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Are STPs the NHS’s greatest gamble?


By Angela Sharda
28 April 2017

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Are sustainability and transformation plans (STPs) the NHS’s biggest gamble? Angela Sharda, deputy editor of Healthcare Leader, gathered four healthcare experts to debate the question.

Delegates

Michael Wilson CBE MW
Chief Executive, Surrey & Sussex Healthcare Trust, STP lead

Dr Joe McGilligan JMcG
Former chair, NHS East Surrey CCG

Are sustainability and transformation plans (STPs) the NHS’s biggest gamble? Angela Sharda, deputy editor of Healthcare Leader, gathered four healthcare experts to debate the question.

Delegates

Michael Wilson CBE MW
Chief Executive, Surrey & Sussex Healthcare Trust, STP lead

Dr Joe McGilligan JMcG
Former chair, NHS East Surrey CCG

Dr Derek Greatorex DG
Clinical chair, NHS South Devon and Torbay CCG

Rob Webster RW
STP lead, West Yorkshire & Harrogate

Angela Sharda AS
Deputy editor, Healthcare Leader

As:  What are the biggest challenges for STPs and how do you think they will be overcome in the next 12 months?

DG: My worry is that this is a very difficult path to take. I think it’s also an eggs-in-one-basket solution, which I don’t think has ever worked in the NHS. They are trying to deliver something that involves significant cultural change and public consultation and I worry that they will make decisions that are not bought into by those at the coalface.

Also I think there is a tension between strategic planning at STP footprint level and local level. They are trying to deliver a one-size-fits-all solution rather than allowing local solutions that meet the objectives in their own ways.

RW: As an STP lead, I’d put it differently. The purpose of the STP is to deliver the best outcomes and the Five-Year Forward View. I think we mustn’t forget it’s a plan that’s owned by local leaders, it’s not somebody else’s plan, so I think that focus on purpose is essential.

The second challenge is a leadership challenge. This is about a network of leaders agreeing how to work together to deliver the best outcomes, which might
not be in the best interests of their own organisations, but serve the bigger interests of the place they operate in.

We must also keep local government on side, because this is place-based work.

Finally, there’s a gigantic wave of pressure to focus simply on survival and A&E waiting times, when that isn’t the job we’re here to do.

MW: I’m also an STP lead. I agree, but I see the problems at a more practical level. One challenge is the money. We have to work within the financial envelope but at the end of the day it is a choice made by Parliament.

The biggest issue I see now – and it’s overlooked at local and national levels –is workforce. We are making a massive assumption that we can transfer huge volumes of activity out of hospital, patients we’ve not dealt with before in community settings. I don’t think we’ve got enough skilled workforce to do some of those things.

In my part of the world, we’ve just done a big piece of analysis that looks at the huge volumes of acute beds being emptied. We’ve got no idea whether we have the people to look after some of these folks in different settings or, indeed, in their own home. And no idea whether it’s going to be any cheaper.

RW: That’s a brilliant point about the workforce. The front-line teams delivering care are the most important thing, alongside the patients. We must not lose sight of that. I think the idea of shifting care is wrong because most care is already delivered in communities. But we don’t intervene at the right time.

The majority of people aged 65 are isolated and lonely. A significant chunk have had their social care support stopped and so they become sick. Then we either give them enhanced social care and NHS support through their GP or district nurse or they get so sick they end up in hospital. So the vast majority of care and contact is already in the community, it’s just disconnected from what happens in hospitals. What we need to do is continue to develop services available in communities with targeted interventions in care homes and specific populations so people stay well for longer.

DG: I agree with what you said about delivery. I’ve had to admit someone to hospital who didn’t need or want to go, but there were no other services. So I’m very passionate about that because I’ve been put in that position. In our area, we’ve gone a long way to redesign services and keep people at home or get them home quicker, but it’s taken us three years to actually introduce those services. And I’m worried that because of the financial pressures, we’re being asked to do that work at a pace that is not deliverable.

As: Do you think STPs were the best option for improving healthcare or do you think there could have been a different solution?

RW: I think a place-based plan that involves all partners is the right thing to do. It doesn’t help that there won’t be legislative changes to give people different powers and there’s a regulatory regime of individual organisations. If we could sort some of those things out that would be nice, but we won’t be soon. So I think we’ll end up with the approach that we’re taking.

To have local leaders working together in a different way is counter-cultural. We’ve got a system that’s grown up on competition and direction from the centre. I think people imagine the STP as a thing like a strategic health authority that has got staff and a headquarters, but it isn’t – it’s a group of chief executives trying to deliver care differently. I think that’s got to be addressed.

In West Yorkshire and Harrogate, we published a compendium of all the engagement we’ve done since 2012. Our plans came from health and wellbeing boards, plus some extra. We’re not starting from scratch and we haven’t finished either.

