Often, when I’m speaking at social care events, I ask people in the audience – commonly owners, managers and staff of residential care and homecare providers – if they’ve come across Sustainability and Transformation Plans (STPs).
More often than not, I get blank looks; or, if people have had bruising experiences in trying to get involved with them, outright hostility. Many social care providers have found it difficult, if not impossible, to obtain any meaningful involvement at the planning stage. The same goes double for voluntary and community groups. So, I appreciate that some readers of CMM may be wanting to hurl the magazine at the wall by this point.
But please stay, because STPs are here; are happening; and will start being implemented this year. They are likely to have a significant impact on the way that healthcare, in the broadest sense, is organised and delivered in your area. For that reason alone, they will have an impact on social care. My argument is that now, when things start to move from plan to implementation and reality intrudes, is the time for social care to show just what it can do and can offer. If ‘no plan survives first contact with the enemy’, then this is when social care can come to the table, put unworkable plans – where it’s not been included – to one side and get everyone to get real.
STPs: The theory
To start with, for anyone who’s not aware of them, this is what STPs are and where they come from. The term was first coined in NHS England’s Delivering the Forward View: planning guidance 2016/17-2020/21. Essentially, this set out a blueprint for how the NHS in England was going to deliver the key aims of its five-year plan, the Forward View, which had been published in 2014. The plan was based on taking a much wider view of health and wellbeing, with an emphasis on a more joined-up, place-based approach. Crucially, these join-ups expressly included collaboration between mental and physical health, and between health and social care, with a view to keeping people healthier for longer; in their homes; and not having to go into hospital unless they absolutely needed to.
The planning guidance, published in December 2015, divided England into 44 large areas, called ‘STP footprints’. In each area, the NHS was charged with coming up with an STP, to reorganise healthcare provision and delivery. The aim was for more healthcare to be delivered in the community via primary care and NHS community trusts, with less of the focus on large, central hospitals.
There was also explicit recognition that those involved with putting the plans together needed to include everybody. ‘System leadership is needed…it involves…developing a shared vision…learning and adapting…and having an open and iterative process that harnesses the energies of clinicians, patients, carers, citizens…and local community partners including the independent and voluntary sectors, and local government. The STP must also cover better integration with local authority services, including, but not limited to, prevention and social care.’
The practice: ‘Not our finest hour’
In practice, links with social care have been very patchy, to the point of non-existence in many cases.
My sense is that there are a number of reasons for this. Firstly, the NHS imposed highly unrealistic timescales to produce highly complex plans – they were originally meant to be completed in a three-month timescale and submitted to NHS England in June. Although the deadlines were subsequently extended until late-October, there was no time or opportunity to go back and revisit things from the start. It also meant that those involved came from a narrow band. It wasn’t just social care that felt excluded: surveys showed most GPs felt uninvolved and not consulted.
This was compounded when the individuals charged with leading the process came from the NHS, didn’t have relationships with social care providers or local government and didn’t know how to go about getting them. In 40 out of the 44 STP footprints, the process was led by a hospital trust chief executive, or their counterpart in a clinical commissioning group.
In addition, there were, and are, very different cultures – an NHS whose natural bent is towards working with what it sees as equivalent large-scale organisations, rather than at the scale social care operates – and enormous financial pressures bearing down on all health and care services. As such, it was never entirely clear to many people whether the aim of STPs was to develop a truly integrated health and care system, or whether it was to fix the NHS’ financial black hole (hospital trust deficits reached almost £2.5bn last year).
If that wasn’t enough, NHS England imposed secrecy (or at least gave contradictory advice) about the plans, not allowing any degree of proper public engagement and involvement. This meant that even when social care providers asked to be involved, they often got knocked back.
The secrecy also put local councillors at risk of being accused of conniving in plans to cut services. The outcomes have been predictable. Firstly, some STP places broke ranks with NHS England, and published their plans before they’d been centrally approved. In Birmingham, the council Chief Executive, Mark Rogers, who had led the STP process, accused the NHS of using STPs mainly to try to sort out its debt crisis. Trust has been thin on the ground.
Secondly, the secrecy behind the process has given others free rein to define STPs as being purely about cuts. There have been headlines in the national press, such as that in The Guardian in November 2016, ‘Thousands of beds to go in NHS shake-up’, and the British Medical Association has weighed in with a view that STPs risk being used as a cover for cuts and ‘starving the NHS of resources’.
Thirdly, there is a widespread view that the plans themselves are not financially credible. A survey of clinical commissioning group leaders carried out by the Health Services Journal showed two-thirds had low or very low confidence that the sums worked. So, when Matthew Swindells, NHS England Operations Director, called the handling of the process ‘not our finest hour’, this was what he meant.
Never let a crisis go to waste
Now, where are we and what can you do as a social care provider to influence what happens and get your voice heard? Well, all of the draft STPs have now been published. If you’re not sure of your STP footprint, go to the NHS England website and search ‘STP Footprints’. You can commonly find the plan on your main hospital trust or clinical commissioning group website too.
Most base their plans on overhauling community-based care; on reconfiguring secondary care in acute hospital trusts; and on reducing NHS costs by having providers come together to share and cut back-office costs. An in-depth analysis by the King’s Fund in November 2016, showed that progress had mainly been determined by local context and history of collaborative working, and confirmed that tight deadlines had often made meaningful involvement, from social care or the public, difficult.
Difficult, but not impossible, though. In Lincolnshire, a strong local care association has been centrally involved at the planning stage, and this is reflected in the quality of the plan. For example, there is a commitment to working across a shared care plan with information shared across sectors, and with care delivered by a health and care workforce that is equally valued.
The summary states, ‘We will bring together doctors, nurses, mental health practitioners, social care professionals, therapists and other community based professionals to work as one team in a neighbourhood, linking in with wider services and support…Staff in nursing and residential care homes will be treated as vital members of the wider integrated team, having immediate access to shared care plans. They will have a more proactive role in the care of their residents.’
The plans are now being assessed by NHS England and NHS Improvement. The likeliest outcome is that in some shape or form, a number will get the green light to proceed to implementation this year, even if much more detailed work needs to be done. However, my hunch is that there will not be the revenue or capital funding on offer for the plans to be implemented on the scale originally envisaged. There will also be a recognition at local level that much more meaningful involvement will be needed for implementation to have any chance of success.
If you’re a provider, I think that now might be the right time to get together with others – either through a care association if you have one that works well, or as a more informal grouping – and start conversations with people involved in the STP process. Initially, I’d suggest using them as a way to explore options of what social care might both give to and get from involvement, and to show people just what social care can do.
Don’t assume that people already know; find allies – such as from primary care or allied health professions – who can influence and make the case for you and with you; and keep persevering if you get a rebuff. Be prepared for this process to take time, and to feel messy and frustrating. But don’t stand apart, or assume that things can’t change. The experiences of care providers in Lincolnshire, or of providers involved in the Enhanced Care in Care Homes new models of care, have shown that they can.
The stakes are high: this could be an opportunity for social care to show health what truly collaborative systems leadership looks like: and how social care can transform the lives of people who use services. Who wouldn’t want that?
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