Whatever the challenges, a return to silos is not a viable option
More from: Analysis: What next for STPs?
As John Sinnott makes eloquently clear, those seeking to integrate health and social care wouldn’t want to start from STPs. Which is a pity, as if we wind back 18 months, everyone agreed the theory was good.
The practice, though, has been sticky enough to make STPs, like the Lansley reforms, something to be worked around. Or should local government simply throw in the towel?
The difficult birth of STPs has often included inadequate involvement of local government and other partners, problems with consultation, and a suspicion that – although established as bottom-up assessments of local requirements – they are driven by central demands for savings incompatible with continuing the same level of service delivery.
Indeed, analysis indicates that health reconfiguration was an important factor in the election result, with twice the swing to Labour in marginal seats with A&E rationalisations proposed than in those without.
My fear is a replacement agenda would be NHS focused and presume the NHS tak
Yet, though unpopular, these are the right conversations to be having. How do we reach long-term financial sustainability in the context of integrated, place-based services? And it’s a big leap from acknowledging the problems to concluding that councils would be better off not playing the game. That would require two subsidiary conclusions: first, that nothing can be done to make the existing process work properly; and, second, that there is an alternative which stands a better chance.
I believe local government should continue to collaborate as actively as possible, accepting that, while STPs may not deliver their aims in full, the process can be used positively – as is demonstrated in some areas. The focus in all areas should be on three or four major initiatives which can only be tackled effectively through joint working, and which will make a difference to the whole system.
Changing care pathways, shifting from acute to community, identifying the right capital investments, and tackling whole system workforce shortages are the kind of actions on which to focus. Local government can also take some comfort from plans to develop accountable care systems, which should in time help reduce the complexity and wrangles caused by the internal market.
Collectively, local government could press for changes which will improve the chances of success. All NHS inspection should be carried out at the level of the STP footprint, not at the organisational level. The Treasury should release the shackles it places on NHS capital investment, and indeed on the preventative revenue investment which represents the only long-term hope of reaching a financially sustainable position.
So what is the alternative? Presumably, a return to silo working in which councils concentrate on making social care, housing and leisure improve the health of their local community. Strategic collaboration would be limited to what is compelled by the better care fund – which, of course, has not proved plain sailing, as witnessed by disputes about what proportion of funds should to go towards ‘protecting social care’. Moreover, the BCF is a partial picture, dealing mainly with projects at the margin rather than a fundamental review of how services are set up.
Fundamental review is needed, and – like it or not – STPs are where it has to start from. It’s too early to conclude that they have failed. Local authorities should do everything they can, singly and collectively, to use STPs to move the agenda forward.
My fear is that a replacement agenda down the line would be one more internally focussed on NHS issues which presumes the NHS takes over social care. For the first time, and for all the faults, councils have been invited into the health tent to shape healthcare as much as social care. Surely, that’s a prize that makes it worthwhile sticking with the difficult journey.
Rob Whiteman, chair, North East London STP, and chief executive, Chartered Institute of Public Finance & Accountancy
Rob Whiteman: It's too early to say STPs have failed