When Simon Stevens became NHS England’s chief executive in April 2014 he disavowed his predecessor David Nicholson’s radical centralisation of specialist hospital treatment into far fewer places.
Stevens also went further, using his first interview in the post to pledge to maintain local hospitals. Every NHS leader, and every MP, knows how attached the great British public is to the bricks and mortar of their local NHS. The last thing Stevens wanted was to face opposition by campaign groups, councillors and MPs to a particular A&E or maternity unit being downgraded or closed, and certainly not a wave of such protests in many parts of England simultaneously battling to save much-loved local services.
Yet that is the growing risk he now faces as a result of the 44 regional sustainability and transformation plans (STPs). The disclosure of controversial changes planned in north-west London, Leicestershire and the West Midlands – including entire hospitals being downgraded or closed – could easily result in England-wide protests.
NHS bosses say the plans are necessary for the sake of better care, modernisation and financial balance but an angry, disbelieving public is expected to fight tooth and nail against the loss of the local services.
The standoff over STPs has been coming for months and prefaces major political battles ahead which will involve unprecedented examination of the government’s record on and plans for the NHS. Are STPs part of an undeclared Tory plot to prepare the NHS for much greater privatisation after 2020? Or are they designed to move the health service from an illness treatment service to one that prevents ill-health in the first place?
Until now, STPs have been shrouded in secrecy. NHS England, which is driving the process, advised the boards of acute hospital trusts to discuss the plans in the private session of their monthly meetings. Labour MP Justin Madders, a shadow health minister, recently outlined his concern about the lack of public attention so far on “Jeremy Hunt’s opaque and secretive reorganisation of the NHS, which is being drawn up behind closed doors at this very moment through sustainability and transformation plans”. That deliberate hiding from public view of plans for significant changes to how and where patients are cared for is now over, earlier than NHS England planned. The public debate about what NHS services need to look like in order for the country’s most cherished institution to survive is now under way, and not before time.
Official NHS documents, albeit laden with the service’s usual array of buzz phrases, set out the purpose of STPs. NHS England calls them “blueprints [which] will be place-based, multi-year plans built around the needs of local populations”. It continues: “STPs are geographic areas in which people and organisations work together to develop robust plans to transform the way that health and care is planned and delivered for their populations.”
The overall rationale is simple: transform how care is organised and provided in order to keep the NHS sustainable as a system of healthcare. But it will be hugely difficult to convince a sceptical public to back such far-reaching changes.
Whether Jeremy Hunt or Theresa May likes it or not, the belated disclosure of the STPs will lead to fierce scrutiny of the government’s performance on and plans for the health service. Are the proposals helping to prepare the service for much greater privatisation after 2020? Have they only come about because the government has for years been giving the NHS much less money than it needs to deal with the rapid, relentless rise in demand it is facing as a result of the ageing population and the emerging disaster of lifestyle-related illness? Or are they a sincere attempt to make a stay in hospital the last resort because people are much better looked after in or near their homes by GPs, nurses, therapists and specialists?
For NHS chiefs such as Stevens, rapid progress on STPs is an urgent priority. They see the changes that STPs will usher in as the best way to achieve three key aims: to improve people’s health; to tackle the fact that there is still far too much variation in the quality of care many patients receive; and to address the £30bn gap in NHS funding which is projected to have emerged by 2020-21. Ministers have pledged to provide £8bn of the £30bn. But Stevens and Jim Mackey, head of the service’s financial regulator, NHS Improvement, have to find the other £22bn. Almost no one in the NHS thinks it can be done, but STPs are their way of trying. They have to satisfy the Department of Health, and it has to persuade the Treasury, that the NHS can sort out a financial mess that, incidentally, it did not create.
Reconfiguration of hospital services – NHS-speak for shutting things such as A&E and maternity units – is a key part of their plans. NHS Improvement last month told the leaders of the 44 STP footprints to plan for “the consolidation of unsustainable services”. The growing fear among NHS campaigners is that the definition of “unsustainable” has already been agreed behind closed doors, and that it will lead to a huge reorganisation of NHS services.
The whole STP process is fraught with risk and uncertainty. As Hugh Alderwick of the King’s Fund points out, closing bits or all of hospitals does not necessarily save money or improve care. There is also the fact that, as the Nuffield Trust health thinktank’s chief executive, Nigel Edwards, points out, care still has to be provided somewhere and that still costs money.
Crucially, for services to be delivered outside rather than inside hospitals there has to be enough capacity in GP and other community-based forms of care. There isn’t, especially with family doctors already struggling to meet demand. They have no spare capacity. There are also, as some of the STP plans admit, too few staff across the NHS to make this bright new dawn a reality. All these practical considerations may prove even more significant obstacles to the implementation of this covert reorganisation of the NHS than public and political concern.