We are starting to see what England’s 44 new sustainability and transformation plans (STPs) might entail. Much of the process has been conducted behind closed doors, but some full versions of STPs have been released – the first being Birmingham and Solihull. We can begin to see how the STPs intend to keep the health service on an even financial keel through the very stormy years ahead, and how likely they are to work.
Their task, as forecast by NHS England, is to lay out plans to achieve £15 billion of the £22 billion in productivity savings needed across England by 2020-21.
It is getting harder to cut costs
Around half the savings are to come from the sort of standard programme of annual efficiency targets that the NHS has been used to. Squeezing down trusts’ costs by reducing the tariff of prices for services has worked in the past, up to a point. But as record deficits show, it has been getting harder. And even if we take an optimistic view, this still leaves another half of the gap – £7 billion or more – to be filled.
Most STPs have set out a long shopping list of measures to achieve this, with many aimed at reducing the use of hospitals and managing the rising tide of demand. One striking feature is their very wide scope, from work on prevention to care at the end of life, and their willingness to tackle the wider determinants of health outside the usual interest of the NHS.
Plans to reduce admissions to hospital, length of stay, emergency department attendances, and outpatient visits, generally by double-digit percentages, are common. There is a focus on patients in hospital who could be cared for in other settings, with ambitious targets for reducing numbers of these patients. Much hope is pinned on investment in primary care and community services, in particular the creation of various flavours of integrated care systems modelled on the accountable care organisation experiments in the United States or Spain’s Valencia region.
More radical plans
Some areas have more radical plans for the rationalisation of hospitals, the closure of beds in community hospitals, downgrades of emergency departments, and other controversial measures. South West London’s plan involves fully closing one of its five acute care sites. Often these changes are driven not by financial calculations but by workforce pressure and a view, not always very well evidenced, that centralisation improves outcomes.
Some ideas are appropriate and based on evidence. Others are on less certain ground. There is little detail to explain by what method some of the more ambitious changes in care will be achieved.
The sheer number of change programmes planned raises questions about whether enough resources or hours in the day exist to do them in the time available. Experience in developing accountable care indicates that success requires several years and a substantial investment that may initially return a loss. Some plans require major capital investment to facilitate new models of care or hospital rationalisation. The NHS capital budget has been repeatedly raided, by £1.2 billion this year, and these plans will struggle to be delivered. Again, the time and managerial effort required to invest well is also an issue.
A last factor is how quickly these plans have had to be put together. Involvement of clinicians, local politicians and others with a stake in local services is often lacking, creating a very significant risk. The tight and often optimistic timetables for change may hit trouble as local people object to proposals.
Looking across all of these uncertain factors, we do not yet have enough detail to know whether these plans can close the financial gap. But certainly some have levels of savings that look somewhat optimistic. There are reasons to be concerned, given the extent to which many of the plans are based on some bold and sometimes experimental assumptions, the time available for change, and the scale of the task.
The NHS will go into next year with no plan B and, in some cases, with plan A far from complete.
A version of this blog first appeared on the BMJ.
Edwards N (2016) 'What do we know about STPs so far?'. Nuffield Trust comment, 25 November 2016. https://www.nuffieldtrust.org.uk/news-item/what-do-we-know-about-stps-so-far