Photo: STP from Coba Flickr Photostream

A note on Sustainability and Transformation Plans in your brand new NHS

 Obfuscation is the obscuring of intended meaning in communication, making the message confusing, willfully ambiguous, or harder to understand. It may be intentional or unintentional (although the former is usually connoted) and may result from circumlocution (yielding wordiness) or from use of jargon or even argot (yielding economy of words but excluding outsiders from the communicative value).

Step right up, the obfuscatory tour is about to begin….

By the end of next month, June 2016, 44 ‘Local Health Economy Areas’ in England will have submitted their Sustainability and Transformation Plan (STP) ‘footprints’ for scrutiny by the six national NHS bodies. These national bodies are:

  1. NHS England
  2. NHS Improvement – comprised of amalgamation of what was previously Monitor (the NHS competition regulator), and the NHS Trust Development Agency
  3. Health Education England (HEE)
  4. National Institute for Health and Care Excellence (NICE)
  5. Public Health England (PHE)
  6. Care Quality Commission.

Perhaps notable by their absence in this list is the Department of Health, the statutory body that traditionally had responsibility for health care provision. The role of the Department of Health is actually dealt with in the Mandate to NHS England, which was published annually, and which sets out the relationship between the Department of Health and NHS England.  The mandate states that “NHS England is responsible for arranging the provision of health services in England” and a key function of the mandate is to set the “Government’s objectives and any requirements for NHS England, as well as its budget.” From this mandate, it’s as if the day to day provisioning of NHS care is to be carried out ‘at arms length’ from the Department of Health, (I won’t get into the link between the Mandate, the DH and NHS England, that is another blogs worth of material).

These STP footprints are a response to the NHS Shared Planning Guidance (SPG) which is intended to set out the necessary steps required to help local organisations, (in the words of the SPG website) to deliver a:

“sustainable, transformed health service and improve the quality of care, wellbeing and NHS finances.”

The SPG, in turn, is an outcome from NHS Five Year Forward View, backed by £560 billion of NHS funding, intended to help the NHS in England meet a purportedly looming annually recurring £30 billion gap between resources and patient needs by 2020/21.

So what do these STP’s look like? They are to be place-based and designed to ‘drive’ the five Year Forward View. According to the NHS England material, this place based planning will combine planning by individual institutions with planning by place for local populations. Is it all making sense now? This place-based planning, we are told, will require ‘system leadership’, where ‘local leaders come together as a team, developing a shared vision with the local community, by programming a coherent set of activities and ensuring execution against plan through processes that enable all parties to learn and adapt’. Glad we’ve sorted that out, everyone can carry on now with a clear sense of the task at hand! The document continues that where “collaborative and capable leadership can’t be found, NHS England and NHS Improvement will need to help secure remedies through more joined-up and effective system oversight,” i.e. if you don’t sort yourselves out, then we’ll sort it out for you. Meanwhile and elsewhere, we are assured the days of command and control public policy are finished…

All of this still seems obfuscatory to me. Maybe it would be more useful to emerge out of the NHS Nu-speak to try and get some sociological insight into these changes. Shadow Secretary of State for Health, Justin Madders, writing in the Huffington Post, asserts that the five year forward view is a lesson learnt from the past. The scorn poured on David Cameron’s 2010 pledge about no more top down re-organisations of the NHS, for Madden, means that the latest reorganisation of the NHS takes place away from any degree of public scrutiny (in this context, the utility of the mandated distance between the Department of Health and NHS England becomes apparent). In a political context, these changes are administrative, they have been subject to only a minimal degree of parliamentary debate or scrutiny. Madden argues there is a very real fear that

“the STP footprints will be used to make unpopular decisions behind closed doors about closing services in order to meet the unrealistic savings demand by Government. That could mean A&E closures and downgrades, at arms’ length from the Government…”

According to Colin Leys, the first priority of the STP’s is that CCGs and providers must cut their expenditure and stay within their budgets in 2016-17. If they do so, and continue to balance the books for the following four years, they will be seen to be in good standing and will be entitled to access a centrally controlled ‘transformation’ funding.

“The incentive to comply is that local health systems whose STPs fail to secure an overall financial balance in 2016-17, or which fail to meet enough of the other requirements spelled out for them, will not get any transformation funding – which will from now on be the only additional funds available.”

So, in a cash starved NHS, with an impetus for £22 billion in efficiency savings, the only discretionary budget is going to be contingent upon local health economy areas demonstrating their financial good health, in order to qualify for any additional funding. Leys continues that these ‘other requirements’ can be measures such as assurances around the areas plans to ‘achieve a step-change in patient activation and self-care, that will help moderate demand and achieve financial balance’, or requiring areas to demonstrate how their STP will ensure that ‘people with learning disabilities are, wherever possible, supported at home rather than in hospital’ – Leys characterises this as a transfer of work from the NHS to unpaid family carers.

In essence, what becomes apparent in this sustainability planning process is a creep towards a system dominated by an economic logic of sustainability, such that any gaps in provision are seen to be caused not by underfunding or any wider ideological opposition to the welfare state, but rather where any limitations in service availability are the result of imputed financial mismanagement (at arms length from the secretary of state for health) by the local providers and CCGs within the local health economy areas. This really does appear to mark the end of a statutory universal service, and a triumph of economic logic over any wider sense of collective health and social care provision