Sustainability and Transformation Plans (STP) are at the heart of the Government's objective to drive greater efficiency and improvements in quality across the health system. Those STPs who are regarded as being of sufficient quality will qualify for access to the Sustainability and Transformation Fund to help them to deliver their plans.
The ability of those areas whose STPs do not pass this test to progress their own plans is highly questionable in the absence of this cash support. As a result, the significance to a health and social care economy of delivering a credible and compelling STP should not be underestimated.
The aim of this note is to summarise the key aspects of STPs and their timetable and to provide some more detailed guidance to Local Authorities as to the steps they should be taking.
The requirement for an STP first became apparent as part of the NHS Planning Guidance of December 2015 (the December 2015 Guidance). Although CCGs were still required to produce individual operational plans (something that they have been required to do since their inception), the December 2015 Guidance also required every health and care system to produce an STP. This was a document which would cover a five year period and demonstrate how local services would evolve, become sustainable and deliver the vision of the Five Year Forward View (5YFV).
At this stage, it is important to bear in mind that a key tenet of the 5YFV was to require stakeholders across health and social care to collaborate and develop more effective ways of delivering care. As such, engagement between the NHS and Local Government is a vital ingredient.
Subsequent to the 2015 Guidance, a "Dear Colleague" letter dated 16 February 2016 (the February 2016 Letter) was sent to CCGs, NHS Trusts and Foundation Trusts, Local Authorities and Local Educational Training Boards adjusting the timetable set out in the December 2015 Guidance and providing further guidance as to how STPs should be developed.
System-wide: The STP is aimed at establishing a plan for local health and care systems, as opposed to individual organisations. With this in mind, it is essential that the STP is prepared after taking into account the views not only of the relevant commissioners and providers, but also the local community. As the December 2015 Guidance states, the scope of the constituency is broad:
"Success also depends on having an open, engaging, and iterative process that harnesses the energies of clinicians, patients, carers, citizens, and local community partners including the independent and voluntary sectors, and local government through health and wellbeing boards"
Place-based: As a place-based plan, the December 2015 Guidance requires the STP to cover all areas of CCG and NHS England commissioned activity, including specialised services and primary care. It also points out that it should also cover better integration with local authority services, including prevention and social care.
Identifying the STP footprint: Perhaps one of the most challenging but fundamental requirements of the STP process is to identify the STP footprint, which the December 2015 Guidance refers to as "health systems". There was consultation on the potential footprints and they had to have been proposed by 29 January 2016. Click here for the 44 footprints have now been published and are available along with guidance and maps. Setting the boundaries for all of the STPs is a complex process, especially given the lack of coterminosity between the NHS and local government and also between commissioners and providers.
The December 2015 Guidance states:
"Transformation footprints should be locally defined, based on natural communities, existing working relationships, patient flows and take account of the scale needed to deliver the services, transformation and public health programmes required, and how it best fits with other footprints such as local digital roadmaps and learning disability units of planning….The footprints may well adapt over time"
The second paragraph of the February 2016 Letter acknowledges that border-setting can be an imprecise science and that additional work to deal with overlaps and geographical gaps may be required:
"The boundaries used for STPs will not cover all planning eventualities. As with the current arrangements for planning and delivery, there are layers of plans which sit above and below STPs, with shared links and dependencies."
The March letter states that the following factors were taken into account in deciding the footprints
- Geography (including patient flow, travels links and how people use services);
- Scale (the ability to generate solutions which will deliver sustainable, transformed health and care which is clinically and financially sound);
- Fit with footprints of existing change programmes and relationships;
- The financial sustainability of organisations in an area; and
- Leadership capacity and capability to support change.
Taking the footprints as currently settled, it is important to recognise within the STP where there are overlaps with neighbours, and where there is a need to cater for subdivisions of the footprint.
The three gaps: In requiring health systems to prepare STPs, the Government's objective, is to harness the efforts of all those involved in the commissioning and provision of health and care on a local basis in addressing its three man health-related goals of better health, transformed quality of care and sustainable finances. The main challenge is to show how the three principal gaps identified in the 5YFV will be closed:
- The health and wellbeing gap: This would identify the plans for a radical upgrade in prevention, patient activation choice and control and community engagement. In particular, this would cover preventable diseases, the reduction of demand for health services, obesity, diabetes, self-care and reducing health inequalities. The December 2015 Guidance expressly acknowledges the role that Local Government could play here.
- The care and quality gap: This would include plans to develop new models of care and how digital technology could be used to improve outcomes and efficiency. This is the heading under which plans to develop Vanguards and new models of care would be detailed.
- The finance and efficiency gap: This would include plans to restore the finances of the NHS across the footprint and to deliver efficiency.
Further detail of the questions asked about how the three gaps will be closed is set out in Appendix 1 of the December 2015 Guidance.
