STP0115
Written Evidence from NHS Confederation
Introduction
1.1 The NHS Confederation is an independent membership body which brings together the full range of organisations that make up the NHS in England. It also includes the Welsh and Northern Ireland Confederations. We therefore represent all types of providers and commissioners of NHS services including hospitals, community and mental health providers, ambulance trusts and independent sector organisations.
1.2 The organisations that make up the NHS Confederation group are: NHS Clinical Commissioners, NHS Employers, the Mental Health Network, NHS Partners Network, the Northern Ireland NHS Confederation and the Welsh NHS Confederation
1.3 Many of our members in England have insight into the development of Sustainability and Transformation Partnerships (STPs) and are directly involved in developing plans and leading STPs and Integrated Care Systems (ICS). Of the 44 STP leaders, a large proportion are drawn from NHS Confederation member organisations. These include leaders from acute trusts, mental health providers and commissioners. Our Chief Executive has previously served as the independent chair of the Somerset STP and our deputy chair Sir Andrew Cash is the lead for Sheffield STP.
1.4 Our headings reflect the questions put forward by the Health Select Committee STP Inquiry terms of reference, that are most relevant to our members. Our response represents members views and draws on their varied experiences of the STP process.
2. Background
2.1 The Five Year Forward View[1] provided a vision for the NHS to deliver new models of care with a greater focus on prevention and integration. Our members have backed this approach and have welcomed the move away from an expectation that individual NHS organisations should operate autonomously and deliver against annual plans. Instead there is support for a different model of accountability which is system-wide, longer-term and place-based. Our members have also welcomed the recognition of adult social care and the NHS working together, as well as the contribution of wider services to the health of the population. As a result, our members supported the founding principles of STPs: to bring together local partners to work collaboratively to improve the efficiency and effectiveness of local health and care services.
2.2 However, we believe that the key to delivering this reform agenda lies in developing local solutions that bring the whole system together. To have a realistic chance of success, it is important for government and national bodies to give local areas the time and resource to invest in governance, relationship building and local engagement. There does need to be a sense of pace and urgency in driving reform, but the timeframes to which STP areas have been working are short, and the overall level of expectation placed on them is high. While STPs can provide a vehicle for difficult conversations about how local health and care services are working locally, many are struggling to bring about fundamental change while their leaders are preoccupied and distracted by immediate operational and financial challenges.
2.3 It is two years since the NHS and local government were asked to come together to develop Sustainability and Transformation Plans. Since then, NHS England has set up a programme to enable some STPs to evolve into accountable care systems (ACSs), now renamed Integrated Care Systems (ICSs). In an ICS, health and care organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS standards and improving the health of the population they serve. In return, ICS leaders are to be given greater freedoms to manage the operational and financial performance of services in their area. Last year NHS England designated eight areas, covering seven million people, as accountable care systems (ACSs), now rebadged as ICSs. This first group of ICSs have agreed to deliver improvements set out in Next Steps on the Five Year Forward View, including reducing pressure on accident and emergency departments, investing in general practice and improving access to cancer and mental health services. They are also expected to be given greater control over the funding available to support transformation programmes.
Key recommendations
Government and national bodies should :
STP/ ICS leaders should :
3. Summary of key points
3.1 The NHS Confederation continues to support STPs and believes that they are important staging posts on the way to a reformed health and care system. Areas where relationships have historically been strongest have made greater progress in working together in the interest of their local populations. These areas are among those identified as emerging Integrated Care Systems. Elsewhere, the STP process has helped bring together local leaders who had not previously collaborated and this has resulted in more positive relationships emerging.
3.2 However, in some parts of the country, STPs have made limited progress in starting to transform health and social care services. The causes of this inertia are complex and it is seldom down to one factor.
3.3 First, this was a national initiative which, with the best will in the world, would still have been seen by some as a top down imposition from the centre. The existing levels of co-operation between agencies at local level vary considerably and, even within the NHS, there are tensions between different parts of the service. The health and care system architecture has long been fragmented, driven by legislation and accountability mechanisms that have helped to create an ‘organisation first’ mentality. This mindset will take time to shift, particularly in the absence of new legislation.
