The most recent sustainability and transformation plans (STPs), submitted in October 2016, continue on a similar trajectory to the June 2016 submissions, with many of the concerns from local government remain.
Although by no means universal, public and political engagement continues to be a major shortcoming of the process. This is likely to result in some plans not succeeding due to opposition. The LGA consistently lobbied for the publication of the plans: the fact that the drafts are now all in the public domain is a step forward, however there is still a long way to go. The LGA is calling for much more co-production as plans are developed and prepared for implementation.
There has been widespread scepticism of the financial planning detailed in STPs and whether this gives a sound platform for the transformation plans laid out. With transformation funding and capital requests exceeding what is available, the ability to raise new money locally in order to meet the ambitions proposed has been a concern for many. Local conversations have led to a greater representation of the immediate pressures in adult social care but not to the degree many would hope and there is little confidence that funding will follow.
, the central NHS bodies called for the current STP proposals to become plans in next phase, eventually giving life to a third phase of implementation which they have termed partnerships. It is right that implementable plans and stronger local partnerships will be necessary for STPs to shape a preventative and place-based heath and care system.
Are social care pressures and demand recognised in STPs?
Like in the June 2016 submissions, two-thirds of the October 2016 submissions at least acknowledge the funding pressures on adult social care. The LGA continues to argue it is essential that plans are whole-system and acknowledge that the interconnected funding pressures across the health and social care system cannot be solved in isolation.
Around a third of plans go further than just detailing the pressures on adult social care and offer whole-system solutions which help alleviate shortfalls or funding pressures in council services – this is a notable increase from the June submissions. Solutions include using the projected surplus in the health economy to alleviate the shortfall in social care; using additional resources raised from the social care precept; and investment in joint priorities such as prevention or extra care housing. A handful of plans gave weight to social care market pressures and the LGA would expect to see this become a bigger priority for STPs to prevent further destabilisation.
Are prevention and public health adequately resourced in STPs?
Although all draft plans acknowledge the importance of investing in prevention, it is not to the scale or scope many would recognise. Most focus more narrowly on health prevention such as smoking cessation and immunisation, while only around a third of plans show a clearer commitment to tackling the wider determinants of health, such as employment or housing.
The strongest prevention work streams have clear leadership from health and wellbeing boards and local government senior officers, with over a third of plans naming directors of public health in a lead role. The strongest plans calculate the return on investment - with one calculating £23m return from £14.5m investment over the lifespan of the STP - and addressing the wider determinants of health through drawing on departments across local government.
What are the next steps for funding STP proposals?
As outlined in Simon Stevens and Jim Mackey's letter, the bulk of the national transformation funding - £1.8bn - will be to support 2017-19 delivery of specific and predefined intervention priorities, which include mental health and learning disabilities. The fund will be allocated based on transformation proposals set out in current STPs. There is an expectation that STP leadership collectively back proposals and this should include account of local government leadership, finances and plans.
As capital requests, averaging around £200m, outstrip central funding availability, plans deemed the strongest will more likely get the green light first. Initial priorities are schemes that are of small-medium scale, implementable over the next few years, and that improve productivity or generate wider savings from service redesign. Many STPs will be required to fund capital proposals locally.
National NHS leaders have acknowledged that the figures presented in the plans are in need of development and that many STPs haven't thought sufficiently beyond acute reconfiguration to how care models and demand patterns need to change.
What integrated arrangements are included in plans?
All the plans propose developing some form of integrated delivery arrangements and often build on locality-based multi-disciplinary teams. These plans tend to develop integration programmes predating STP planning, although many have accelerated their plans. Around a quarter propose new organisation or delivery vehicles to carry the proposed models, such as integrated commissioning functions or accountable care organisations.
A handful of STPs detail proposals to streamline clinical commissioning by federating or merging clinical commissioning groups (CCGs). There are also a small number that set out to streamline or merge health and wellbeing boards (HWBs). Feedback indicates that progression in this area might be more widespread and that the plans do not reflect the progress being made.
