Sustainability and Transformation Partnerships (“STPs”) are, in principle, an excellent idea. They bring commissioners and providers together to plan for the future of the NHS in a local area. They are designed to bang heads together, force NHS and local authority leaders to look at the footprint of services across their area and to recognise what is going well and what should change. They make NHS and local authority leaders ask the difficult questions about resources, the staff they are able to recruit and retain and to inquire how technology can be engaged more effectively across organisations to deliver better, more joined up services from a limited budget.
To date at least, STPs have largely been in a planning phase but they are now moving to the delivery phase. Some are finding that roadblocks along the way make delivery of logical, well thought out solutions nigh on impossible. So what are the problems?
First, STPs have no legal status. They cannot be set up as joint committees of CCGs because they sensibly include providers and local authorities. In law, they are advisory talking shops which make suggestions which feed back to Boards of the CCGs and providers which are free to ignore their suggestions. That also means that a CCG which takes decisions on the basis that it feels mandated to do so by a STP decision may well be acting unlawfully. The power of decision making lies with the Boards of the commissioners and providers, not with the STP. The government was planning to legislate this autumn to change that, but all that changed on June 9th. The STPs will just have to muddle along with the present legal structures. There are increasing signs that local CCGs, local authorities and NHS Trusts have woken up to the fact that they are not bound by STP decisions, but are looking at STP plans with a critical eye, and are refusing to adopt those that do not serve their sectional interests.
Secondly, STPs have been decision makers who have not engaged beyond their own members. STPs have often met in secret, have not engaged with the public and are viewed with hostility by those who are not around the table at the STP meeting. This hostility includes the press which sees STPs as an establishment cabal drawing up secret plans to close down much loved NHS services without any public involvement. As with all caricatures, there is an element of truth in the complaints, albeit they are often wide of the mark. But, perception can be as important as reality. Decision makers who fail to be open to the media and the public about change management plans are rarely successful in the long run.
Thirdly, STPs can be characterised as “forums of technocrats” with no politicians present to apply a “political reality check” to proposals. Both the NHS and community care services are decisions made by public bodies who are accountable to the public via those who are elected to serve as councillors and MPs. The NHS generally only makes real savings by closing buildings. The economists tell us that demand for health services is “elastic”, meaning that a supply of a service will often create a demand for that service, especially when the patients do not pay on a per service basis. Hence NHS service reconfigurations which does not lead to the closure of buildings simply means that one set of clinicians are replaced with another, often at an even higher cost. Hence without building closures, money needed to develop the community services to replace those delivered in a hospital is spent on delivering other hospital based services. So, as a rule of thumb, buildings have to close, not merely change function to makes a change process work.
But closing hospitals is massively unpopular and so cannot be delivered without political support. That would be possible in a stable political environment but any elements of political stability were swept away at 10pm on June 9th when the shock exit poll told us we were in for a rocky road ahead. A government without a majority operates in a holding pattern, and cannot deliver unpopular change. So every local MP can demand that the STP plan for an A & E to scale down to a minor injuries unit or to close a consultant-led maternity unit should not happen. When the backbenchers or even council leaders demand a stop to plans to wreck the local NHS (as they see it), the Secretary of State will have little choice but to send the message down the line.
Fourthly, managing change properly is expensive and there is insufficient capital to pay for the structural changes and insufficient revenue for the double running needed to deliver change successfully.
So even where STPs have drawn up sensible plans for a sustainable NHS and social care services, they have formidable challenges in being able to deliver them. I remain a broad supporter of the STP concept, with all its limitations, but these challenges give rise to endless legal possibilities for those who want to oppose reconfiguration plans. NHS bodies will thus continue to need legal advice as one of the professional services needed to turn plans into real changes on the ground.