3.4 Secondly, there was some lack of clarity about the purpose of STPs when they were established. At the outset they were seen as a means to pursue the triple aim of “better health, transformed quality of care delivery, and sustainable finances”. They were also seen as a catalyst for facilitating conversations that may not have taken place, with potential to overcome local challenges that could not be addressed by individual organisations.
3.5 However, it quickly became clear that government and the national bodies were also keen to use STPs to deliver key national priorities. These included implementing recommendations from the national cancer task force, looking at ways in which acute care reconfigurations could deliver savings and implementing the recommendations of the mental health taskforce at a local level.
3.6 More significantly, it became clear that doing everything possible to deliver local control totals was the overriding priority. This was reinforced by the introduction of system financial control totals for STP footprints. Not surprisingly, many STPs have therefore focussed on making short-term financial savings, rather than tackling longer term challenges.
3.7 Thirdly, local government and, to a certain extent, other players such as third sector organisations regarded the establishment of STPs and the subsequent plans they produced as products of the NHS, to the exclusion of others.
3.8 Finally, the STP process quickly became political, with accusations that it was about breaking up and privatising the NHS. Among NHS leaders this was not and is not a view that carried much currency. There is nothing in the STP proposals or subsequent shifts to developing ACOs and ICSs which suggests that the intention is, or result will be, privatisation. No state assets are to be sold off and no patient will need to pay for their care at the point of use. Indeed, there is some concern among independent providers that the new arrangements could exclude them and create a system that amounts to a state-run monopoly. However, the perception that this might be about privatising has made some players wary and even hostile. There has also been concern among local and some national politicians that STPs could be a device to close or cut local services. This has been reinforced by the huge pressure on health and care budgets.
3.9 In reality, those pressures have resulted in STPs being preoccupied with managing the immediate financial crises as their member organisations have struggled to balance their books, and this has often come at the expense of driving fundamental reform in the way services are run.
4. Effectiveness of STPs in joining up local health care systems
4.1 STPs have been able to bring different parts of a local health and care system together to agree a plan to address shared challenges. However, it is widely accepted that their effectiveness varies considerably.
4.2 There is some evidence that smaller-scale transformation can be effective, targeted at a geographical area – so called place-based working. This involves bringing different organisations and disciplines together to make local plans on a smaller geographical scale. These local plans can fit around a simple organisational structure, with, for example, one CCG, one local authority, a major voluntary sector provider, one mental health trust and a single combined acute and community provider, all working together around a shared sense of place and shared agenda.
4.3 In some places, progress made in building relationships and working together at the most senior levels is translating into change on the ground and they have, for example, started to co-locate teams with staff from social care, mental health, community and primary care.
4.4 The evidence from this country and overseas suggests that using data to segment populations within an area enables services to identify those who need support at an earlier stage, as well as the most frequent users of services who can benefit from more intensive help in their own homes. In some areas using this pooled data from across the STP is starting to make a difference.
4.5 A variety of approaches have been taken to encourage collaboration and in many STPs major partners lead at least one key area of activity. In some areas, STPs are also looking beyond health and care at integration in its broadest sense, including housing and using techniques such as social prescribing. There are now different conversations across organisational boundaries that were not happening before.
4.6 The most significant factor in enabling STPs to work effectively and at pace appears to be pre-existing relationships between leaders. These have usually been built up over a number of years. The STP process has helped to put these on a more formal basis and has given momentum to their discussions. In Greater Manchester, leaders argue that this was also greatly helped by the devolution deal.
4.7 The size of population covered by the STP appears to be significant, with areas with more manageable populations able to progress faster. Having co-terminus boundaries between the NHS and local authorities is regarded as a major advantage, as are boundaries which match how local people access services. Unsurprisingly, the scale of the financial and operational challenges facing organisations within a footprint also seems to have affected their ability to work in partnership and bringing money into discussions was often seen as having a negative impact on progress. The quality and capacity of local leaders was also an important factor and members have highlighted the importance of consistent, stable leadership. The high turnover of leaders within STPs was seen as a crucial in slowing down progress, not least because it disrupted relationship-building at the top.
4.8 While progress across the country is variable, even some of the more advanced STPs say they struggle to convert conversations into changes on the ground. Again, there are a variety of reasons for this.
