STPs are loose coalitions of agencies without statutory powers, so they cannot implement change, only encourage it. With little money left in the Transformation Fund, they have to “work around” their local NHS and social care organisations. At the launch of the King’s Fund report ‘Delivering sustainability and transformation plans: from ambitious proposals to credible plans’ (on 21st February) we heard that “with the right leadership” STPs could stabilise the NHS, that STPs mean that “politicians must be brave” (and not impede changes in the NHS in their constituencies), that NHSE and NHSI need to work as one (because they don’t), and that “there is no Plan B”.


Much of what was said at the launch was familiar. Plans to shift care into the community and integrate health and social care have surfaced several times in the last decades, leaving little trace. There is little new in the STPs, except perhaps the higher profile of local government.  The NHS is famous for its lack of memory, a point made gently by Chris Ham of the Kings Fund at the end of the launch event. The language used was standard NHS speak – “challenges”, “conversations”, “journeys”, “taking plans forward”, “meaningful engagement” – and the speaker who described how the STPs were “moving fast” surprised those who thought progress was painfully slow.

It was not clear from the discussion that there really are many parts of the NHS or social care where practitioners are straining at the leash to change, are constrained by present structures and rules, and are ready to innovate given permission and leadership. Perhaps the Vanguard sites are such places.

The impression I left with is that transforming social care and health services that are struggling to survive is a David versus Goliath battle, in which STP advocates are hoping for a lucky shot. The Kings Fund launch did say that in a way, suggesting that STP footprints should prioritise two or three changes, in effect abandoning transformation as an objective. The NHS Confederation has since urged ‘patience’ in developing STPs, not the current unrealistic timetable. This may be an opening for Labour to gain some traction within the NHS, and avoid being marginalised into “Slash, Trash and Privatise” rejectionism. We need to look at provision over the whole health and social care system and sort out a governance framework for a single health and social care service. STPs are an attempt to bring together relevant players at a higher organisational level than Joint Planning Boards, so could offer the overview and design the governance. If the STPs were led by local government, with a topped-up Transformation Fund and a ten year remit to bring about change, we might just make haste slowly.

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  1. Tony Jewell says:

    Interesting commentary Steve. Thing is that LAs have been hammered over recent years and some are a shell of what they were. Victims of budget cuts and outsourcing and loss of officer competences. Health and Social Care is a financial hot potato that causes the ‘hand offs’ we see between the NHS and LAs. As you say STPs are not empowered by statutory power so not sure what their traction on system reform will be.

  2. healthaudit says:

    Steve , You underestimate your oponent. This is not the same old stuff repackaged. This is the first stage toward creating ACOs in the UK. Do a wiki search on ACO and Managed care and it is all there.
    As always the beauty of words is that they mean the opposite of what is intended. They will not be accountable ; they will not care and they will disorganise and destabilise those providers in the UK who we all rely on.
    If you dont believe me read the STP’s which have been collated on Health Campaigns together
    A report is being prepared but dont forget to support the National Demonstration on 4th March.
    The STPs are moving fast ; they are seeking to create executive bodies with full delegated powers to implement STP’s. They will be up and running before most people knew they existed. It is a Putsch.
    That sensible people are going along with it is a sign of desperation on their part along the lines of anything is better than what we have got now. If only that were true.
    Labour needs to be clear to the people in the NHS and outside.
    The trouble is they agree with STPs or are mealy mouthed , have fantasies that local government will have a new role and they think STPs will bring new money to the pot.
    Labour should reject STP’s and Labour councils that have signed up unthinkingly need to think again; Local Government need to oppose the harm being done by central government to social care and to expose the fact that the STPs are threadbare , wishful thinking; that are economically incoherent and a waste of money.
    Prevention is not going to halt the rising tide of ill health and neither will pretending it will.
    Moving from a reactive to a proactive model of healthcare will cost more in the short term.
    Transforming the acute sector is code for knocking down perfectly good hospitals and building expensive new ones. The sums don’t add up as the Kings Fund are belatedly saying.
    The NAO have reported there is no evidence the plans will work.
    The UK spends about 20% of GDP on health and social care while France spends 30%. Those that pretend the future is in chiseling at the 20% in order to be able to reduce taxes some more in order to get elected are missing the bigger picture.
    The NHS will be unsustainable unless it gets more.
    The Labour Party will be unelectable unless it recovers its powers of speech.

