Will STPs lead to further cuts to health and social care?BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5506 (Published 05 December 2017) Cite this as: BMJ 2017;359:j5506
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Indeed one consequence of STPs is that they may result in more health services becoming means-tested. In addition Councils will bear legal responsibility for any healthcare deficits, but without power to address inadequacies of pre-set budget control totals. Handling of public finance, public scrutiny of decisions affecting health care, viability and stability of services are all subject to potentially serious risks.
Dr WIght's belief that the purpose of STPs/ACOs is to roll back the Health & Social Care Act 21012 is understandable, but is an error of judgement. STPs/ACOs will not draw an end to contracting; larger prime providers on 10-15yr contracts will be able to sub-contract almost any services to whom they like. Power for commissioning will move upwards and away from CCGs and Councils, but providers over-represented. NHSE's 5YFV intention would allow, encourage or choose large private providers who can fulfil multi-billion pound ACO contracts to operate as prime providers. United Health, among a few others, fit this bill. This will still become possible precisely because the H&SC Act has not been reversed.
I completely agree that the H&SC Act 2012 should be repealed and its effects reversed, but all the talk about integration and collaboration in STPs whilst reducing acute demand is largely wishful thinking and re-inventing the wheel. Integration between Health and Social Care could be achieved without STPs; the problem now and under STPs is not that patients are not getting suitably integrated care and managed discharges, it's that they're no longer getting the social care at all, and medical provision is also shrinking.
STPs do indeed harbour massive cuts - what is a CCG to say when NHSE demands: "How will you achieve £0.5bn savings while improving organisation collaboration, integration and better health outcomes for patients. You have three months.Think the unthinkable."?
STPs do indeed plan cuts to A+Es, Maternity Units, whole hospitals - reducing the already threadbare safety net we have. 7,500 community general practices will be cut and merged into 1500 centralised hubs.
STPs will downskill provision of healthcare in England's NHS, with doctors and nurses replaced by Associates (despite evidence that that's unsafe), pharmacists and community support workers, IT self-help and dumbed-down triage.
But are the STPs even what they're cracked up to be: a hastily assembled rescue plan mandating fundamental redesign of the NHS in response to a policy of underfunding by this govt? Or are they actually a follow-through from the Health and Social Care Act, a business plan mirroring the themes of global health corporations seeking to align and expand their markets in UK? ACOs appear to be re-creating Regional Health Authorities, but with the private sector embedded.
Ridiculous, huh? Except that the WEF Global Health Innovation workstream at Davos 2012/13 - led by UnitedHealth's Simon Stevens - did indeed present this model of care as the only way to relieve inexorably rising demand. A number of attendees became key leaders and proponents in STPs and NHSE.: Rob Webster, Amanda Doyle, Michael MacDonnell, Thomas Kibasi, Alan Milburn, Bruce Keogh, and others.
STPs and ACOs are really just another business model for delivering health care, but delivered with such exigency in the context of a dangerously underfunded NHS, that we are compelled to believe it's the "only game in town". It isn't, and we shouldn't play, because this game is rigged.
If STPs are cheaper at all it's because they will provide less care, and less good care. Some say let's have a mixed system like Germany, but perhaps they don't realise Germany spends annually 50% more per capita on health than does the UK.
STPs, ACOs and Devolution - a bit like Health and Social Care Act 2012 - present a number of important but unaddressed risks to our futures. We must not be led by the nose again through yet another massive reorganisation with warm words and empty promises. The funding situation, and the narrative, may change.
Competing interests: No competing interests