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STPs: for better or worse?

7 March 2017

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I have just waded through the first iteration of STPs for my area. What struck me most is that I have seen them before. Even if all the assumptions about efficiencies come true, there is still a hole in health and social care budgets.

The issue is that social care is means tested and healthcare is free. For decades, we have had the problem of deciding which side a patient’s problem falls. Each tries to get the other to fund the care and the patient suffers as they get neither adequately. I have a patient who has been medically fit for discharge since October who languishes on an acute surgical ward waiting for a residential home placement. Someone has decided he cannot look after himself at home, yet the cost of his hospital care would cover a full time carer.

As more plans are published across the country it is clear that the issue is the lack of funding for health and social care. The business models are all wrong, with far too many extrapolations of pilot schemes or economic modelling. Jacqui Smith, chair of the University of Birmingham NHS Trust, has said of her STP: ‘despite unprecedented and good joint working between NHS providers, clinical commissioning groups (CCGs) and local authorities’, the plan is doomed to fail as it is based on ‘heroic assumptions’ that massive efficiency savings can be made.

In some places, there are plans to close hospital beds and merge hospitals into super-hospitals – with cries of ‘centralise, centralise’. In others we hear ‘localise, localise’. With every part of the system under pressure and funding limited, there will have to be casualties or explicit rationing.

The STP boards were supposed to be a way of getting the cultural change needed between all the organisations to work together for the sake of the public they serve. True to form, the NHS saw them as a call to re-organise, and an army of people are desperately digging around to get plans on pages. At the boards, everyone agrees what the problems are and what could be done and who has to make the sacrifices for the sake of the system. But secretly they say it won’t be their organisation that will take the hit – and so the battle for the public pound starts all over again.

If it is going to be as easy as the plans make out, we would have done it years ago. The cultural change has to come from the public using the system. It is not free and never has been. It has always been funded by the taxpayer. I had a patient say that no-one pays, not even the Government, and that it is free like magic. Politicians cannot continue asking for more for less from the system and promising nirvana.

Learning from history, we have had plans coming out of our ears but were never able to implement strategically or consistently across the country. Everyone is starting from a different place and says ‘it won’t work here’ when challenged with solutions. I always believed naïvely that the NHS was one organisation – until you ask it to work together, and you find it is a disparate conglomeration of competing organisations that jealously guard their piece of the pie.

Dr Joe McGilligan, Member of Council at the National Association of Primary Care, former chair at NHS East Surrey CCG