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Analysis: What next for STPs?

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Frustrations abound at the STP process, but they remain the best hope for reform

The announcement of ratings for the 44 sustainability and transformation partnerships earlier this month marked a new phase in their short but controversial history.

By publishing what it has stressed is a “baseline”, NHS England has effectively formally moved STPs from planning to delivery, with a performance framework they can be assessed against.

It is the first time NHS England has rated health economies rather than organisations. The greatest weight is given to financial health of the health service in the area, a judgement on “system-wide leadership” and three “prevention” indicators including delayed transfers of care and rates of emergency admissions.

Of the 12 other metrics that also contribute to the overall rating, all are NHS performance measures.

Writing for LGC, Leicestershire CC chief executive John Sinnott, whose STP received the second highest rating of ‘advanced’, warns that the NHS “pathway of process” is in danger of destroying all that was good about the STP concept. He is not alone in thinking this.

One chief executive in an area rated in the bottom half of STPs said: “At the core of the STP is the tension between whether it is an NHS governance process or a partnership endeavour.

The chief executive said her local footprint “fundamentally fails the test of place” and has not created “a sense of ownership” as it is not coterminous with local authority boundaries.

The STP footprints set out by NHS England in March 2016 have faced criticism from local government from the start, with many crossing local authority boundaries or involving close to 20 or more organisations. Seven councils are in more than one STP; Essex CC is in three and Surrey CC is in four.

The chief executive said that while the configuration of acute, mental health and ambulance services was necessary on the scale of STP footprints, integrated social care and community health systems are better created in smaller, localised areas.

However, she added that the scale of the governance required by the STP footprints, which is still reliant on informal agreement, could complicate this process.

“What’s needed is some kind of settlement – an agreement on what is going to be done and at what level,” she said. “When you have got different places [within the STP] all evolving at different speeds it is really difficult to get to a central configuration.”

One STP footprint which has successfully taken this approach is Lancashire and South Cumbria, which has split itself into five smaller systems. It has been rated as ‘advanced’ by NHS England both overall and for its system leadership.

However, footprints based on coterminous, local authority boundaries do not always offer a platform for quick success.

The Northamptonshire STP, which includes the county council and just four NHS organisations, has been given the lowest rating both overall and for its leadership.

Northamptonshire CC chief executive Paul Blantern says tight central NHS controls combined with political sensitivities around the necessary reconfiguration of acute services had hindered progress in the STP.

He added: “The problem is interference by health regulators. When you try to do anything locally, if it is not exactly what they want, they interfere enormously and there is a huge fear culture that exists among health providers so they are paralysed to act on a system level.”

Mr Blantern is scathing on the criteria used to set the ratings, claiming they offer little insight into efforts to create long-term sustainability, with delayed transfer rates used as a “whipping tool” on those deemed not to be addressing short-term NHS pressures.

Norfolk CC managing director Wendy Thomson was one of four local government figures to be selected to lead an STP but this week announced she was stepping down due to the commitment required.

She said the Norfolk and Waveney footprint, which has been rated as ‘advanced’, benefited from the fact that, while it was not “naturally united”, plans to establish collaborative system-wide working were already being developed before the STP process was launched. This enabled those involved to influence the geography of the footprint and maintain momentum behind the plans.

Ms Thomson added: “Our hospital configuration is also quite good in that we are not going to be closing a hospital and [the trusts] are not in huge rivalry with each other. There is no A&E closure, which is where it strikes at the heart of a lot of communities.”

She added that a meeting between STP leaders and NHS England chief executive Simon Stevens before the general election had left the impression that legislation would be put forward to formalise STP governance, but the lack of a “strong and stable” government meant that was now unlikely.

LGC asked NHS England to address the concerns raised by Mr Sinnott and others. In response they provided a comment from Nottinghamshire CC deputy chief executive and director of adult social care David Pearson, who leads the Nottinghamshire STP. 

He shares concern at the lack of governance arrangements that reflect the differing accountabilities of councils and the NHS. Writing for, Mr Pearson said it was right that many STPs had begun by addressing the “local quirks and complexities” of the NHS but urged councils to stay involved.

“It is crucial that we all take a seat at the table and seize the opportunity to lead conversations that should have been happening for years,” he said. “There is a major leadership role for councillors, given their democratic mandate and strong citizen focus.

STPs were initially promoted as providing freedom for bodies in local areas to integrate health and adult social care. While for many in local government the reality of the STP process has been very different, walking away from attempts to tackle the biggest challenge facing public services is not really an option.

stp table

stp table



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