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Much hope surrounded the announcement of sustainability and transformation plans in late 2015, particularly the news that for the first time councils were to have an official role in shaping health services in their area. Five years into austerity many in local government felt reforming health was essential to a sustainable future for public services in their patch and were eager to get involved.
Writing for LGC, Leicestershire CC chief executive John Sinnott describes how NHS England chief executive Simon Stevens met with local NHS and council leads during those early days with a “welcome message that STPs were about identifying your two or three shared integration priorities”. However, in many places much of that early hope has faded, swallowed up in the “NHS pathway of process”, as Mr Sinnott describes it.
The first sign that STPs might not quite live up to their promise came in March 2016 with the announcement of the 44 footprints. The lines on the map drawn by NHS England took little account of local government boundaries, and were organised instead around clinical commissioning groups and patient flows, leaving a number of councils members of more than one STP.
As one chief suggested to LGC recently you can change patient flow, indeed reconfiguration of services may involve exactly that, more easily than you can alter local government boundaries. Another told LGC this week that their STP “fundamentally fails the test of place”.
Even where the boundaries do make sense, the sheer number of organisations involved, up to 40 partners in at least one case but regularly more than 20, make even organising a meeting a challenge. Achieving a productive outcome with so many partners around the table is also difficult, not least as each organisation is dealing with its own financial pressures and regulatory demands that complicate attempts at collaboration.
Add to this a widely shared concern about the lack of formal governance arrangements for STPs that can accommodate the differing accountability arrangements of local government and the health service and it is easy to see why, as LGC’s analysis finds this week, some council chiefs are extremely frustrated.
Yet despite these many challenges in some places things are working well and progress is being made, as Nottinghamshire STP lead and director of adult social care David Pearson attests this week. The STP ratings published by NHS England last month show a distinct correlation between those judged to have advanced leadership and those rated among the top half for progress. This suggests in some cases strong local relationships and ambitions can transcend the mire of NHS process.
However, where those relationships do not exist, even within the NHS, it is questionable to what extent council chiefs can be expected to overcome NHS turf wars, historic bad blood and regulatory interference. As Norfolk CC chief executive and outgoing STP lead Wendy Thomson notes, the fact the acute hospital trusts in the Norfolk and Waveney STP are not in competition with each other and do not face closure has made things easier.
The North East London STP has a history of intractable problems and a hospital trust that has been subject to regulatory intervention for years. Nevertheless, its independent chair Rob Whiteman, president of the Chartered Institute of Public Finance & Accountancy, believes despite the many issues with the STP process local government must continue to engage with them from “inside the tent”. He warns that there is no other game in town and that without local government involvement the health service’s journey to sustainability would become even more NHS focused and the presumption would be that the “NHS takes over social care”.
Fundamentally, the problem with STPs seems to be one of expectation. While local government had hoped STPs were a sign the NHS was adopting a place-based approach to public services, in much of the health service there is little understanding of what that entails. There is a long way to go before STP can hope to stand for sustainably transformed place, but local government involvement is essential if that is ever to be a reality.