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John Sinnott: NHS bureaucracy is killing all good in the STP concept

John Sinnott
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Questions about the future of sustainability and transformation partnerships have not been answered by the view that their local unpopularity and the new national politics will kill them off.

NHS England is pressing on with announcements about STP ratings and capital awards linked to them, but politics is so volatile that no-one really knows if the destiny for STPs is a grave, a shelf or somewhere more productive.

From a local government perspective it looks as if NHS England now regards STPs as being all about NHS bodies and financial control, with local authorities a sort of optional add on. The state of NHS finances may make that understandable but it is no reason for social care to be given a back seat when a whole system solution remains the answer.

The Five Year Forward View Next Steps document sets the current scene. Now NHS England and NHS Improvement instructions and requirements in the compulsory move to accountable care systems show how far removed STPs have become from the spirit of partnership working towards health and care integration. Everything is imposed from the NHS centre and, whilst a softening of the commissioner/provider split and moving away from the annual contracting round are welcome (something has to be done to encourage medium term NHS planning), it feels very different from the spirit when STPs were first promoted.

Spring 2016 saw a good idea phase. Simon Stevens was then meeting with local NHS and local authority leads with a welcome message that STPs were about identifying your two or three shared local integration priorities and producing a suitably challenging action plan. Unfortunately that was followed by the first bureaucratic phase alongside a me too phase. Out came the inevitable NHS England guidance, regional NHS England oversight and the arm’s length bodies all wanting their own input. The small number of local priorities soon grew.


Draft STPs appeared later in 2016 as the process entered a straining credibility phase. No drafts were to be published without NHS England sign off and therefore delay; some were published anyway; and local NHS organisations could not consult on the drafts, rather they were allowed to ‘engage’ with interested parties, not least apprehensive communities. Since acute closures were central to many STPs, it felt that the process was tripping over itself and that NHS England had created something it was struggling to control.

More recently there was a black hole phase, prompting questions from local politicians about STP whereabouts, and the second bureaucratic phase, with the next steps document containing the memorable requirement that each STP needs a “basic governance and implementation support chassis”. STP plans were somewhat disingenuously rebranded as STP partnerships but STPs (quickly reverting to ‘plans’) were to be redrafted according to NHS England and NHS Improvement guidance by late June. Whilst this work went on in some places, the guidance never materialised causing some to wonder if digging in the black hole might have stopped.

It seemed until a few weeks ago that we were in a call it what you like phase with Simon Stevens saying that what is being fashioned locally is more important than a set of initials: STPs, ACSs or ACOs (accountable care organisations). That did not last and we are now in the ACS only phase with the accompanying third bureaucratic phase, wrapped in STP rating. It is unlikely to be the last phase. All that was good about the original STP idea is in danger of being lost up a NHS pathway of process.

Perhaps no-one should be surprised because STPs have always begged the question of the extent to which the NHS centre and its regional outposts can let go. The learning from the eight ACS areas will be interesting not least around governance, where NHS England seems unwilling to address the conflicting responsibilities and accountabilities of its own trusts and boards, never mind local authorities.

What NHS England envisages for the remaining 36 areas in the short-term is arguably more important. With STPs being relaunched yet again and progress to date being rated there is a risk that focus on a single model may get in the way of ongoing integration in places where achievements are in spite of STPs. There is also a risk that the latest relaunch could mean a reappraisal of support and renewed critical comment. Local politicians and the public have largely remained silent because there has been nothing to comment on for six months.

There is no doubt STPs will remain contentious. Whatever their future, to many in local government they will be judged on whether they can show the NHS is able to integrate itself as a prerequisite to health and care integration, and that STPs are not just the latest NHS England performance management tool. The many pages of STP dashboard data now published unfortunately suggest that is exactly what they are.

John Sinnott, chief executive, Leicestershire CC

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