Richard Smith: STPs—too much sustainability, too little transformation?

richard_smith_2014STPs (Sustainability and Transformation Plans) are the device that it is hoped will save the NHS in England by dramatically improving efficiency and allowing NHS bodies to balance their budgets. They are being drawn up in the 44 “footprints” of England and are intended to cover acute hospitals, mental health, community services, and social care. Can they work or is there “too much sustainability and not enough transformation” was discussed at this week’s Cambridge Health Network meeting

Lord Carter, a non-executive director of NHS Improvement and the author of a report on improving productivity in NHS hospitals, argued that sustainability alone won’t achieve the aims; there will have to be transformation, meaning doing things differently, and the NHS does not have a good record on transformation. The NHS is trapped in a triangle of an aging population, new and often expensive technology, and a reluctance to increase taxes. It is not alone: all health services face similar problems. The new oncology drugs coming through are “terrifying in their cost” and which politician will be able to resist them, asked Carter.

Talking mainly about acute hospitals (“because that that’s where the money is”) Carter proposed three broad responses: increasing efficiency; introducing new ways of working; and consolidation.

There is no big lever to improve efficiency. It requires, he said, a “line by line analysis of everything.” “The devil is in the detail” was the most quoted cliché in the meeting. But the data produced for Carter’s report showed huge variations in efficiency. Some hospitals are world class, whereas the people running some others have “no idea what they are doing.” Some hospitals require 40% more nurses or 60% more clinicians than other hospitals to deliver “like for like services.” This is, said Carter, “totally unacceptable,” and yet is accepted. (I thought at this point of a venture capitalist who said to me that he would never invest in a business that depended for success on somebody in the NHS losing their job.)

The NHS is spending £600 million a year on advice from consultants, but, said Carter, we know what to do in that somewhere in the NHS there will be best practice. Unfortunately, as in other health systems, best practice doesn’t spread. “The NHS,” said Carter, “has done everything right once.”

Consolidation, conceded Carter, “is not easy.” He told the story of how he lost two suits to rotten eggs and tomatoes when trying to close a community hospital in Cornwall. It dawned on him that people didn’t understand what the hospital actually did, so he commissioned a poll that showed that 80% of the population thought that the hospital did heart surgery. Another speaker told a story of taking 20 years to close an old, long-say hospital infested with cockroaches: the population objected to the closure of the Accident and Emergency Department when there was no such department. “I thought that at one point I might have to open one,” she said.

The announcement of a third runway at Heathrow was made the morning after the meeting and illustrated clearly the political difficulties of such changes. The decision has been pending for 50 years, and yet many politicians, including cabinet ministers, have confidently predicted that it will never happen. “We British are experts at obfuscation,” said a politician on the radio.

One trick is to consolidate services that nobody notices: radiology, pathology, and back office functions like finance, human resources, and information technology.

For STPs to succeed they will need, said Carter, political will, stability, and help. Politicians need to accept that painless efficiency savings are “not real,” and people need guidance on what to do. Carter told the story of visiting a hospital where the radiology services were “appalling.” “Are they really that bad?” asked the chief executive; “What does good look like?” People need guidance on best practice.

Christine Outram, chair of the Christie Foundation Trust (the biggest specialist cancer centre in Europe), addressed the question of whether the STPs would succeed by reflecting on her experience of 30 years in the NHS, 20 of them as a chief executive. Her positive story was being part of the team that closed half of the quangos that proliferated after the NHS plan of the 90s. The closures saved three quarters of a billion pounds and the only people who objected were some junior ministers who could be “quashed” and the devolved powers who could be “ignored.”

The bad story, which is more relevant to the STPs, was trying to reform healthcare in North London where primary care was of mixed quality, there were too many medium sized hospitals, and on average it took patients six days after admission to hospital to see the specialist they needed to see. Progress was slow and painful.

Outram, like Carter, emphasised “what’s-not-to-like projects?” and described how the Christie had within three years changed from delivering 80% of chemotherapy in the hospital (with some patients travelling eight hours for one hour’s treatment) to 80% being delivered in outlying stations, a mobile clinic, or patients’ homes. The change didn’t save money but delivered greater value, particularly for patients, and there were no losers, it was clinically led, within one organisation, sustainable, and allowed staff development.

STPs, in contrast, are “massive,” and even if they can deliver it may not be in time. And they are more likely to be successful in places, like Manchester, where there are teams working on the project; places that depend simply on a local chief executive chairing meetings are unlikely to succeed.

A primary care doctor in the audience regretted that the speakers had not mentioned primary care, prevention, and public health, and there was agreement that they would all be important in STPs. Why, asked somebody else, were people who no longer needed acute care being kept in hospitals at £2000 a week when they could be managed in nursing homes, which currently have 2000 empty beds, at $800 a week. The answer seemed to be that clinical commissioning groups won’t spend money on care homes (perhaps, I thought, because it might destabilise their local hospital). There were several examples shared of “obvious” changes that were hard to make happen.

The unsurprising conclusion was that some STPs would succeed but others would not, meaning perhaps that the successful might have to bail out the unsuccessful ( a perverse incentive). There was also agreement that “time is the enemy.” The next two years will be “very rough.”

Richard Smith was the editor of The BMJ until 2004. 

Competing interest: RS is the chair of the board of and has equity in Patients Know Best, which will hope to benefit from STPs; and he has shares in UnitedHealth which will also hope to benefit from STPs, although he has no influence on its decisions and the share price is unlikely to be affected by what happens in Britain. Perhaps his biggest competing interest is that he is approaching his dotage (has already arrived, according to his children), has no private health insurance, and may soon be needing the care of the NHS.