Kate Laycock is a researcher at Reform. Its report “Saving STPs” is published today.
The Government is under pressure on the NHS. The Prime Minister has already given ground on social care, accepting that current provision is not adequate, and that she wants a new “long term” solution. The wider difficulties of the health service, in particular the over-crowding of hospitals and the worsening performance against targets, has become Jeremy Corbyn’s favourite line of attack at Prime Minister’s Questions.
In his major interview on the NHS “crisis” last week, Jeremy Hunt rightly said that while the pressures on the service are real, critics should remember that the Government has a “plan” to put it on a much more sustainable footing. The problem for Ministers is that the plan is not going to deliver in its current form, as new research for Reform shows today.
Ministers’ hopes lie in the radical reform programme set out by the de facto head of the NHS, Simon Stevens, two years ago. His “Five Year Forward View” explained how the NHS would reinvent itself by the end of this Parliament. It would focus on preventing ill health in the first place, and then on diagnosing illness more quickly. As a result it would reduce the pressure on acute hospitals and restore financial balance. The “Forward View” is to be delivered by 44 “Sustainability and Transformation Plans” (STPs), drawn up by all NHS organisations and local authorities across England.
The idea of STPs is a good one. The division between health and social care has damaged both services, and STPs are designed to bridge that. STPs also aim to overcome divisions within the NHS itself. That includes the longstanding but out-of-date distinction between mental health and other kinds of healthcare. They also seek to overcome a “fortress mentality” in the NHS in which some organisations (in particular hospitals) seek to expand their own activity even when resources could be better spent elsewhere.
The Reform research shows that STPs are not translating these ideas into the action that the NHS needs. Theresa May will be concerned that the involvement of local authorities in the plans has been minimal, meaning that they cannot come up with a solution for the problems of social care. (It also means that the NHS cannot learn from the local authorities’ experience in balancing budgets and thinking about how to meet the needs of whole populations). The extent of the involvement of mental health providers is also uncertain.
To have a chance of implementation, STPs will need the support of local NHS staff and voters. Surveys last year, however, found that most NHS clinicians had not even heard of the plans. Citizens are yet to be involved. Experts interviewed for the research worried that, as a result, local politicians may withhold their support for reform proposals when they are presented.
Most importantly, STPs have no powers to solve the underlying reasons for the NHS’ current problems. They cannot change the perverse funding arrangements. These encourage acute hospitals to increase their activity yet discourage GPs from increasing theirs, exactly the reverse of what the service needs. They have no formal powers to have the different constituent parts of the NHS, and local authorities, work to a common agenda of improving healthcare for a local population.
To make STPs work, Ministers need to have the courage of their convictions. That starts with the NHS and social care budget, of which STPs should take full control. That would give them the real authority to reshape health and care services in their areas.
Alongside the budget, STPs should also take the power to set the desired health outcomes for their population, which they can use to hold local providers to account. Manchester has already drawn up population outcomes based on “starting well”, “living well” and “ageing well”.
In due course, Ministers should make a directly elected individual responsible for the NHS budget, whether a metro mayor or a new Health Care Commissioner. Such an appointment would create the link with voters that will be needed to legitimise controversial changes to local services.
Finally, Ministers have to clarify the existing legislation on competition. STPs have to join up some services and have others compete vigorously in order to hold them accountable. Confusion over the current legislation is one of the factors paralysing STPs at present.
Ministers may object that these far-reaching recommendations amount to the kind of “structural reorganisation” which went wrong under the Coalition Government. What STPs have revealed, however, is that true NHS reform cannot be delivered by well-intentioned conversations alone. The devolution of health and social care to Manchester, also achieved under the Coalition, shows that the right kind of changes can be made without upheaval or even controversy.
George Osborne gave the NHS two emergency spending increases, in November 2014 and then a year later. The difficulties in hospitals in the last few weeks suggest that another one-off payment in the coming Budget would be a sticking plaster solution rather than a true step forwards. Ministers have a good NHS plan. They need to give it the force to deliver.