that hospital reconfiguration did not save very much and could actually increase costs, while others have put down significant savings. Similarly the assumption that integrated care, ACOs and demand management can deliver savings is simply not supported by the evidence; and more caution is needed about both scale and timing than some plans allow for.
More focus on how changes will be managed and in particular on engaging those who will be leading the change locally – and the patients, public and staff who will be affected by it – seems to be the most significant priority. We will be exploring these issues in more depth in a follow up blog.
Edwards N (2016) ‘How are Sustainability and Transformation Plans coming together?’. Nuffield Trust comment, 19 August 2016 https://www.nuffieldtrust.org.uk/news-item/how-are-sustainability-and-transformation-plans-coming-together