Sustainability and transformation plans for the NHS in England: what do they say and what happens next?BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1541 (Published 28 March 2017) Cite this as: BMJ 2017;356:j1541
- Hugh Alderwick, senior policy adviser to the chief executive,
- Chris Ham, chief executive
- Correspondence to: H Alderwick
- Accepted 27 March 2017
Planning guidance produced by national NHS bodies in December 2015 asked NHS organisations to work together to make plans for the future of health and care services in their area.1 The plans—called sustainability and transformation plans (STPs)—needed to cover all areas of NHS spending up to 2021 as well as how NHS services work with social care and other local authority services. NHS organisations were asked to describe how improvements would be made in three areas: population health and wellbeing; quality of services; and healthcare efficiency.
The plans are based on 44 areas of the country, with an average population of 1.2 million (range: 300 000 to 2.8 million).2 STPs are the local plans for delivering the Five Year Forward View,3 which is the strategy for transforming NHS services closely associated with Simon Stevens, the chief executive of NHS England.
STPs are based on the idea that collective action is needed to improve care and manage resources. This represents a major shift in the approach taken to NHS reform in England, embracing collaboration rather than competition as a means for driving health service improvement.4 This shift is taking place without changes to legislation, causing a tension between the statutory framework for the NHS, created by the Health and Social Care Act 2012, and the direction being set by STPs.
Theprocess of developing the plans has not been simple5 and was criticised by some council leaders for taking place behind closed doors and not involving relevant stakeholders, such as patients and the public, NHS staff, and local authorities. Despite these difficulties, all 44 STPs have now been published, and work has begun on implementing their proposals. Here we describe their content and the challenges they present.
Content of the plans
We reviewed the 44 plans and identified eight major themes (box).
Major themes in STPs
Redesigning primary care and community services
Changing the role of acute and community hospitals
Strengthening prevention and early intervention
Improving care in priority service areas, such as mental health
Improving productivity and tackling variations in care
Supporting and developing the workforce
Improving IT, estates, and other “enablers”
Organisational changes to support STPs
All STPs explain how they intend to redesign primary care and community services. The plans describe ambitions for closer coordination of health and social care services and for staff to work together in multidisciplinary teams. West, North, and East Cumbria, for example, is developing “integrated care communities” to manage care for geographically defined populations, bringing together staff from general practice, social care, mental health, public health, and community services, as well as some specialists based in hospitals.6
The plans often propose that GPs should work together at greater scale through networks of practices. They propose new roles for managing care in the community, such as health coaches and care coordinators, alongside new care processes, such as care planning. Target populations for these new care models include older people and people with chronic conditions. Some areas are seeking to extend the range of services delivered in the community. These new ways of working are expected to reduce demand for acute hospital care.
STPs also aim to change the role of acute and community hospitals. Proposals include concentrating some services—such as those for stroke, maternity, and orthopaedics—in fewer hospitals to tackle workforce shortages and concerns about quality of care and the financial sustainability of services. Some plans also propose reducing the number of acute hospitals. South West London, for example, makes the case for reducing the number of acute hospitals from five to four.7
Some plans propose reducing the number of acute hospital beds. In Dorset, ambitions to provide more integrated care in the community and to redesign hospital services are expected to lead to a reduction in hospital beds from 1810 in 2013-14 to 1570 in 2020-21. 8 They are also expected to reduce unplanned medical admissions by 25% and unplanned surgical admissions by 20%. Several plans propose to cut the number of beds in community hospitals and in some cases to cut the number of these hospitals.
All STPs aim to strengthen prevention and early intervention. Proposals include ambitions to promote healthy lifestyles, to work more closely with local authorities to tackle non-medical determinants of health, and to support people to manage their own health. They propose targeted prevention programmes for people with chronic conditions. Some plans also describe how they will draw on assets in their community to improve people’s health—for example, by introducing “social prescribing” schemes to refer patients to support in the community.
STPs outline commitments to improve care in priority service areas, which vary depending on local context. They include improvements in specific services—such as mental health—and for defined population groups—such as older people. North Central London, for example, wants to increase mental health support, including by improving access to mental health services in primary care, developing a psychiatric intensive care unit for women, investing in mental health liaison services, and introducing teams for eating disorders.9
Improving productivity and tackling unwarranted variations in care are priorities in all STPs. Areas for action include variations in elective referrals.10 Many areas are seeking to standardise clinical processes, while others aim to engage patients in decisions about their care. The plans also identify non-clinical services where efficiency could be improved, such as procuring equipment. These and other proposals are intended to bridge the financial gap projected by 2020-21 if NHS organisations “do nothing” to change how care is delivered.
Many STPs have set out system-wide approaches to recruiting and retaining staff, as well as measures to reduce agency costs. They also describe the skills and roles that need developing to support implementation of new care models—such as health coaching and quality improvement methods. Some STPs set out the expected changes in staff numbers that would result from their proposals. Nottingham and Nottinghamshire’s plan11 suggests a 12% cut to the number of band 5 nurses and similar roles and a 24% increase in staff in community and primary care.
The plans outline the changes to organisational arrangements and infrastructure needed to help deliver their ambitions. They include improvements to IT and digital services—such as developing electronic health records and introducing apps to support people to manage their conditions—as well as changes to the NHS estate—such as disposing of assets and developing new facilities. Proposed changes to NHS structures and incentives include plans for more integrated approaches to commissioning, new contracting models and payment systems, and collaboration between NHS and social care providers.