4.9 One area of concern has been a perceived lack of engagement with primary, community, voluntary, independent and mental health services, as well as with other sectors and particularly local government. NHS guidance strongly recommended involving local government leaders, including health and wellbeing boards, as well as clinical leaders and the wider workforce in developing and taking forward local plans. However, the level of involvement and engagement has been variable, with some areas still reporting considerable challenges in agreeing a shared approach.
4.10 Within the NHS itself, some sectors have also felt excluded. Ambulance trusts say they have struggled to engage and interact with the many STPs and emerging ICSs within their catchment areas. There are ten Ambulance Trusts nationally, covering 44 STPs/ ICSs. This is a concern given the importance of urgent and emergency care in turning around the fortunes of many health economies.
4.11 While university hospitals have been engaged and are in many cases leading STPs, there has been little involvement of medical schools, which should be a driving force of innovation, research and leadership.
4.12 As noted above, many in local government believe that STPs are too focussed on the NHS, rather than on transforming the whole health and care system. This perception was not helped at the outset when most STP leaders were drawn from NHS organisations and many of the footprints were out of line with local authority boundaries. The sense of exclusion has applied to both council officers and elected members. In some instances, local politics has been seen to ‘get in the way’ of progress, particularly in the run up to local and national elections, when sensitive issues were put aside and decisions delayed. Again, those areas with good pre-existing relationships between NHS and local authority leaders in place were more likely to have made progress.
4.13 STP engagement beyond the publicly owned NHS has also been variable. The NHS Partners Network (a part of the NHS Confederation that represents independent sector providers) reports that the vast majority of its members felt that STP engagement with the independent sector had been either “not very effective” or “not at all effective”. Despite being responsible for £9 billion of NHS spending and treating more than 10 million patients a year, most of the network’s members reported frustration at being excluded from what they perceived as ‘NHS only discussions’. This lack of engagement has also led some STPs to be viewed primarily as vehicles for stabilising the acute sector, rather than as the means to bring in system-wide approaches to improve local services.
4.14 The third sector has also expressed concern about its exclusion and the exclusion of the public. There is plenty of rhetoric about wishing to involve community based organisations but it is fair to say that the statutory sector has often struggled to create meaningful long-term partnerships with voluntary organisations. There is widespread acceptance that this is an underused resource, not least in helping to tackle underlying health issues such as loneliness and their considerable expertise in areas such as long-term conditions and end of life care. If we are to secure the major transformation that is required we need to find new and better ways of engaging with the rich variety voluntary groups and organisations. The third sector itself could do more to co-ordinate its own efforts and come together to map what they can offer.
4.15 In some places, differing priorities among partners has slowed progress, even where there is collaborative working. Where NHS England and NHS Improvement have not adopted a joined-up approach this has not helped by placing conflicting expectations on organisations. This has led to confusion, and at times tensions, at local level.
4.16 There has certainly been tension between the need to sustain the current system and the ostensible purpose of STPs, which is to deliver transformation. Local financial deficits meant that sustainability and transformation funding was only ever used in most areas to address short term financial challenges rather than transform services. The capped expenditure process introduced in 2016/17 by national bodies in 14 STPs imposed further pressures and made meeting control totals or reducing overspends the overriding priority to the point where transformation of local services was inevitably downgraded. The national bodies at various times also sent mixed signals about whether it was the system’s or individual organisations’ performance that really mattered.
4.18 There is still a lack of clarity about how accountability for services should work. Organisations remain accountable for their clinical and financial performance, yet may be expected to sacrifice one or both of these for the greater good, without statutory or regulatory protection. STPs have had to develop local solutions to address this. For example, some are recruiting panels of lay-members to take on a role similar to non-executive directors in order to facilitate coordinated decision-making. In others, such as the North-West London STP, the Health and Wellbeing Board has widened its membership to include NHS provider organisations to provide stronger governance to underpin the STP. Overall, STP governance is still developing. Most areas include a delivery structure, often a strategic board with a delivery board to oversee workstreams, underpinned by a programme management office. As with much of this process, each area will have a slightly different model.
