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'Unaccountable' and 'fraught': Chiefs tackle the STP question

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Council chief executives have expressed major concerns about the lack of accountability of the NHS’s sustainability and transformation partnerships and their inability to bring about the level of change required to stave off financial collapse.

The concerns emerged in an LGC roundtable, held in association with Civica, about the STPs, which were conceived in the spirit of local collaboration  inspired by the NHS’s landmark Five Year Forward View document.

Chairing the roundtable, LGC editor Nick Golding described the partnerships, and their forerunner sustainability and transformation plans, as “that rare thing; the NHS not prescribing a central solution on the entire system – in theory”. 

But panellists revealed councils felt that between the publication of the forward view in October 2014 and the Next Steps document in March this year, the role of councils in shaping the reforms had been diminished and with it local cooperation had ebbed.

Given the government’s recent focus on delayed transfers of care targets and push towards accountable care systems (ACSs) as the right vehicles for integration, there is concern the aims of the STP project are narrowing. Panellists asked to what extent STPs represent an opportunity for effective reform of a system preoccupied with the impact of cuts at a time of growing demand. 

Panellists

Amanda Deeks, chief executive, South Gloucestershire Council

Nick Golding, editor, LGC – chair

Richard Humphries, senior fellow, social care, The King’s Fund

Mike Jackson, chief executive, North Somerset Council

Nick Page, chief executive, Solihull MBC

Eric Robinson, chief executive, Wirral MBC

Paul Sanders, clinical systems director, health and care, Civica

Paul Sheehan, chief executive, Walsall MBC

Darren Walklate, divisional director, solutions and service design, Civica

Margaret Willcox, president, Association of Directors of Adult Social Services

Structures and funding

Walsall MBC chief executive Paul Sheehan said the councils in the Black Country STP footprint had “profound reservations” about its plans because of the £530m cuts these would entail. 

He added: “We’re not entirely happy about the way [the STP process] was kicked off and the way it has been entirely NHS-led, so we’re trying to carve out the place-based commissioning role for ourselves.” 

His Solihull MBC counterpart Nick Page said the Birmingham and Solihull STP, of which his council is a participant, faced the additional challenge of the rapidly changing NHS landscape. 

“We moved from three clinical commissioning groups into one CCG. We’re also seeing the amalgamation of hospitals and acute settings,” he said.

Mr Page said Solihull MBC was trying to establish how it should conduct place-based commissioning in this changing environment. “It feels like we’re moving forward but it is very fragile indeed,” he said. 

“You can’t blame the STP process for problems that are just there anyway in the system. The lack of local democratic accountability around health decisions has always been there.”

Mike Jackson

Margaret Willcox, director of adult social care at Gloucestershire CC and president of the Association of Directors of Adult Social care, said money was also problem in the Gloucestershire STP. 

“Our acute trust has got a financial hole,” she said. “We feel we’re being punished because of that. We can’t progress at the pace we want to. Until the financial hole is filled, the NHS won’t allow us to.” 

Amanda Deeks, chief executive of South Gloucestershire Council, said the reform process concerning the Bristol, North Somerset and South Gloucestershire STP was “really difficult”. 

“We have an STP that has been categorised as one of the really poor ones; we have a massive financial hole right across the sector; we have also just a very late [proposal to merge some] CCGs, and all of those things coming together has made the whole thing particularly fraught,” she said. 

Ms Deeks added the plans did not “address the issues within the health community” and did not involve engagement of the councils at a strategic level. 

Another member of this STP is North Somerset Council. Its chief executive Mike Jackson agreed with the picture painted by Ms Deeks. However, he thought there were gains to be made from the process. Weston General, a small general hospital in his patch, had suffered from the “predatory view” of neighbouring acute trusts, but the STP had brought “a more sustainable future for Weston by linking it to the wider acute sector in the biggest geography”. 

More generally, Mr Jackson added: “You can’t blame the STP process for problems that are just there anyway in the system. The lack of local democratic  accountability around health decisions has always been there. The problems about discipline around budget management in acute trusts were always there.”

Wirral MBC chief executive Eric Robinson was sceptical that STPs could fix long-standing problems in health. He added reform was easier on a smaller scale and there had already been examples of this on the Wirral, but the geography of the Cheshire and Merseyside STP “made no sense to anybody involved”.

The interplay between the STP process and devolution was another source of tension, Mr Robinson said. “We had a devolution agreement in Liverpool City Region. Our leaders are wondering why it wasn’t a city region-wide STP,” he said.