The NHS mandate: STPs also need to show how they will support the delivery of the NHS mandate (see Appendix 2 of the December 2015 Guidance) which the February 2016 Letter describes as "must dos".
The February 2016 Letter made it clear that the governance arrangements in an STP should identify a single leader who would be responsible for overseeing and coordinating the STP process for that area. It also suggested that this person be drawn from the senior role in either the NHS or local government. The list has now been published with very few local government names on it which is perhaps not a surprise given the NHS dominated approach to the whole process. Sir Howard Bernstein (Chief Executive, Manchester City Council) for Greater Manchester; David Pearson (Director, Adult Social Care and former President of ADASS), Nottinghamshire County Council and Mark Rogers (Chief Executive), for Birmingham and Solihull made it onto the list. Just because local authorities are not in the leadership role does not, however, mean that they are not actively involved in development and delivery of the plans. Inevitably due to the size of the footprints and the number and types of organisations involved local authority leaders were always likely to be in the minority.
In several commentaries, this has been viewed as an attack on organisational independence. Despite this requirement for a single, leadership role, the complexity of the requirement will still mean that it is essential that all stakeholders retain a voice and the ability to make a meaningful contribution to as well as to shape the STP for their health system. Decision making will in all probability need to be taken back to individual decision by the stakeholders, although it is unclear just who will be required to sign up. Evidently NHS Trusts and Foundation Trusts, but what of social care providers, or non statutory providers of NHS care including primary care?
The February 2016 letter acknowledges that building relationships and the collective leadership needed to make STPs real will take dedicated time, effort and resource. Different areas will be at different starting points. In some areas, local leaders are already working together on established transformation projects. In other areas, relationships and strategies are less mature, requiring intensive focus in the early stages.
The chosen leader needs to command the trust and confidence of the system, being responsible for convening and chairing system-wide meetings and facilitating open and honest conversations that will be necessary to secure sign-up to a shared vision and plan.
Simon Stevens, Chief Executive of NHS England, said: “Now is quite obviously the time to confront – not duck – the big local choices needed to improve health and care across England over the next five years, and STPs are a way of doing this. Their success will largely depend on the extent to which local leaders and communities now come together to tackle deep-seated and long-standing challenges that require shared cross-organisational action. The NHS nationally will be working closely to support them in doing that.”
The key dates for the timetable are set out below. The timings of other activity and other interim steps are identified in the February 2016 Letter.
Click here to view table.
The national bodies will also publish guidance and templates to support areas in submitting information about their governance and priorities by 15 April, in advance of final submissions by the end of June.
It is important to note that the February 2016 Letter also highlights the availability of assistance, provided on a national basis, to help with the delivery of STPs.
It is also the case that the timetable does not sit comfortably with the need for public and patient involvement and consultation on the proposals, nor indeed with the potential need for equalities impact assessments
Criteria for success
Both the December 2016 Guidance and the February 2016 Letter include helpful insight not only into what STPs are expected to contain, but also the basis from which they should draw their conclusions. It is clear that what is required is a document which is based on strong analysis and detailed insight into the issues faced within a health system. As such, great care will need to be taken to ensure that there has been a complete review taking all opinions into account, not only in relation to the underlying problems but also the solutions identified to address them.
"The best plans will have a clear and powerful vision across health, quality and finance, owned by all local partners in the system. They will create coherence across different elements, for example a prevention plan; self-care and patient empowerment; workforce; digital; new models of care; trusts in special measures and finance. They will systematically borrow good practice from other geographies and adopt national frameworks"
The criteria against which STPs will be considered are set out in both Guidance documents. It is important to note that the February 2016 Letter included, as an additional, criterion, the extent to which systems can already point to early, tangible progress. It seems that those who are already "walking the walk" will have a head start on others who are only "talking the talk".
There are disparaging references to "glossy brochures", and in a recent edition of the Health Service Journal, 9 March, 2016, Jim Mackey, Head of NHS Improvement, is described as having warned against building STPs around "trendy" new organisational reconfigurations and that he will "push back hard" against any STP which suggests the use of a new model to address sustainability. As such, real substance is a fundamental requirement.
As mentioned above, STPs which are regarded as being of sufficient quality will qualify for access to the Sustainability and Transformation Fund ("STF") to help them to deliver their plans.
In 2016/17, the STF stood at £2.139bn of which £1.8bn has been earmarked to bring the NHS provider sector back into financial balance. The STF will grow to £2.9bn in 2017/18, rising to £3.4bn in 2020/21, with an increasing share of the growing fund being deployed on transformation.
This is a significant incentive to submit a high quality STP.
A key desired outcome for the NHS is effective seven day services, under which there are three distinct challenges:
- reducing excess deaths by increasing the level of consultant cover and diagnostic services available in hospitals at weekends. During 16/17, a quarter of the country must be offering four of the ten standards, rising to half of the country by 2018 and complete coverage by 2020;
- improving access to out of hours care by achieving better integration and redesign of 111, minor injuries units, urgent care centres and GP out of hours services to enhance the patient offer and flows into hospital; and
- improving access to primary care at weekends and evenings where patients need it by increasing the capacity and resilience of primary care over the next few years.
