Sustainability and transformation bodies – whether they be plans, partnerships (STPs), integrated care systems (ICSs) or accountable care systems (ACSs) – have not been a universal success story.
NHS England’s first name change – from sustainability plan to partnership – presumably came about when the plans demanded of local systems exposed massive financial gaps, undermining any pretence of sustainability. Small wonder that local authority partners questioned the credibility of the process.
It is also reasonable to assume that the five-year growth in the NHS budget confirmed by the chancellor will be nowhere near enough to close financial gaps identified in 2016 for a service whose demand continues to grow.
Yet NHS England and NHS Improvement are embarking on a new planning process in part to achieve financial balance, not just for the five years from 2019-20 but for 2018-19 as well. In their centralised world that is unsurprising, irrespective of outcome, but local government is entitled to ask what this means for a social care and public health authority as a partner in the local system.
The NHS bodies’ letter to clinical commissioning groups (CCGs) and trusts, stipulating a new planning process, but silent on social care, said: “During the first half of 2019-20 we will expect all [STPs] and [ICSs] to develop and agree their strategic plan for improving quality, achieving sustainable balance and delivering the (NHS) Long Term Plan.”
When STPs were launched, there was little doubt NHS England was reaching out to local government. Talk was openly of health and care systems, and broadly welcomed. Then a prescribed process strained relations, causing questions as to whether NHS England lacked understanding of local government or respect. Those questions have not gone away.
In the NHS bodies’ letter, partnerships are told to produce system plans but, in contradiction, those plans are said to be for “your local NHS system”. There is a sense that the local authority is just one stakeholder and the NHS is being told to focus on itself in response to its additional funding.
Social care, not yet covered by any long-term government planning, has literally disappeared off the page. Those in local government contemplating social care moving into the NHS may want to take note.
It is timely to take stock of STPs. In terms of meetings in the calendar and initials in the lexicon, they seem to be with us permanently, but without any performance appraisal.
NHS England and NHS Improvement should be asked what they see as the status of local government if they do not see STPs as a partnership of equals.
Likewise, do they believe STPs can be partnerships embracing health and social care if they are increasingly driven by NHS planning requirements? And is there more than token NHS recognition of social care’s funding problems?
While most aspects of STP governance and accountability have been managed locally, it has not always been easy. It is somewhere between awkward and impossible for a partnership to have an executive body which can take binding decisions when a local authority has its own accountabilities and the NHS commissioner-provider split still exists.
I have not met anyone in local government who does not agree with the policy objective of health and care integration. There are many of us who continue to believe that there is something in the STP concept with which to persevere, if only to stop all the money going into the acute sector.
But confusion and lack of clarity about roles, expensive meetings with little product, and the parking of complexities of governance at a time of growing public and political opposition to STPs – portrayed as a means of cutting services – suggest a timeout is needed.
The NHS bodies’ letter about the new NHS planning process can be a case study of the uncertainty around the exact purpose of STPs.
If that letter is written as intended, it raises a basic question on how a local authority as a member of the partnership could sign up to a new strategic plan for the local NHS when it is not responsible or accountable, when the intention appears to separate social care, when it is before any scrutiny, and when there is every reason to believe that the aim of financial balance is unrealistic.
Similar questions were, of course, around two years ago. Hopefully this time NHS bodies will think about the answers if they want to keep local government on board.
John Sinnott, chief executive, Leicestershire CC