Transformation plans are overambitious and will not work, say service leaders

BMJ 2016; 355 doi: (Published 13 October 2016) Cite this as: BMJ 2016;355:i5545
  1. Adrian O’Dowd
  1. London

NHS service leaders have warned that many of the much talked about sustainability and transformation plans (STPs) that have been prepared by 44 areas across England to improve care for their local populations are overambitious and will not work.

Witnesses at an evidence session of the parliamentary health committee on 11 October raised several concerns about how the STP process had been unfairly dominated by financial saving expectations. The inquiry into the current state of NHS finances was prompted by a report from the National Audit Office published in July.1

STPs are five year plans drawn up by clinical commissioning groups, NHS trusts, and local authorities in 44 areas identified as a geographical “footprints” covering all areas of NHS spending in England. Areas have to submit their final plans to NHS England this month.

Chris Hopson, chief executive of NHS Providers, the membership organisation for NHS acute, ambulance, community, and mental health services, giving evidence, said, “We think it’s a very important process that’s got lots of good in it—the idea of asking a local health and social care economy to come together and plan on a long term strategic basis seems to us to be important.

“However, there are two big problems. First, we are going at breakneck speed here. In some cases, these organisations have not really spoken to each other before, and if you really want to get to a quality plan, they need to be given time.

“The other danger, which virtually all of our members say to us, is that they are now being required to meet a 2020-21 financial allocation. They are spending quite a lot of time creating plans that, in their view, are not deliverable and usually involve major structural service changes because that is the only way that they can create a [financially] balanced plan.”

All NHS providers were “up for a realistic, stretching efficiency challenge” to improve care for local populations, he said. But he warned, “If you are told you have to balance, that means people are coming up with vastly overambitious plans that effectively rely on either overambitious demand management plans or, more often, service reconfigurations that we know are not going to happen because they won’t command the required political support and there simply isn’t the capital available.”

Fellow witness Stephen Dorrell, chair of the NHS Confederation and former chair of the health committee, said that the aims of the STP process were a “step in the right direction” but added, “There are very real concerns in the local authority world about the extent to which, in some parts of the country, local authorities are true partners in the STP process.

“The STP process itself, on the one hand, wants to deliver medium term plans for sustainability and transformation and, at the same time, is seeking to deliver a process governed by a series of spreadsheets, which make it very much more difficult for the partners in the STP process to deliver the objective for which the STP process was set up.”

Julie Wood, chief executive of NHS Clinical Commissioners, which represents clinical commissioning groups, also giving evidence, said, “We need a balance between how you address the three gaps [quality of services provided, different outcomes, and finances]. The predominant focus of STPs has been on closing the financial gap, and we need to make sure that we are putting emphasis on the care and quality gap as well.”

MPs asked the witnesses just how bad the financial situation was in the providers sector. Hopson said, “It’s unprecedented in terms of the scale of the financial deficit. Although the official published deficit is £2.45bn (€2.7bn; $3bn), it’s relatively widely accepted that that is about a billion pounds smaller than it really is, so the provider sector deficit . . . is probably about £3.5bn or £3.6bn.”

Recent promises from the government of additional doctor numbers being trained to work in the NHS were questioned during the session. Hopson said, “Around 70% of an average trust’s budget is spent on its workforce. We can’t see how we can afford the extra levels of staffing that are being talked about over the next three or four years.”


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