Mr Robinson said local politicians did not feel involved in the process and he found the leadership structure of the local NHS difficult to navigate. “When we talk about it, it’s ‘who do we talk to?’ Do we have to talk to 10 people in the NHS?’ It seems too complicated because of a lack of system leadership in the NHS locally,” he said. 

Aims and ambitions

Paul Sanders, clinical systems director of health and care at Civica, believed the STP process was fundamentally about “trying to take a larger view of things and recognise the fact that  there does need to be merging” of NHS institutions. 

But Ms Deeks said the project should have a wider aim than this. She said the process “was supposed to be around transformation and, at its best, would have been right out there looking at technologies, skills, health, and trying to work out what sort of NHS you need”. 

However, Ms Deeks added: “It’s gradually got crunched down to be the vehicle dealing with cuts and with winter pressures. The minute you use it as a vehicle for organisational reform, you’re missing the opportunity.” 

Mr Page said failing to properly engage councils in STPs would mean blocking the savings available through influencing the “wider determinants of health”. 

“Getting people into a job and getting them into decent housing; that’s the biggest determinant of mental health and wellbeing,” he said. 

“I used to be frightened of Ofsted and the Department of Education. I thought that was tough but working with NHS England and NHS Improvement; that is just brutal.”

Nick Page

Richard Humphries, senior fellow for social care at the King’s Fund, said recent research the thinktank published on STPs in London reflected many of the sentiments expressed at the roundtable. While he said the King’s Fund strongly supported the STP approach as a “workaround to Andrew Lansley’s legacy”, he added several plans were unrealistic about savings. 

“In part that’s because the assumptions about how much care you’re going to shift away from hospital are absolutely heroic,” said Mr Humphries.

“In the last 15 years hospital admissions have risen by around 4% per year. There’s absolutely no sign of that abating. We are simply not going to shift that continuing relentless growth in demand that quickly.” 

Mr Humphries added there was “a profound schism” within the STP project because “the whole process has been driven by an NHS control total” which did not and could not “involve social care figures”, and yet was reliant on “an integral approach to … social care”. 

Nevertheless, Mr Humphries said there was “goodwill and collaborative spirit” on which to build. Focusing on structures, Mr Sheehan said more drastic reform than currently imagined might be on the cards. 

“There is a widespread recognition at local level that the future of CCGs is integration with local authorities,” he said. “Only something the size of a local authority and the commissioning budget of a CCG is going to shape the market.” 

Mr Page said he thought it likely that in his area the STP would result in “the big acute trust running the whole system”. 

“There would be an ACS [in which] there would be us, the big hospital, the mental health trust, a delegated CCG budget linked to our place, and potentially GPs centrally contracted to a big hospital,” said Mr Page. 

”I am optimistic because there is a lot that could be done and because it is such a burning platform, government will have to tackle this.”

Darren Walklate

Ms Deeks said “structures and money” were only part of the equation. The “missing agenda” was the broader one about reforming healthcare to focus on prevention and bring in technology. 

“If we look at things like genetics and DNA, there’s actually a way of being more effective,” said Ms Deeks. “If you modernise [care] and then deal with the wider determinants of health, you start to reshape what care looks like. I don’t think there is any of sense of starting to think about artificial intelligence and what that means in a new health and care system. One thing that troubles me is ending up potentially just spending a lot more on the same model and we all know that won’t work because it will just generate more demand.” 

Mr Robinson cast doubt on whether there was “the capacity in the NHS to think like that”. 

“Most people, I hope, within the NHS [understand] budgets and organisational change, [but] using new technology, doing things really differently, wider determinants of health? Sometimes you’re talking to the deaf,” he said. 

Accountability

Mr Jackson said NHS leaders struggled to take a broad view because of the targetdriven culture of the health service. 

“[Acute trust chief executives] have to spend all their time thinking about metrics that are watched by the [Department of Health] and will result in someone coming down like a ton of bricks on them if they go in the wrong direction,” he said. 

Mr Page agreed NHS culture often choked off innovation. “I used to be a director of children’s services and I used to be frightened of Ofsted and the Department of Education. I thought that was tough but working with NHS England and NHS Improvement; that is just brutal and it is top-down and fear-led. I’ve found the behaviours quite shocking at NHS England and NHS Improvement,” he said. 

Mr Sanders asked to whom health systems should be accountable. 

“Ideally they should be accountable to some sort of local governance model,” said Mr Humphries, but Mr Jackson said taking on local accountability of a system subject to the total power of the centre was a problem. 

“Whatever you’re doing locally together, you run the risk that literally the next day, because a target has not been hit, there will be a central diktat and … the centralised NHS system will just pull the rug out from under you,” he said. 

“Those with a mandate, who are elected, need to be able to say powerfully, ‘there is a solution, but you’ve got to change your behaviour for longer to let it work’.”

Paul Sheehan

Ms Willcox said some partnerships had worked out a better model of local ownership than others, but governance structures aside, she added another problem was that the NHS was “an entitlement service” whereas local government services “have an eligibility about them”. 

“You’ve got clinicians who are interested in what they are specialists in and want to do more of it, faster and better, and with fancier equipment and newer drugs,” she said. 

“The only way you’ll ever take money out of the NHS is to change that clinical behaviour and to learn how to say ‘no’ to people. 

“The NHS doesn’t seem to have ever learned how to say that it’s not going to do something. We say, ‘we’re not going to do this any more, we’re going to do something else instead, we can show you the evidence of why it works’,” she said. 

The way forward

Mr Sheehan said the only way to solve all of these problems was with “a national, cross-party consensus” and an acceptance “no single government can sort this”. 

“This is a 15-year project that requires all-party buyin,” he said. Mr Robinson agreed this was necessary, but questioned whether it could happen when NHS staff found it difficult to stand up to the DH. 

Mr Sheehan said local government must help here: “People who say that in the NHS will disappear. Those with a mandate, who are elected, need to be able to say powerfully: ‘There is a solution, but you’ve got to change your behaviour for longer to let it work’.” 

Mr Humphries said meaningful reform was possible but not without “transformation funding” to set up alternative provision while current services were still in operation. 

Ms Willcox was concerned about the impact of overuse of agency workers in the NHS and how STPs would not fix this. 

“There’s a direct exploitation of clinical skills in agencies, where people are being paid ransom amounts of money to do the day job because [the trust] can’t fill the day job because there is a whole group of people who have left the NHS,” said Ms Willcox.

“We had a situation last winter where we would have an emergency doctor coming in to A&E on a Saturday morning, and he’d be 10 minutes away from the hospital, and the company would ring and say, ‘Worcestershire is paying more; you need to increase your pay for him or he’s going to turn right around’. We need an open conversation that says: ‘That’s not how you spend the public purse’.” 

Darren Walklate, divisional director of solutions and service design at Civica, said he had seen examples of this problem being tackled. He said he had recently worked on a project with clinical coders, who sift through patients’ clinical records in order to convert the information into codes, which the NHS then uses to set resource management targets and claim reimbursement for treatments.

This project, said Mr Walklate, demonstrated three or four trusts working together could set up academies to recruit and train staff to “break the back” of dependency on agencies. 

However, Mr Walklate said solving problems like this was easier in a council where management had the “ability to get that political consensus to invest in a solution”, which the NHS lacked. 

Mr Golding asked panellists whether they thought ACSs were the “inevitable” fix. 

“I don’t think any of us really know what an ACS is,” said Mr Page. “I wouldn’t worry about whether it’s an ACS. It’s about what we can do locally at a significant scale, and health and wellbeing boards have that political representation.” 

Ms Deeks said ACSs could work but said the structure of central NHS bodies must change.

“There are seven national [NHS] organisations,” she said. “If you don’t find some way of localising all of those different branches into your STP or your ACS, how do you really fundamentally make the change?” 

Mr Golding asked if, overall, panellists were optimistic about STPs. 

Mr Humphries said the situation reminded him of neo-Marxist theorist Antonio Gramsci, who wrote of his “pessimism of the spirit and optimism of the will”.

“His immediate circumstances are dire but he has this great burning hope about what could be achieved,” Mr Humphries explained.

“What I find inspires hope in me is the amount of commitment in frontline staff. If we could somehow unleash that more fully, that is the future.”

Mr Sanders said there were reasons for optimism, not least that everyone involved in reforms seemed to acknowledge the same necessary ingredients: “A strategic view, cross-party buy-in, make sure the right behaviours are driven, and allow the people who know the answers to do their job.” 

Ms Deeks said the key to success for STPs lay with “the medical profession” realising “this isn’t a sustainable solution” but added councils could “do our bit”. 

“If you do something about regeneration and poverty, that would make the biggest difference to health and wellbeing and [would] help to play a part in reducing demand,” she said. 

Mr Walklate said the potential for technology to assist with health and care integration, from digital platforms for patients to single patient records, was significant.

“I am optimistic there is a lot that could be done and because it is such a burning platform government will have to tackle this,” said Mr Walklate. “The best thing local government can do is say: ‘We’ll help’.” 

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Civica logo 267 197

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