4.19 All this can make partners reluctant to engage in a process where roles and responsibilities are not clearly defined. As noted above, it has also caused local politicians to be wary and prompted accusations from some that this could be the route to privatisation; this is not a view we share.
5. The STP progress dashboard rating
5.1 The NHS Confederation has concerns about the STP progress dashboard ratings published by NHS England in July 2017. In particular, our members were concerned that the metrics did not reflect the original objectives for STPs around improving local population health and wellbeing, nor did they take account of the different starting points from where STPs began. Without this context, it is hard to compare progress between STPs. For some, just bringing key partners together to discuss local challenges was significant progress, while other areas had long been doing this and had already started to reshape services.
5.2 The dashboard was also resented by STP leaders because it meant they were being held to account for aspects of the service over which they had no control.
5.3. We question whether a nationally determined performance dashboard is the best way to motivate a process which is so dependent on local contexts and sensitivities. A better approach at this stage might be to take a wider view, based on discussion with local system leaders and, importantly, the views of the local population on whether they feel that their priorities are being addressed. It should also include the reviews carried out by the CQC of local health and social care systems, which focus on how care providers are working together to meet people’s needs.
5.4 We believe that any national assurance process, as well as considering local intelligence, should measure progress in relation to health and wellbeing, care and quality, and finance and efficiency. These are the areas which the STPs were originally established to address.
5.5 Consideration could be given to developing a communication and engagement indicator as a standalone item on the dashboard to make sure this aspect is measured and best practice highlighted.
6. Public and community engagement to enable STPs/ICSs
6.1 Like so much else, public and community engagement with STPs and ICSs has been variable. While many see it as a priority and have engaged local communities, there is still an enormous amount to be done throughout the country.
6.2 Some STPs have a good record of local community engagement, working in collaboration with organisations such as Healthwatch. Some of this is done through local plans, rather than at an STP level, which can better capture the perspectives of patients, users of social care and local communities.
6.3 According to some of our members, the fact that STPs have become politically controversial has made it more difficult to engage with the public. The negative image of STPs has made it more difficult to engage on local plans, and there is some frustration that positive work has been drowned out by hostile comments and negative coverage of STPs more generally.
6.4 There is fear among some leaders about writing down or publicly discussing what they ‘really need to do’ for fear of public or political reaction. If this is to be overcome, there is a need for political support and support from the centre, making it clear that in many areas the current configuration of services is not sustainable and does not produce the desired levels of safety and quality.
6.5 Engagement with local MPs is crucial. Some of our members are doing this through individual meetings, parliamentary events, MP newsletters and private meetings. Securing political support and working with local MPs to explain plans in a meaningful way, which makes sense on the doorstep, and to set out what will be different, is seen as hugely beneficial. However, it is important that support should not just be for new forms of community provision, but also for the more difficult and challenging task of reshaping community services, and especially the reconfiguration of acute services.
6.6 We also recognise that in some STPs the lack of public engagement has itself contributed to negative views. Where STPs have not been able to develop or share their plans openly this has led to claims that the process is secretive and lacking in transparency. It will be important that this is addressed everywhere through engaging more with local politicians, ensuring greater public scrutiny of the planning and implementation process, and holding more public engagement events.
6.7 As well as building trust with the local population and politicians, a louder and clearer voice is needed from government and from national bodies. We need an unequivocal commitment to this process which goes beyond the technical and structural changes that are being demanded and sets out a vision of what it is intended to achieve. In short, it is not enough just to leave local leaders to make the case for change, it needs to come from all levels.
7 Deliverability of STPs
7.1 The view within STPs is that further action is required nationally if local delivery plans are to succeed.
7.2 Funding remains a key obstacle. As we have seen, organisations that spend their time fire-fighting often find it difficult to establish the band width to take on major transformation. Health economies that are severely stretched can resort to mutual recrimination with relationships breaking down and progress on longer term plans postponed. The NHS is already failing to meet its constitutional targets and according to NHS England the additional resource allocated for the coming year will at best retain the status quo. On the ground the view is more pessimistic than that. Either way the capacity to transform is limited by current pressures.
