Whatever happened to the STPs?

UNISON update on Sustainability and Transformation Plans and Partnerships in the east of England

This report by John Lister was commissioned by UNISON to give members and representatives a realistic analysis of the situation in each STP area and to be able to offer a positive but informed response to genuine proposals for partnership and collaboration to improve services.

There are six STPs in the region, covering Bedfordshire, Luton & Milton Keynes, Cambridgeshire & Peterborough, Hertfordshire & West Essex, Mid & South Essex, Norfolk & Waveney and Suffolk & NE Essex.

Sustainability and Transformation Plans emerged from the aftermath of the Chancellor’s Autumn Statement in 2015 that had underlined the tightening financial squeeze on the NHS.

NHS England faced a tough task in delivering the projected £22 billion of cost savings to enable the NHS to balance its books by 2020/21. Just before Christmas 2015 NHS England sent out a directive to every NHS provider and commissioning body setting out proposals for a rapid, substantial change in the way the NHS was to work.

Less than three years after the complete reorganisation of the NHS as a result of the Health & Social Care Act, it called for a fresh reorganisation. The NHS had been carved up by the Act into smaller geographical areas defined by 207 Clinical Commissioning Groups: NHS England now called for the creation of a more strategic ‘place-based’ system.

Clinical Commissioning Groups (CCGs) were supposed to collaborate not only with local government, but also with local NHS providers, who in turn were expected to collaborate rather than compete with their fellow providers. This fresh change had to be done to a very swift and demanding timetable.

The result of this process was NHS endorsement in March 2016 of proposals dividing England into 44 “footprints”, each of which began the process of creating a local leadership team and drawing up Sustainability and Transformation Plans (STPs).

As the plans were published in late 2016 It was clear that many were still a work in progress rather than a finished plan. Few published the detailed financial appendices, workforce plans and implementation plans that would be required to make any assessment of how realistic and viable the proposals might be. Many developed their own distinctive jargon and their own interpretation of the “new models of care.”

The secrecy and obscure language have contributed to public ignorance over STPs, while the documents themselves appear incomplete and unconvincing. However this does not mean that the plans themselves are unimportant. If NHS England had got its way, they would have potentially represented a landmark moment in the development of the NHS in England.

This brief survey of what has transpired since in the six STPs in our region shows that many of the hopes for what STPs might represent and achieve have proved unrealistic. Few have progressed to any extent down the path of genuine collaboration and local partnership. Much of the “integration” that has taken place has in fact been alliances and mergers of commissioners on the one hand and providers on the other – leaving the NHS “purchaser/ provider split” substantially intact.

Most of the proposals depend on availability of capital (in desperately short supply), increased revenue funding (while STPs seek cash savings) and of course adequate numbers of suitably qualified staff (while vacancy rates have continued to increase, and with them spending on agency and bank staff to fill the gaps created).

But another crucial weakness has been exposed – the limited engagement with local government. Three of the four council participants in the Bedfordshire, Luton and Milton Keynes (BLMK) STP have warned they will pull out of their limited engagement with the process unless there was more serious attention paid to the issues facing councils and a more realistic timetable for implementing changes. The BLMK STP was supposed to be in the vanguard of developing “Integrated Care Systems”. If NHS leaders have got things so wrong in this area, how far adrift have the others gone in the implementation of the STP project?

Finally it is worth drawing attention to the near-universal deficits facing acute hospital trusts across the six STPs. While some of the CCGs have built up substantial surpluses they show no inclination to move towards any genuine integration or sharing of resources and decision-making. The limited increase in planned NHS funding through to 2024 will provide some relief. However almost all observers agree  this will not rectify the problems caused by eight years of virtually frozen real terms funding for NHS, nor will it provide the necessary capital and revenue investment required to implement ambitious STP plans.

UNISON wants to see an NHS that is properly funded, staffed and equipped to meet the growing needs of a growing population: but we are also determined to ensure that in the process our members are treated with proper respect and given the right resources, training and support to deliver safe and high quality care to their patients.

Read or download the full report, including an analysis of each of the six plans Whatever happened to the STPs?