A decision is due to be reached in early 2017 on which areas will receive a single system control total, with a number of the proposals including social care. A few STPs are building on local plans for devolution and combined authority priorities, but many are not, missing opportunities for leveraging wider public sector reform. Many also do not align in terms of footprints, which continues to cause additional planning challenges. STP footprints continue to be an issue for some, especially where authorities and providers are split over multiple footprints.
The LGA has launched a self-assessment tool which seeks to support local leaders to assess their readiness, capacity and capability to lead integration and transformation locally. This includes considering how STP ambitions align and support local integration visions. If you are interested in your area taking part, contact firstname.lastname@example.org
What level of political engagement and accountability is included in the plans?
Where governance arrangements are published in the October plans, virtually all acknowledge the role of HWBs in their governance arrangements. There is little evidence of alignment of decision making across partners, however, and existing arrangements rarely give sufficient weight to local government.
Around half the plans evidence tangible political engagement and oversight from HWBs, scrutiny committees or cabinets. The LGA has consistently argued that there is a need for greater clarity on where accountability for the plans rests, particularly in sign-off arrangements. This includes continuing to insist that a local government body, most likely the HWB, sign off plans if they are to be supported and made operational.
The LGA also continues to stress that political engagement must be central to the development of STPs, given the democratic mandate from local communities, although reports suggest there is still a lack of progress on this front since the June 2016 submissions. The publication of all the STPs is a step forward, but much more engagement is needed to engage and secure the support of the public. The LGA has also stressed that ongoing dialogue is necessary, ahead of any consultation processes, and that this is most effective when describing change as part of a positive vision to improve health and wellbeing rather than as simply closures or services reconfigurations.
What role is local government playing in STP programme boards and work streams?
All STP governance arrangements should include members from local government in their programme boards. The more effective models have a joint programme board with members drawn equally from all partners including local government. More and more footprints are establishing delivery boards or groups to support implementation. A handful include political members such as the chair of the HWB and a couple have established reference groups of councillors; many more have council officer representation at CEO level.
The more inclusive plans include local government representatives and issues evident in the programme work streams, and council leads at director level are heading up work streams in a number of areas, such as prevention, workforce integration or the integration of services for older people.
What does ‘good' public engagement look like?
Some STPs have shown efforts to consult the public and service users through specific engagement strategies, others have bolted onto existing engagement activity, while others present less evidence of specific engagement. Around a quarter of plans evidence STP public engagement activity to date and under half of the plans have presented detailed plans for public engagement going forward. To promote system-wide engagement and assurance, one area has established a ‘community council' of residents, councillors, voluntary sector and other key stakeholders.
With over three-quarters of STPs planning acute service reconfigurations, the LGA will continue to argue that predetermined proposals cannot be presented to communities or their political representatives and that local government partners must be involved at an early stage to discuss concerns and secure their support.
Overall, public engagement has been a well-reported weakness of the process. Many plans have not sufficiently engaged the public on reconfiguration options or gone to the necessary lengths to present the ‘case for change'. NHS leadership has recognised this to some extent and called for renewed efforts going forward. The LGA will continue to encourage greater coproduction with citizens, including sharing examples of good practice.
What programme management arrangements are place in order to support implementation of the plans?
There is a mixed picture in terms of programme management, with a number of footprints attempting to secure specific resource from national NHS bodies in support. Most will need to use existing resource. It has been noted that the health side of many STP footprints tend to have more capacity to support this, although all partners are struggling to meet STP and operational capacity demands.
Implementation requires leadership capacity and investment and feedback from local government colleagues shows concerns that not enough is being allocated to support STP leaders to develop their plan. Above all, colleagues urge national NHS bodies to set out a clear route map for implementation, including central expectations in regard to governance, communications and engagement, finances including capital, and timescales.