7.3 This has been exacerbated by shortages of capital to develop new models of care and lack of resource to double run services while new models are developed. The promise of more capital announced in the budget will help, but the reality is that in previous years capital allocations have been used to keep services running and there is now a significant backlog of repairs and maintenance that needs to be addressed.
7.4 Alongside funding, the biggest pressure facing both health and care is recruiting and retaining the staff. The health service recognises that it must do more to recruit and retain its staff, but it also needs more support at national level. This will take a coordinated effort from national bodies and greater recognition of the scale of the workforce challenge and the consequences of not making it a priority in the past. The recently launched workforce plan from HEE is a start, but any serious strategy must include projections of what staff the health and care system will need over the next fifteen years, where they will come from and how they will be paid for. Only then can local leaders have confidence that their own plans are deliverable. Furthermore, we recognise that STP’s would benefit from drawing on expertise from those in the independent sector with an understanding of the data requirements and models necessary for effective patient segmentation and place based care, as well as those with experience of delivering integrated care in the UK and abroad.
7.5 Another key factor affecting the ability of STPs to work effectively has been the behaviour of, and relationships with, the national bodies. There have been concerns about some aspects of NHS England and NHS Improvement activity, some linked to national policies, some to local behaviour and interpretation. In particular, our members have highlighted the different ways of handling control totals for providers and commissioners, the persistence of penalties and incentives which can drive ‘organisation first’ behaviours at the expense of the system as a whole, and the focus on top down performance management of individual organisations. All these can undermine a locally led system-wide approach, built on trusting relationships. The focus on individual organisational targets is specifically seen as encouraging silo working. The number of national performance measurements for local organisations and systems makes it more difficult to develop coherent joined-up plans, especially where different targets are pulling in different directions.
7.6 Our members have also been concerned about the inconsistency from and between national bodies. At the outset they were told STPs were set up to deliver long-term change, but this was quickly replaced with a demand to control in-year spending as a priority. The Sustainability and Transformation Fund payment incentive system exemplified this. Access to the fund was made contingent on an individual organisation signing up to deliver short-term savings to meet a control total, regardless of longer term, system-wide needs and ambitions.
7.7 None of this is easy. Everyone, including the national bodies, must operate within rules and structures that can militate against what we are all trying to achieve. Local leaders need time and space to work together to develop local solutions, in partnership with the centre.
7.8 The current STP footprints were determined nationally and some of our members noted the lack of openness regarding the leadership appointment process. The geography of the footprints also created initial problems where there was a lack of local relationships or where new boundaries cut across existing relationships.
7.9 If STPs are to focus on delivering improvements in health and care around the needs of whole areas, not just individual organisations, then they must be enabled to do so. This should include realistic investment to allow for double-running of services where that is needed and investment to release capacity within local leadership teams to take on the transformation challenge while managing current services.
7.10 There will be STPs that submit locally-owned and deliverable plans that may not balance the books by 2020-21, but are realistic in what they can deliver and propose long term changes that will create sustainable services with the potential to yield benefits for patients. These areas should not be penalised for this.
8 Credible and realistic plans
8.1 The NHS Confederation has repeatedly made clear that we can only achieve system-wide change by ensuring system-wide involvement and engagement. It is not surprising that the most detailed, robust and achievable plans are those which have been built on longstanding relationships and genuine partnership. In other areas, where relationships are less well developed, progress has been slower. We must be realistic about what local health economies are expected to deliver and the tight timeframe in which they were asked to formulate and begin implementing plans. The reality is that relationship building takes time and fundamental transformation will not be achieved overnight. We believe that most areas will ultimately get there, but that they require support and engagement from all local partners, from the national bodies and the political class. The onus is on all of us to support local leaders to make the right decisions for their local communities.
8.2 This means supporting local decision-making, engaging local communities and challenging the notion that local transformation is about making cuts. The latter does reflect the reality and often presents an additional barrier to change will deliver better services to local communities.
8.3 The next stage of the process must be about ensuring that all parts of the system and all those with an interest in this process are bought into the vision; and where there are gaps, be it in primary. community, emergency care or social care, we must support local areas to address these.
8.4 Our members across the NHS support the drive towards integrated care systems and we must all support them to deliver this ambitious agenda.
[1] https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf