The NHS is well and truly back in the news, thanks – if that’s the word – to the sustainability and transformation plan process.
The STPs are supposed to address the NHS’ immediate financial woes and implement locally the big ideas in the ‘Five Year Forward View’. This, in turn, is the big plan that was published two years ago [my blog post] to try and close a gap between funding, demand and costs that could otherwise reach £30 billion by 2020-21.
There are 44 STPs being drawn up [HSJ map] by NHS commissioners (the clinical commissioning groups that plan and purchase care locally), trusts (which run hospitals and mental health services) and local authorities (which are responsible for social care, which has a funding crisis all of its own).
So far, you would have to say that the process is not going terribly well. To put it mildly.
When is £10 billion for the NHS not £10 billion for the NHS?
Firstly, there are two increasingly public rows about the financial background against which the STPs are being drawn up.
The first concerns whether the government is funding the Forward View, as it claims. In its best case scenario, the plan assumed the NHS could find £22 billion of efficiency savings; leaving the government to find the remaining £8 billion.
In last year’s budget, then-chancellor George Osborne claimed he’d done a bit better, and that he would “fully fund” what he was quick to call “the NHS’ own plan” with £10 billion.
However, a succession of Parliamentary health select and public accounts committee hearings [my blog post] have established that it’s only possible to get that figure by counting in £2 billion for 2014-15, which had already been announced.
In addition, as Prime Minister Theresa May has been forced to admit [Guardian] in the past couple of weeks, the remaining £8 billion includes £3 billion that would previously have gone on things like running the Department of Health and paying for public health programmes.
May has said this is because the government is focusing on the ‘frontline’ NHS – but that in itself that sort-of admits it has diverted, rather than found new, money for the service.
Meantime, the £8 billion figure is also generous because the government has, unusually, counted the ‘extra’ in 2019-20 prices (rather than base year prices) and only factored in general inflation (rather than NHS inflation, which is always much higher, because of the high cost of new drugs and treatments).
Also, the way the money is being phased means most of the cash is going in this year (2016-17), when it will get a real terms funding increase of 3.7%. It will only get 1.3% next year (2017-18), 0.3% the year after (2018-19) and 0.7% the year after that (2019-20).
In Parliament, Stevens came close to saying this was not, in fact, what he asked for. He also pointed out that his plan relied on funding for public health and social care being maintained.
Don’t panic, Mr Hopson:
This brings up the second row. Despite repeated questions from MPs, Stevens was not ready to say that the logic of his comments is that the plan cannot be delivered.
Indeed, he told MPs that questions about what would happen if the STPs ‘failed’ made no sense, because the NHS will be bigger in 2019-20, whatever happens, and those areas will be delivering something.
Naturally, he didn’t spell out that ‘something’ might be a service in which there is more rationing, longer waiting lists, a bigger backlog of maintenance, and perhaps lower quality care.
This would be political suicide. Also, the whole point of the STPs is to avoid this scenario and Stevens is determined not to let the NHS itself think there is any alternative to restoring financial control and delivering on the plans.
However, others are happy to oblige. Chris Hopson, the chief executive of NHS Providers, reminded the health select committee that the acute sector (hospitals) finished last year £2.4 billion in the red – or a billion more than that, without some creative accounting.
This forced NHS England to throw most of its planned sustainability and transformation fund into the acute sector black hole this year, dramatically reducing the amount of money available for investment on projects that might save money in the long-run.
Despite this, and 2016-17 being the NHS’s “year of plenty”, Hopson said the “NHS was struggling”. Worse, he argued demand, NHS constitution commitments, targets, and funding could no longer be squared and something would have to give.
Worse, he argued areas were drawing up STPs in which they simply did not believe. Hopson was out this week making similar points ahead of next week’s Autumn Statement.
He told the Guardian, Today programme, and other outlets that May would have to “rip up” the government’s plans for the NHS and either find more money or “risk it becoming unable to function properly.”
So far, Hopson’s a lone voice. The country’s big three think-tanks have come together with their own statement for the present chancellor [Nuffield Trust website], Philip Hammond.
However, they are calling for more money to go into social care, on the grounds that it’s in an even worse state, and improving things would help hospitals discharge elderly people stuck on acute wards for lack of anywhere else to go.