Where relevant, local systems need to reflect this in their 2016/17 Operational Plans, and all areas will need to set out their ambitions for seven day services as part of their STPs.
Strong STPs will set out a broader platform for transforming local health and care services. However, as a minimum, the letter of 16 February suggests that all plans will:
- describe a local cross-partner prevention plan, with particular action on national priorities of obesity and diabetes and locally identified priorities to reduce demand and improve the health of local people;
- increase investment in the out-of-hospital sector, including considering how to deliver primary care at scale;
- set out local ambitions to deliver seven day services. In particular: (i) improving access and better integrating 111, minor injuries, urgent care and out-of-hours GP services; (ii) improving access to primary care at weekends and evenings; and (iii) implementing the four priority clinical standards for hospital services every day of the week;
- support the accelerated delivery of new care models in existing Vanguard sites; or in systems without Vanguards, set out plans for implementing new models of care with partners;
- set out collective action on quality improvement, particularly where services are rated inadequate or are in special measures;
- set out collective action on key national clinical priorities such as improving cancer outcomes; increasing investment in mental health services and parity of esteem for mental health patients; transforming learning disabilities services; and improving maternity services;
- ensuring these and other changes return local systems to financial balance, together with the increased investment that will come on-stream as set out in NHS England’s allocations to CCGs; and
- be underpinned by a strategic commitment to engagement at all levels, informed by the ‘six principles’.
The 2016/17 Operational Plan should be regarded as year one of the five year STP, and the NHS expects significant progress on transformation through the 2016/17 Operational Plan. Credible plans for 2016/17 will rely on a clear understanding of demand and capacity, alignment between commissioners and providers, and the skills to plan effectively.
The role of Local Government
Although, in many health systems there is effective cooperation between the NHS and local authorities, this does not appear to be happening in every case. Indeed, some local authorities have claimed that their views are not being sought and that the detailed knowledge of community needs held by Health and Wellbeing Boards is not being factored in to STPs as they are not being properly engaged.
Both the December 2015 Guidance and the February 2016 Letter are clear that Local Government involvement is not only a requirement but fundamental in developing a high quality STP. Local authority responsibilities around public health, promoting health and wellbeing and residential care and support cannot be ignored and in many ways offer keys to unlocking some of the problems faced by the NHS and delivering patient centred health and social care.
Perhaps one reason for the lack of local government involvement is that there does seem to be a lack of confidence on the part of the NHS in the ability of HWBs to deliver change. A recent survey of CCGs by the Health Service Journal illustrated a serious disconnect between the NHS and HWBs in terms of what is being asked of them and what they feel can be delivered. It is probably also true that local government is wary of the NHS England top down approach to planning exemplified in the Better Care fund schemes for 15/16.
However, local disagreements as to participation in this important process will only lead to a sub-optimal STP.
Key issues for Local Government
Local authorities need to fully engage with the process to get a slice of the action. Differences between organisations should be put to one side in order to effectively compete for the STF resources. Whilst resources are not significant in 2017/18 they grow significantly by 2021.
Lessons from Vanguards and the Better Care Fund should be shared. Local authorities should also focus on how they can support the aim of seven day working by helping to prevent people seeking emergency admissions and assisting them to be supported in the community as soon as possible following admission to hospital. There are key roles for local authorities in improving mental health and dementia services as well as care for those with learning disabilities.
Local authorities have a key role to play in shaping the future of health and social care in their areas and need to ensure that they have meaningful input to the STPs. This could happen in a number of ways through formal joint meetings of HWBs, involvement of political leaders, through to pooled teams of officers representing each footprint.
The size and outline of the footprints may in some cases match the geography of the Combined Authority areas – in others it may not. Whilst Greater Manchester and Cornwall are the two areas that have so far secured health devolution, interest elsewhere varies at present. Perhaps the STPs need to be flexible enough to fit with the devolution landscape as this changes and develops over time and potentially assumes more responsibility for health and social care.
There needs to be more trust and transparency developed around working together in the interests of place and the health and wellbeing of the local populations that span a number of local authority areas. As the Kings Fund notes:
"The involvement of local authority leaders is often helpful in the process as local government has considerable experience of working across organisational and service boundaries and has already proved to be beneficial in a number of the PACS Vanguards."
One of the main outcomes of the STP process should be the creation of a path towards better quality healthcare for populations.
However, given that not all STPs will reach the required standard and will fail to attract transformation funding as a result, it Is also clear that the process will result in a two-speed NHS where the health and care economies with supported STPs continue along a path to improved care while the stragglers follow a less certain road. This could have serious consequences for local populations.