Familiar and wide reaching
STPs echo the proposals made in a succession of NHS policy documents dating back several years.121314 They are broad in scope—covering prevention through to specialised services and incorporating nearly everything in between. The level of detail about how these proposals will be delivered varies widely between the 44 plans, largely depending on the history of collaboration in each area.5 Detail is particularly lacking in plans to give priority to prevention and early intervention. The plans also vary in quality and completeness, with more work needed in some STPs to describe how service changes will be made and how they will improve the quality of care.
Testing the assumptions
The plans contain key assumptions that need to be tested. The most obvious is the ambition in some STPs to reduce capacity in acute hospitals. The NHS already has one of the lowest number of hospital beds per capita compared with other countries in the Organisation for Economic Cooperation and Development.15 Attendances at emergency departments and emergency admissions to hospital are rising.16 Delayed transfers of care are at record levels.16 Bed occupancy rates are above 85%.17 And services outside hospitals are struggling to cope, with growing pressures in general practice,18 district nursing,19 mental health,20 and adult social care.21
Against this backdrop, any moderation in demand for acute hospital services—let alone bed reductions—will only be possible if care outside hospitals receives substantial investment first. This investment is currently lacking: additional funding for the NHS is being used primarily to reduce hospital deficits, leaving little scope to develop new care models.22 Cuts to social care and public health budgets also make these ambitions harder to achieve.2123
Opportunities do exist to manage care more effectively in the community.2425 Areas involved in NHS England’s vanguard programme are seeking to do this by improving integration of primary, community, mental health, and social care services, as well as working with care homes and acute hospitals. These new care models offer promise, but they are still in development and are not a short term fix. The time it takes to implement large scale change in the NHS is often underestimated, while the expected effect of new care models is overestimated.2627 NHS leaders and government need greater realism to allow new care models time to produce evidence of impact.
Proposals in STPs to reconfigure acute and specialist services also warrant stress testing. Some proposals to reconfigure care by concentrating services in fewer hospitals may be both necessary and desirable, but others will require close scrutiny. Evidence on the impact of major reconfigurations on quality of care is mixed and is strongest in specialist services, such as trauma and stroke care.28 Evidence that reconfigurations produce financial savings is almost entirely lacking.
The financial backdrop for STPs is important. Local leaders were asked to show how their plans will tackle current and projected financial deficits in the NHS. A survey of 172 NHS trust chairs and chief executive officers carried out in September and October 2016 found that achieving financial balance by 2020-21 was seen by these leaders as the most important matter in STPs.29 Previous analysis3031 indicates that bridging these gaps in NHS finances will be challenging at best, and more likely impossible, even with the ambitious plans outlined in STPs.
STPs face a number of barriers to implementation.532 The limited time available to write the plans made it difficult to meaningfully involve clinicians and frontline staff in their development. The involvement of local authorities varied widely, and patients and the public were largely absent from the process. Although the plans have now been published, their jargon and technical language limit their accessibility. Without broader and deeper engagement in STPs—with staff, local people, and politicians—the support needed for implementation will be lacking.
Another barrier is the wide ranging nature of STPs. Every area should now identify a small number of service changes that offer the greatest potential to improve care. Dedicated teams must then be put in place to support the implementation of the plans across organisations. NHS organisations and their partners will need new governance arrangements to enable them to make collective decisions while recognising the accountability of individual boards. This is an example of the tension between the current statutory framework and the process by which STPs have been developed and will be implemented.
STPs do not have a legal basis or any decision making authority. Improvements to services can still be made through organisations and teams working together, but the emphasis on competition in the Health and Social Care Act 2012 does not make this easy. The complex and fragmented organisational arrangements in the NHS also create challenges. Legislative changes are likely to be needed to support the major shift in approach to NHS reform that is occurring through STPs.
Despite these challenges, STPs offer an important opportunity to transform health and care services in England. The proposals to improve integration of health and social care services and to invest in preventing ill health should be prioritised across the country. Plans to reconfigure hospital services should be supported where the clinical case for change has been made. Local leaders will need to fill the gaps in the plans related to general practice33 and other services that have not received sufficient attention. Social care and the NHS will need more funding to support the changes.
The plans will require a more realistic timescale for implementation, but some changes will need to be made urgently where the clinical case has been made. The government must be willing to support the proposals in STPs that will bring benefits for patients, even in the face of opposition from some stakeholders. If it doesn’t, serious questions will have to be asked about the future of the Five Year Forward View and the government’s commitment to the direction set by Simon Stevens and others.
STPs are wide ranging and propose changes to all aspects of healthcare in England. Key assumptions must be tested for realism, including proposals to reduce capacity in acute hospitals and deliver large efficiency savings
Plans to develop new models of community based care will require investment and take time to implement
Engagement in the STPs needs deepening and their leadership and governance need strengthening
National and local politicians should support the plans where the clinical case for change has been made
Contributors and sources: CH is chief executive of the King’s Fund and Hugh Alderwick is senior policy adviser to Chris Ham. The paper is based on research and analysis carried out by both authors on the process of developing STPs and the content of the plans. A research paper on the STP process was published by the King’s Fund in November 2016. A review of the plans was published by the King’s Fund in February 2017. Both authors contributed to the drafting of the article. CH is the guarantor.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.