Not live from Leeds:
While all this has been going on, NHS England (the body that runs the NHS’ planning and purchasing set-up from Leeds), has been trying to keep a tight grip on the STP process.
Working with NHS Improvement (the body that decides whether trusts are financially fit to operate) and the Care Quality Commission (a quality inspectorate), it managed to keep the first cut out of the public eye.
These had to be submitted in June, just as everybody was off on holiday – and then, of course, mightily distracted by Brexit. But it signally failed to keep the second cut quiet. Since the plans were finalised at the end of October, a bunch of councils have broken ranks and put them on their websites.
NHS England didn’t want the plans published until its communications teams had made sure they contained “positive” messages. It didn’t seem to stop and think that councils are not beholden to NHS’ PR-wallahs.
Or that elected councillors wouldn’t be able to live with any suggestion that they were ‘hiding’ or tacitly supporting the closure of local hospitals, which the early STPs tend to propose – or, more accurately, revive, since many have been under ‘threat’ for years.
So, in North West London, the STP has been published with a rider from local councils saying, flat out, that they just don’t agree with hospital rationalisation plans.
Secret – a tag that’s going to stick
The way the plans have come out is unfortunate, because it has established the idea that the STPs have been drawn up in ‘secret’; an idea reinforced this week by the King’s Fund think-tank.
It sent a couple of junior analyst to follow the development of four STPs, and issued a short report full of the kind of wonk-speak that these reports tend to contain about the difficulties of working across organisational boundaries and the need for leadership.
In noting that the fast pace of STP development had left little room for staff or public involvement, however, it left open a gap for a slew of headlines about how “NHS bosses are ‘trying to keep cuts secret’” (BBC) or “NHS cost-cutting plans are ‘kept secret from public and media’” (ITV).
Chief executive Chris Ham must be kicking himself; and has indeed been out and about trying to say that while the process is tough, it’s the NHS’ only hope [Public Finance magazine].
Too late. The ‘secret’ tag will now follow the STPs into every local paper, focus attention on the ‘cuts’ and ‘closures’ elements, and ensure the NHS is firmly on the back-foot when it comes to making the case for them.
This morning, the Guardian duly led its Saturday paper with a story analysing 24 STPs that was headlined “A&E, cancer and maternity units to close in major NHS overhaul.”
“Thousands of hospital beds are set to disappear, pregnant women will face long trips to give birth, and a string of A&E units will be downgraded or even closed altogether, as part of controversial NHS plans to reorganise healthcare in England,” it said; before quoting campaigners on how this would be untenable locally.
Back to the politics of the 1990s
This is an absolute gift to Labour and campaign groups such as 38 Degrees. The first has a ‘national day of action’ on the NHS today, and the second has a big “Save our NHS” petition on its website that claims “the NHS isn’t getting the cash it needs” while “the government is letting money-hungry private companies carve out profits from treating the sick.”
Expect future reports from Oxfordshire, where former Prime Minister David Cameron’s presence as a constituency MP probably saved the Horton Hospital from an almost inevitable downgrade that is now refloated in its STP proposals.
Also, from South London, where a lot of journalists live close to the Epsom and St Helier hospitals that have been under ‘threat’ for years and are now up for review again as part of an STP plan that says it can afford only three or four of its five hospital sites.
Good in parts; if not enough parts
Whether this kind of coverage really informs the public about what is happening and what is at stake is another question. Because the STPs are about a lot more than ‘cuts’. All of those published so far certainly make heroic assumptions about the level of ‘efficiency’ their local services can come up with in the next four years.
But they also propose to focus on prevention, so fewer people get sick in the first place, and on focusing support on the elderly and those with long-term conditions, so they need fewer trips to hospital.
Some talk about introducing long-overdue digital services to take pressure off GPs and reduce pointless trips to outpatients, and some certainly want to create specialist centres for maternity, A&E or cancer, on the grounds that these will do a better job than the local DGH can manage to do.
At the same time, the growing furore may encourage some trusts to resist their local STP plans. An awful lot are still behaving like there is going to be a hospital bailout – although why is anybody’s guess, since the government has said repeatedly that there won’t be, and it has bigger global issues on its plate.
It will make it harder for those managers that do want to be bold to execute change. And, finally, it will distract aattention from the multi-billion pound question. Will implementing the STPs, if it can be done [my blog post], save the kind of money that the NHS needs to save? And what on earth will happen if not?