In March 2016 NHS England organised the geographical division of England into 44 Sustainability and transformation plan areas (or footprints) with populations between 300,000 and 3 million, which would implement the Five Year Forward View. These areas were locally agreed between NHS Trusts, local authorities and Clinical Commissioning Groups. A leader was appointed for each area, who is to be responsible for the implementation of the plans which are to be agreed by the component organisations. They will be "working across organisational boundaries to help build a consensus for transformation and the practical steps to deliver it".
Contents
Areas
This geographical configuration differs in some respects from previous arrangements - Regional Hospital Boards, Regional Health Authorities and Strategic Health Authorities - because the configurations have been locally agreed, rather than imposed from the centre. They also vary very considerably in size, the largest having more than ten times greater population than the smallest.
Staffing
Three of the leaders are from local government: Sir Howard Bernstein, the chief executive of Manchester City Council, David Pearson the director of adult social care at Nottingham City Council, and Mark Rogers, the chief executive of Birmingham City Council and president of the Society of Local Authority Chief Executives and Senior Managers. The remainder are NHS managers.
Finance
The NHS planning guidance for 2016-17 states: “For many years now, the NHS has emphasised an organisational separation and autonomy that doesn’t make sense to staff or the patients and communities they serve… System leadership is needed.” It also suggests that the financial problems of individual organisations are no longer critical. What is important is the financial situation of the organisations in each area considered together. Each area is required to produce a Sustainability and Transformation Plan by end of June 2016.
In February 2017 the National Audit Office produced a report suggesting that plans to save millions of pounds ‘may be optimistic’, that there was poor oversight of the various initiatives and that progress with integration plans had been slower and less successful than planned. £5.3 billion spent through the Better Care Fund in 2015/16 had not delivered value for money. Furthermore there was ‘no compelling evidence’ to suggest that integration would lead to financial savings or less use of acute hospitals.
Development
Simon Stevens described the progress made in December 2016, saying that the most advanced areas were "capable of combining the purchaser and provider, the commissioning and provider function, a la Frimley Health”. In some cases he expected a "governance partnership of the relevant statutory bodies" which in some cases might become integrated organisations. But in some areas there were only proposals, not yet progressed into plans. He proposed to give the most advanced money and authority to progress their plans. NHS England would organise national support programmes, particularly for “primary care provider development”, support urgent and emergency care systems, rather than to individual organisations, and set up clinical standardisation and productivity initiatives under professors Timothy Briggs and Tim Evans.
Accountability
Steven Broomhead, the chief executive of Warrington Borough Council, complained to NHS England in July 2016 that decisions were being made "without any local transparency". He said changes to where people receive services and what services they receive needed "local scrutiny and local community involvement".
Reaction to proposals
According to Dr Brian Fisher, "STPs are driven by the Treasury. They are focused on reducing NHS spend. (...) Unless STPs meet the funding demands of the Treasury, the plans will not be approved and areas will not receive any transformation money." An article by the King's Fund states, "Allocations from the fund for sustainability and transformation must be agreed in advance with HM Treasury and DH’." The same article states that the spending review, "is both ring-fenced and needs HM Treasury agreement to unlock."
The Nuffield Trust think tank claims many suggestions would fail to implement government financial targets and involve a "dauntingly large implementation task". Sally Gainsbury of the Nuffield Trust said many current plans involve shifting or closing services... "Our research finds that, in a lot of these kinds of reconfigurations, you don't save very much money - all that happens is the patient has to go to the next hospital down the road. They're more inconvenienced... but it rarely saves the money that's needed." There will be a shift from inpatient to outpatient care but critics fear cuts that could put lives at risk, that the plans dismantle the health service rather than protecting it, further that untested plans put less mobile, vulnerable people at risk. By contrast, NHS England claims that the plans bring joined-up care closer to home. John Lister of Keep Our NHS Public said there are too many assumptions, and managers desperate to cut deficits were resorting to untried plans. A survey of ninety-nine clinical commissioning group chairs and accountable officers conducted by the Health Service Journal in October 2016 found very little confidence that the plans would deliver.
An article in The Guardian suggests possible substantial benefits from the plans. The system as a whole lacks money and an ageing English population has growing complex requirements. Health and social services need to be coordinated, STP's got people working enthusiastically together. The article suggests NHS England 'made up the policy on the hoof' and managers were under pressure to produce plans fast. NHS England gave fragmented guidance, coming in bursts with frequently insufficient time for responding to requests. There are fears secrecy within the NHS is hindering effective public discussion and without public discussion there is a risk of later delays, protests, judicial reviews. The Guardian argues that full-time leaders are needed who will not put the interests of their own department before the needs of the whole and will send money where it is needed. Another Guardian article questions whether the plan might be to prepare for greater privatisation after 2020. Transferring services from hospitals to the community will only work if there is spare capacity in the community and GP's are already overstretched. There are too few NHS staff generally to enable the reorganisation.
Critics are concerned that the plan will involve cuts but supporters insist some services will be cut while others will be enhanced. Senior Liberal Democrat MP Norman Lamb accepted that the review made sense in principle but stated: "It would be scandalous if the government simply hoped to use these plans as an excuse to cut services and starve the NHS of the funding it desperately needs. While it is important that the NHS becomes more efficient and sustainable for future generations, redesign of care models will only get us so far – and no experts believe the Conservative doctrine that an extra £8bn funding by 2020 will be anywhere near enough."
Plans were generally kept secret until December 2016. 43 out of 44 were published by December 2016. Oxfordshire, Buckinghamshire and Berkshire was, at that stage, still in dispute. One local manager described keeping plans confidential as 'ludicrous' and another said the 'wrong judgement call' had been made. Another person spoke about being in meetings where, 'real people' like patients and the public were not involved. The King's Fund reported the public and patients were mostly absent from plans potentially involving large scale service closing. Chris Ham of the King's Fund described suggesting out-of-hospital services and GP's could take over work now done by hospitals as a “heroic assumption” since both are under too much pressure. Some councils that disagree with the secrecy have published plans on their websites. Funds that should have gone to easing transition of services after closures instead went to plugging other NHS deficits.
Sir Bruce Keogh defended the process in December 2016 saying "I think in a number of areas, {services} will look very different. But what we have to be really careful about is that they serve the needs of patients and the local community. People are always up for change, but they fear loss, and I think that those who are proposing the change have a duty to explain to the local communities why those changes offer an improvement."
Legal considerations
STPs are not statutory organisations so any changes resulting from the plans most be implemented by their component bodies, and those bodies may be required to conduct public or staff consultations, or, in the case of foundation trusts, ballot their governors. Local authorities have the power to call decisions in for scrutiny. The Health and Social Care Act 2012 provisions may also require approval of proposals from the Competition and Markets Authority.