  3. davidakirby says:

    The phrase “‘Slash, Trash and Privatise’ rejectionism” implies that those of us who consider that attempts to reduce NHS spending substantially whilst continuing with massive PFI payments and further privatisations, in which services are landed with the large extra costs of paying for investors’ profits, and simultaneously improving social care provision are somehow opposed to any development or change in the NHS or social care. On the contrary, we want change that is improvement in both, and recognise that this will require both funding and commitment to social justice and collective ownership..that is, things that are absolute anathema to the current administration of NHS England.

    These people were appointed, clearly, to oversee the next phase in a long game the aim of which is to destroy collectively funded health care and social care, which is an object of hatred, all the more strong because it is successful and efficient, for neoliberals the world over.

    Local government is currently non-existent; the central control and restriction of funding of local government is so severe that the election of Labour or other councillors makes little or no difference, indeed it suits the neoliberal elite for Labour to be selling off Council-owned and NHS property, restricting access to services, and forced to slash funding for social care.

    This article seems to be lacking in some sort of basic understanding of the current balance of power in political life, and the current direction in which those who control an ever-increasing share of the world’s wealth are travelling. The NHS, as it was portrayed in US electoral politics, has to be demonised – it has to be made to fail, through staff demoralisation (that is why Hunt goaded and demoralised the junior doctors) and lack of funding – and what better way than for larger and larger parts of its ostensible funding in fact to be directed straight into their pockets through privatisations, PFI and inflated drug company profit margins?).

    Please wake up and espouse ‘rejectionism’ – all socialists and all concerned with public health MUST reject the strategies of NHS England (and particularly its dishonest use of the language of improvement and renewal to cloak a demolition process) and the suppression of local democracy, Trump, Farage, LePen, Jeremy Hunt and Simon Stevens. What is being rejected is lies, dishonesty, and the discredited belief that the greed of a few owners of capital, who incidentally would never consider using the NHS, will somehow benefit society. We reject the “hidden hand” which is the hand of a thief.

    1. Steve Iliffe says:

      Local government is suffering, but working with the NHS may bring it advantages, pooled budgets being one. The NHS could gain a lot from joint working with local government given its experience with commissioning (dire in the NHS) and with public involvement (the NHS lacks democratic legitimacy). Then there are local governments’ different perspectives on prevention, service integration and mental health. The STPs could be the framework for such co-operation, taking Labour from an oppositional stance to promoting an alternative shape for the NHS, and opening up a political movement as urged by Corbyn’s leadership team. Given the debates about federalism, we might even see the health service managed by elected local government, one day.

      I will tell my councillor comrades that local government does not exist; they will enjoy the joke, except for those who will think the view ignorant and arrogant. Copeland shows us that the NHS will not save Labour. The government has more support than Labour (in the polls) as custodian of the NHS. It is hard to underestimate such an opponent, but we can overestimate, seeing dark and sinister forces mustering on the horizon, catastrophic portents of the end of the NHS, as if we were characters in Lord of the Rings. This dramatic composition for political effect is so NHS. Think of the shroud-waving that breaks out with any proposal for change.

      Catastrophising is a problem for us, not an asset. At the SERTUC conference on the NHS last weekend the topics brought up by trades union activists for discussion – reconstructing social care, responding to management bullying, even STPs – were crowded out by the muddled thinking of rejectionist rhetoric. Let’s hope that the much-needed Labour Movement show of force on March 4th is not marred by the same thing.

  4. Adrian Mercer says:

    Thanks for this overview of STPs. I think that , as you conclude, with some patience and more resources, and a more reflective approach to change (as I describe in my recent blog on this site), there is some hope for the future. I share the reservations about ACOs, and privatisation, mentioned in other comments. Despite this, we should all think positively about how the NHS needs to change and improve. Not to do so opens the door to those with a more radical agenda.

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