Sustainability and transformation plans for the NHS in England: radical or wishful thinking?
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1043 (Published 01 March 2017) Cite this as: BMJ 2017;356:j1043
- Kieran Walshe, professor of health policy and management
- Kieran.Walshe{at}manchester.ac.uk
Planning is back in fashion in the NHS. Over the past 15 months, NHS England has overseen the production of sustainability and transformation plans (STPs) for health and care services in 44 geographical areas or “footprints” covering the whole country.1 They have been produced by local NHS organisations, with varying levels of involvement from local authorities, senior clinicians, professional associations, patient groups, and the public. The King’s Fund think tank has described how they have been produced2 and analysed the content of all 44 STPs.3
We have had almost three decades of health reforms in the English NHS emphasising competition and markets, patient choice, provider autonomy, and the like.4 A journey that started in the early 1990s with Kenneth Clarke’s introduction of NHS trusts, GP fundholding, and the internal market concluded with Andrew Lansley’s abolition of strategic health authorities, primary care trusts, and much of the organisational infrastructure of the NHS, just leaving clinical commissioning groups, NHS and foundation trusts, and a few national NHS bodies to run the NHS between them.5
Five year forward view
All that has changed since NHS England and other national NHS bodies published their Five Year Forward View in 2014, articulating a vision for reforming health and social care services and meeting ambitious savings targets set by government.6 Competition and autonomy are out of favour—integration, collaboration, and planning are now the order of the day. STPs are meant to be the key to how the NHS will transform the way health and care services are organised, delivered, and used and to make them financially, clinically, and socially sustainable in the longer term. It is, as they say, a “big ask.” So how do the 44 STPs measure up?
There are some eminently sensible common themes across the STPs. They set out proposals for improving prevention and early intervention; strengthening and integrating primary and community care services; integrating NHS provided health services with social care services funded by local authorities; reconfiguring acute care and diagnostic and specialist services; and rationalising supporting “back office” functions, such as IT systems, estates, human resources, and training. There is a welcome focus on changing services—rather than organisational structures—and on dealing with multimorbidity, chronicity, and frailty. STPs aim to keep people well and help them to care for themselves and use health and care services more appropriately.
The main problems
The direction of travel is right, but that is not the whole story. There are four main problems with STPs, which if not resolved make it unlikely that these plans will work.
Firstly, they are being launched at a time of unprecedented levels of financial constraint and challenge in the NHS.7 The changes that STPs envisage require considerable investment, and any resulting savings from rationalisations, reconfigurations, and better managed demand for health and care services are both hypothetical and some way in the future.
Secondly, the plans have been written in a rush, and professional and public consultation and engagement have been largely neglected. The mantra “nothing about us, without us” has been ignored. As a result, the response from the medical profession, the public, and the media has defaulted to suspicion and opposition, mostly focused on hospital cuts and closures.
Thirdly, these plans have no statutory force or authority—they are simply agreements among sets of NHS organisations and some other stakeholders. Lansley abolished the organisations—strategic health authorities—that might have carried these changes through, and his Health and Social Care Act 2012 contains a host of provisions on competition and market access that make these changes open to legal challenge and difficult to implement.
Fourthly, these plans are founded on the sound idea that we should bring health and social care services together—but social care services are funded separately by local authorities, whose funding has been cut by 37% in real terms over the past six years,8 and social care services are means tested whereas healthcare is not. There are many institutional barriers to integrating health and social care, but funding is the most problematic.
Government action required
Fixing these problems and giving STPs a real chance to succeed requires action from government—to provide realistic transitional funding for the changes; to give political backing to the changes and allow for proper consultation at a national and a local level; to enact legislation to remove the competition and market access provisions of the Health and Social Care Act and to allow for statutory bodies to be created to lead STPs; and to tackle the health and social care divide by implementing the recommendations of the Barker commission9 for a single system of funding to commission health and social care.
The NHS and its leaders have done what they can to map out a sustainable future health and social care system for England. But without a much greater commitment from government, it seems unlikely that these plans will work.
Footnotes
Competing interests: The author has read and understood BMJ policy on declaration of interests and has no relevant interests to declare.
Provenance and peer review: Commissioned, not externally peer reviewed.