So the engagement process, although we’re on the back foot with it, will continue for years.
JMcG: In 1973, we tried to introduce care in the community and have been struggling with this problem ever since. I’m a former chair of a health and wellbeing board and of a clinical commissioning group (CCG). If you ask anyone else who is not involved, STPs are just another change like practice- based commissioning, then we had primary care trusts. This is just another iteration of what the NHS always does.

We should be focusing on education, employment, housing and local services, but if you invest in one service, you’ve got to take from another because there’s only one public pound, and unless you spend it properly everyone just fights over it.

That’s why this cultural change has to happen. The vanguards and different models of care are great but they don’t count the costs of how they deliver it. Then, when the money runs out, we go back to the culture as usual.

RW: I think the point about the public pound is really important. I can only speak for my STP, but we all now understand as never before what the financial realities are for every organisation across West Yorkshire and Harrogate.

We understand what we’re going to do with the £4.5bn we spend every year and what the consequences are for different bits of the system.

The plan sets out an expectation that we will maintain capacity in the acute sector by investing about 1% a year of our money in it. We need to invest in mental health and community services disproportionately – 3 or 4% – to allow hospitals to operate at 1%. The cultural elements there will take time.

We need to invest in profound leadership to drive the cultural change.

But I think we could all say we’ve tried this or that before, we need to make sure we’ve got a place-based approach that builds on the work being done by health and wellbeing boards, CCGs and others, and drives improvements while managing the risks of new models of care. We must only take evidence-based decisions.

As: Do you think any further consultation should have taken place?

RW: We need to have plans that patients and partners can buy into. Our plan was published alongside a compendium of all the consultation from the last four years, with the STP priorities.

I think the key thing that causes a lot of worry is that the narrative around STPs has become about closing hospitals. That’s not what we’re planning to do, but media headlines often scream about secret plans to cut beds. And there was a massive mis-step when NHS England apparently tried to stop people publishing the draft plans, which only made everyone worry further and think we weren’t consulting or engaging properly. We have to make that better.

As: In your local STPs, what do you think is missing?

MW: I think the plans will keep developing as we all get better at this. The thing to remember is that this has never been done on this scale. We keep coming back to the workforce challenges, particularly the community services, primary care and mental health. Unless we can address those and find ways of funding them, we won’t be able to make the move from hospital into community settings.

We talk a lot about pathway management, but there are very few places in the country that are good at it. We need to learn what the really good places are doing and adapt those models. Also, it’s about education, how we work with the deaneries and primary care, how we incentivise GPs. I don’t talk to many young GPs who want to spend the next 25 years in a consulting room on their own. We’ve got to incentivise primary care, otherwise I don’t believe we’ll get people wanting to be GPs any more.

RW: This focus on local is incredibly important. We tell people we want to
think of the STP as West Yorkshire and Harrogate and it’s in charge at that level. But Calderdale is different from Wakefield in terms of geography and population, so keeping it local is really important. I don’t think we should move the primary care point either, and there are fantastic developments in primary care and general practice happening in this country.

If you look at something like the Primary Care Home model, which is gathering pace, it is an extended version of general practice with access to social, mental and physical healthcare across a bigger population and focuses on people’s lives and outcomes. It’s great. If you look at some of the vanguards, they’re doing similar work. So that focus on primary care and a positive narrative about changing services and supporting staff is essential.
JMcG Three years ago, I raised the possibility of having a local health police, and I was shouted down by people in the audience and the panel. I think the only way you can get the funding to all health and social care is to locally determine who pays for it, because all we ever do is argue that we didn’t get enough money. We pass the debt around the system but I think the STPs with the right leadership will get that cultural change.

There is only one public pound and you can only spend it once, but the public have to decide how much they want to pay into that care system.

RW: Unfortunately, there’s an inverse relationship between the ability to raise the money and the need. But I think the Government has crossed a line in terms of allowing councils to have a tax for social care purposes.

Behind all that, there’s a bigger question that again comes back to STP leadership. I think somebody said at the beginning that there have been political choices about how much money is going into the NHS. And that’s not my choice, that’s the choice of the chancellor and the prime minister. You get there’. We need good motivators and non-demoralised staff to do this. The vast majority of people working in the NHS want to help people, they don’t want to be hands off.

Somehow we’ve got to create a cross- organisational culture, which means that people facilitate patients moving through the system, not put up blocks.

RW: We need a way of mapping what’s going on. We’ve got a set of services that make sense in isolation but when added up are duplicative and very inefficient.

Part of the issue has been that there’s been no incentive to make sure there is consistency of those services, especially community services, which have grown in response to particular issues and aren’t designed to be joined up and consistent. So if you’re a hospital that engages with multiple CCGs, you have multiple ways of doing things and that can’t help but drive inefficiency.

