When the wider media began to report that plans were afoot to radically reconfigure health and care services across the country many campaigners, commentators and politicians quickly cried foul.
But the role of local government in sustainability and transformation plans and the significance for the future of adult social care were often lost in the general noise generated by fears over NHS cost-cutting and impending threats to established hospital provision.
While some councils voiced concern over a lack of involvement and democratic accountability, four of the 44 national STP “footprints” had a local government voice firmly positioned at the centre of the process.
However, this has proved to be no guarantee of wider involvement of councillors or of sufficient attention to social care pressures.
Mark Rogers, Birmingham City Council chief executive and leader of the STP which also includes Solihull, has been vocal about the financial challenges facing STPs.
In a recent interview with LGC’s sister title HSJ, Mr Rogers accused national NHS leaders of applying pressure for STPs to focus on the financial gap in the health service rather than looking at the system as a whole, including social care.
Speaking to LGC for this article Mr Rogers said since he made the comments he had a “growing sense” from the top of the NHS that “we need to be all in this together”.
But he admitted those involved in the STP were still “staring at a cliff edge” over finances and without further funding for social care the process of implementing change was only “do-able” for the first two years.
Mr Rogers said: “There is now consensus on what needs to be achieved but we haven’t yet reached agreement on is the range of new models of care we want to see in our community settings.
“That is a function of the fact of the belated but welcome recognition that social care has to be part of this – we have come to that agenda late on.”
Nevertheless Mr Rogers said he believed having a local government lead in the process had been an advantage as it brought “the notion of place” into discussions.
“We were able to bring our experience as well as our responsibilities planning for communities rather than institutions,” he added.
However, he admitted challenges lay ahead to ensure all elected members and the communities they serve felt engaged in the process.
Mr Rogers said: “There is a high level of risk that many councils feel only lead members have been engaged.
“They are waking up and saying we need to own this like we would any other piece of local public policy and could put pressure on officers to press the pause button and delay much needed change.”
David Pearson, corporate director, adult social care, health and public protection at Nottinghamshire CC, is leading the STP process across the county and Nottingham City Council.
He said: “Clearly an issue is how far local politicians feel able to support changes to services that involve, for example, reducing hospital beds or provision in favour of increased primary, community and social care.
“[The process] will certainly help to have a rounded conversation and develop integration based on the principles and objectives of social care and local government, as well as the NHS.”
Mr Pearson said difficulties were created by the “size, scale and speed” of the task and finding the “space to build a better future” at a time when the organisations involved were dealing with immediate financial pressures.
Norfolk CC chief executive Wendy Thomson, who is leading the STP across the county and neighbouring Waveney DC in Suffolk, told LGC local government leadership offered vital skills and experience of problem-solving.
She added: “We have learned in local government to do what we have got to do and if we have to do it, it can be done.
“There is scope for changing the system – it is a big opportunity with a massive prize.”
But she admitted dealing with “very different cultures” had posed a significant challenge.
She said “There is a confluence of pressures on different [NHS] organisations, including targets and the separation between NHS England and NHS improvement.
“We can bring [NHS] organisations into community life more but inevitably with big organisations they get preoccupied with their language and discussing internal operations.”
Ms Thomson said that although the STP was still awaiting the results of its acute services review, opposition to the process in the community was already “live”.
She said: “Sometimes things need to be cut. Sustainability is not just about cutting costs, sometimes services need changing.”
She said in Norfolk and Waveney it was “not about the money but a multi-disciplinary primary care offer”.
Sir Howard Bernstein, chief executive of Manchester City Council and leader of the Greater Manchester STP, told LGC the process in the region was “very different to the journey others had been on”.
With devolution of the area’s £6bn health and social care budget agreed in early 2015 and a plan to integrate NHS services and social care with pooled funding and commissioning in place since last December, the STP began in what appeared to be ideal circumstances.
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Sir Howard told LGC he believed the STP process, as outlined in the NHS Five Year Forward View, “must have been influenced at some level” by the experience the NHS had gained in Greater Manchester. He said as a result of the work already done in Greater Manchester, producing the region’s STP was as much an “administrative enterprise as a leadership one”.
But he admitted the task of aligning health and social care had been “challenging”, with those involved in the process working “very closely” with NHS England and NHS Improvement to ensure “all the resources associated with the NHS are properly aligned in accordance with our transformation plan [for wider public services]”.
However, while Greater Manchester is widely viewed as better placed than most regions to deliver its STP, not least due its £450m transformation fund, earlier this month Sir Howard was a joint signatory of a letter to ministers and NHS England warning of the threat posed to local transformation plans by a £176m gap in adult social care funding by 2021.
With even Greater Manchester concerned about implementation the realisation of STPs looks far from certain. While some progress appears to have been made in council-led footprints towards tackling the clash of cultures which has hampered progress in some areas, the significant challenges of financial sustainability and securing popular backing for politically problematic reconfiguration remain.