In a previous article I said one of the problems facing sustainability and transformation partnerships has been bureaucracy imposed by NHS England.
The recent imposition of accountable care systems as the only way forward for STPs presents fresh concerns around the involvement of the local authority and respect for its role. Prescribing ACSs as a gradual approach questions the relevance of STPs, which are taking up so much time and energy, to immediate service crises.
When STPs were introduced in March 2016, NHSE was asking (a verb more in the spirit of partnership) health and care systems to come together to produce an inclusive, “truly place-based plan”. In the Five Year Forward View Next Steps, 12 months later, local authorities were seen as an optional partner. ACSs were to be much more about how local NHS bodies work together in service delivery, governance and in their contractual relationships with NHSE.
If the role of local authorities was assumed to be something to be determined locally, it was accompanied by a marked silence from NHSE on the matter of accountability. If we are talking about an accountable health and social care system, NHSE needs to answer a fundamental question: to whom is an ACS accountable?
The Next Steps document says “ACSs will be an ‘evolved’ version of an STP that is working as a locally integrated health system”. The subtext also ignores accountability apart from the obligatory link with NHSE and NHS Improvement. Quite why “evolved” was put in quotation marks, if care systems and health systems are used interchangeably or to draw distinction, or if the whole thing suffered from sloppy drafting, are moot points. In any case, the wider accountability question remains open.
Accountability is not a technical issue; it matters to citizens and their elected representatives. If politicians, in their community role and whose organisations have front-line responsibilities, feel distanced from any service planning process and not engaged in discussions about emerging models of local accountability, STPs and ASCs are courting a serious risk of failure.
As a footnote, existing ACS models in the USA and the southern hemisphere are certainly interesting but not relevant to democratic accountabilities here since they have different governance structures and forms of service provision.
Eight places have been identified by NHSE to develop ACSs. A lot of resources have been spent on producing draft memoranda of understanding and in trying to find ways of separating local authorities from NHS bodies in terms of status and responsibilities, whilst openly recognising any new accountability cannot override existing NHS trust and clinical commissioning group board accountabilities; a condition laid down by NHSE. It would be churlish to criticise the work that has been going on given its complexities, but equally it is fair to suggest the need to draft MoUs to bring NHS bodies closer together is an admission of the failings of the 2013 reforms. The NHS getting its act together is the prime requirement for change in the local system.
Whether any of these eight places can get to grips with local authority accountability and the role of elected members within an ACS remains to be seen. It could take some time (or run into sand), during which local criticisms of proposed closures of front-line establishments and reduced spending on specialist services will surely grow, even before the next iteration of STPs goes to public consultation.
Yet the health and care system all the while remains broken and its inability to cope with demand becomes ever more apparent. STPs and ACSs will not be the answer to NHS pressures this winter. Their evolutionary journey surely allows time to pause and to check if NHSE wants to develop something that is genuinely about social care as much as health care; to ensure STPs are not a distraction to existing joint working; to test if there is a depth to STPs that goes beyond channelling more resources into A&E; to address accountability rather than swerve around it; and to create space for a wider and better informed conversation in order to avoid the pointless exercise of STPs going to expensive consultation with little or no chance of support.
A pause would also have the added benefit of focusing more on the short-term pressures not just on A&E, but in mental health and in other areas, where heavy performance management disappointingly appears to be the standard response from NHSE and NHSI. This is affecting social care authorities and rightly there is resistance to the imposition of unattainable targets. Again, there has to be a greater and shared understanding of what is happening on the ground. STPs and ACSs will be of no value if the system is broken beyond repair by the time they arrive.
John Sinnott, chief executive, Leicestershire CC