As: Are STPs the NHS’s biggest gamble and what do you think will get us out of the NHS crisis?

RW: You can’t get away from the financial issue. We are struggling to deliver with a budget that is shrinking, so some very difficult choices are being made, and I think honesty is important, both on a political level and in the NHS.

In the end, it comes down to relationships. I think the place-based plan is for local government and the
NHS to make sure health inequalities and care variation are addressed, that we live within our financial means. The STP leadership must be given time to mature and deliver change. We need to give people the authority and freedom to do the right thing.

JMcG: For me, it’s exactly that – relationships – but also responsibility. For me, everyone’s responsible in their own different way and that goes back to that public pound.

Eventually you stop fighting over it and make the right decisions based on what’s best for the patients rather than the organisation you’re serving.

We all have to live with the consequences and one thing we can do with STPs is be really clear about what is possible rather than pretending we can do everything.
 

If we stand together as a group of leaders I think we can come up with more credible plans than if we pretend we’re going to be able to deliver everything that’s ever asked of us.

As: What’s your political perspective? Do you think STPs were thought out thoroughly enough by the Government?

RW: The Government will constantly refer to the Five-Year Forward View and say it’s given the NHS the money it’s asked for, and the STPs are the vehicle for delivering it. Central government believes it has the right to hold us to account for this. I think that’s highly questionable because funding was cut, social care funding didn’t keep pace with what’s required.

So I don’t think the Government has given the health and care system what it asked for. Also, it’s obviously dealing with Brexit, which has taken a lot of time. What we have to deal with is how it’s turned out in local politics, and to make sure the NHS doesn’t get blamed for having to make tough choices.
JmcG There’s a book written by Jeremy Hunt, Michael Gove and Douglas Carswell in 2005 called Direct Democracy: An Agenda For A New Model Party. The authors say their ambition is to denationalise the NHS. And if you starve something of funds, eventually it’s going to degrade and then we all blame each other for why it’s fallen over.

At the moment, the Government hasn’t accepted that the NHS is a socialist ideology trying to be delivered by capitalist business models.

Unfortunately, the people who designed the NHS in 1948 haven’t been able to find a funding formula for it, especially the NHS that people will need in the next 20 years. By making an STP, you’re engaged with the councils who are very good at outsourcing work to public providers, and people move with their feet to private providers.

And what’s the long-term view of this? Very much that the ideology is wrong.

As: In the budget £325m was dedicated to stps, spread nationally. Is this enough money?
RW That’s the capital, isn’t it? The capital requirements for two of the acute organisations in my STP are greater than that figure.

JMcG: I think we’ve never looked at what the offer is and that’s why every area does a different thing.

We need to get joined-up thinking between health and social care and the wider community, things like education, housing, and employment, and look at all the ways we can improve the health and wellbeing of the country.

RW: I’ve got a slightly more positive view about the recent focus on health as well as illness, and quality as well as capacity. But that doesn’t get away from the fact that we’re pathologically programmed to think of the NHS as about the buildings and it’s not – we spend most of our resources on our staff. That’s what the NHS is; it’s not the buildings.

MW: I think we’ve got to a situation where for a patient going through the system, it’s hands off all the way along – ‘That’s not my problem, that’s somebody else’s’. This is very disjointed and frustrating for the patient.

We need to change that attitude so that NHS people say to patients ‘okay, I can’t necessarily deliver what you need but this is where you get it and I’ll make sure you get there’. We need good motivators and non-demoralised staff to do this. The vast majority of people working in the NHS want to help people, they don’t want to be hands off.

Somehow we’ve got to create a cross- organisational culture, which means that people facilitate patients moving through the system, not put up blocks.

RW: We need a way of mapping what’s going on. We’ve got a set of services that make sense in isolation but when added up are duplicative and very inefficient.

Part of the issue has been that there’s been no incentive to make sure there is consistency of those services, especially community services, which have grown in response to particular issues and aren’t designed to be joined up and consistent. So if you’re a hospital that engages with multiple CCGs, you have multiple ways of doing things and that can’t help but drive inefficiency.

As: Are stps the NHS’s biggest gamble and what do you think will get us out of the NHS crisis?

RW: You can’t get away from the financial issue. We are struggling to deliver with a budget that is shrinking, so some very difficult choices are being made, and I think honesty is important, both on a political level and in the NHS.

In the end, it comes down to relationships. I think the place-based plan is for local government and the
NHS to make sure health inequalities and care variation are addressed, that we live within our financial means. The STP leadership must be given time to mature and deliver change. We need to give people the authority and freedom to do the right thing.

JMcG: For me, it’s exactly that – relationships – but also responsibility. For me, everyone’s responsible in their own different way and that goes back to that public pound. Eventually you stop fighting over it and make the right decisions based on what’s best for the patients rather than the organisation you’re serving.

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