Hugh Alderwick

Sustainability and transformation plans (STPs) have now been produced by NHS and (sometimes) local government leaders in 44 parts of England. The plans are important, setting out the proposed direction for health and care services over the next five years. But they been developed at significant speed and, for the most part, without the involvement of frontline staff or patients. They also propose major changes to services that will be unpopular with politicians.

For those in need of a primer: STPs were introduced in NHS planning guidance published in December last year. NHS organisations and their partners were asked to work together to make plans for the future of health and care services in their area. The plans needed to cover three broad themes: improving quality and developing new models of care; improving health and wellbeing; and improving efficiency of services. First drafts of the plans were produced in June and ‘final’ plans were submitted to NHS England in October. We have been carrying out research in four STP areas and will be publishing the first tranche of findings from this work in just over a week’s time.

The task of developing the plans has not been easy. Timescales have been tight. Expectations have shifted over time. And the challenges facing local services are significant and growing. National leaders in the NHS are under pressure from the Department of Health, Number 10 and HM Treasury to reduce NHS deficits, and this has been translated into pressure on local STP leaders to show how their plans will bring NHS services back into balance as quickly as possible. This pressure has grown as the process has gone on.

The plans have also been developed in an NHS environment that was not designed to support collaboration. The legacy of the Health and Social Care Act 2012 looms large over the STP process; in many ways, STPs represent an imperfect ‘workaround’ to the fragmented and complex organisational arrangements in the NHS created by the 2012 Act. But making this workaround actually work in practice is difficult when the previous rules of the game still apply – and are often toughly enforced. NHS providers, for instance, face strong incentives to improve their organisation’s own performance and only weak incentives to collaborate.

This has made the already difficult process of developing STPs even more challenging. And it’s important to recognise that the ability of local leaders to overcome these challenges is far from equal. Progress on the plans varies widely depending on local context – including the nature of relationships between senior leaders, the history of collaboration between organisations, and the size and complexity of the STP footprint. This means that some of the plans submitted in October are much less ‘final’ than others – and all will need further work and engagement before they can be implemented.

NHS England had hoped to check the 44 plans before making them public later in the year. But four STPs – two in London, one in Birmingham and one in the north east – have been published early by local authority leaders amid growing criticisms of the process and its lack of transparency. More areas are likely to follow suit.

These plans provide a taste of what will follow. They highlight the severity of the financial pressures facing NHS services. In north-central London, for instance, the combined NHS deficit ‘if nothing changes’ in how services are delivered is estimated to be £876 million by 2020/21. The gap in Birmingham’s plan is estimated to be £712 million, including a £130 million deficit in adult social care services.

They also demonstrate the major service changes being considered by NHS leaders. In south- west London, for instance, the plan proposes a cut in the number of acute hospitals from five to four or three. In the north east of England (in Durham, Darlington, Teesside, Hambleton, Richmondshire and Whitby), plans are being made to consolidate acute medical services and close accident and emergency (A&E) services at one of their major hospitals. In both cases, the changes are projected to save money and improve care quality.

The plans also include ambitions to prioritise prevention, strengthen primary and community services, and develop new models of care between the NHS and local government. We have argued elsewhere that doing this is the ultimate prize on offer for STPs.

But the risk is that these ambitions will be drowned out by bitter public debate about changes to acute hospital services, despite evidence suggesting that major acute reconfigurations rarely save money and sometimes also fail to improve quality. As a recent debate in the House of Commons showed, changes to hospital services are also likely to face opposition from politicians – particularly given next year’s local government elections and the lingering possibility of an early general election too.

So the STP process is at a precarious point. What will happen next? The reality is that the plans submitted last month represent the start of a longer-term process of improvement rather than the final word on how services will change. This process must continue, and the current plans need to be heavily ‘stress tested’ to ensure that the assumptions underpinning them are credible and the service changes they propose can be delivered. Realism is needed about what the plans are able to achieve within the levels of funding and timescales available. Honesty will be needed in communicating these messages to politicians and the public.

The most important priority for STP leaders in the short term is to strengthen involvement in the content of the plans – particularly among clinicians and other frontline staff, local authorities, patients and the public. Collaboration to improve services and manage limited resources is the right thing to do. But this collaboration must extend to those responsible for delivering those services, as well as the people who pay for and receive them. The next job will be to equip staff with the skills and resources needed to make these improvements happen in practice. The focus of the process so far has been on planning, but the real challenge lies in turning the plans into reality.

• Tracking the development of sustainability and transformation plans in England
• Upcoming event in London and Leeds: STPs from planning to implementation