In his major interview last week on the pressure the NHS is facing, Jeremy Hunt said that the healthcare service would radically improve due to the government's NHS “plan.” That plan aims to divide the country into 44 areas, each charged with developing a "Sustainability and Transformation Plan,” or STP. These set out how the areas will work together locally to modernise healthcare and also to integrate it with social care. The government’s problem is that STPs are not on track to deliver the wide scale reforms that are needed.
The hope for STPs was, and remains, that they would overcome the highly-fragmented nature of the NHS. New research by think tank Reform suggests that they have not managed to do that. One of the reasons STPs struggle is because the way NHS organisations are funded creates perverse incentives, motivating hospitals to increase activity (by calculating acute care budgets based on activity) and primary care providers to evade it (by calculating funding by the number of patients registered).
With separate funding streams for healthcare, social care and public health, it is difficult to move money around the system to where it will have the most impact. This results in cases like that of Iris Sibley, who waited six months in a hospital bed for a suitable nursing home place. Aside from the adverse effects on patient health, cases like this indicate that NHS spending can be much better used. The National Audit Office estimated the annual cost of people remaining in hospital who no longer need acute care is around £820m, compared to the £180m it would cost to deliver this care in the community.
There are pockets of success where these problems are being overcome. Greater Manchester now controls one integrated budget for NHS and social care. It has been able to redirect money and effort to where it can do most good. Salford Hospital, for example, has successfully reduced hospital admissions for elderly people by employing a General Practice solely for nursing care residents. The GPs identified urinary retract infections as the main cause of nursing home residents being admitted to hospital. They organised visits to nursing homes to encourage preventative measures such as good hydration, and reduced hospital admissions as a result.
Without this formal organisation, STPs run the risk of being little more than talking shops. They, too, need full control of a single health and care budget. They need to agree common goals covering both of these areas, and then to hold local organisations to account to their contribution to those objectives.
STPs also need the public on board. NHS England asked STPs not to reveal their plans until they were approved. This has created political and public suspicion, and accusations of “reform by the back door.” Changes to some NHS units, such as Accident & Emergency, will always be controversial but public involvement means that decisions of this kind can be made. Without this backing, politicians will withdraw support and stop reform before it has even started. If ministers gave each STP a locally elected leader, they would make STPs accountable to the public and give STP boards the strong leadership they need.
STPs are the right idea and they can move the NHS forward. Ministers however must give them the powers, and the financial muscle, needed for them to deliver. The government’s whole health reform agenda depends on it.