“Secret plans to change our NHS”: This is the allegation levelled at sustainability and transformation plans (STPs) – the government’s latest NHS reform initiative – by campaigning group 38 Degrees. Some politicians seem to agree, with former shadow health secretary Diane Abbott calling them “a dagger pointed at the heart of the NHS”.
Simon Stevens, the chief executive of NHS England, sees it differently: “Now is quite obviously the time to confront … the big local choices needed to improve health and care across England.” For him, STPs are a way of delivering the reforms he set out in the NHS Five Year Forward View (pdf) and the £22bn of efficiency savings he promised to the government, while maintaining or improving the quality of care.
As details of the STPs have been made public and the extent of the winter crisis in the NHS has become apparent, the debate about their role in the health service has become dangerously polarised. The question is whether these controversial plans will prove to be kill or cure. Based on a detailed analysis of all 44 plans, we at IPPR think the reality is probably more nuanced and complex than either side let on.
On the one hand, it’s clear that some elements of the argument made by campaigning groups – for example, that the government is knowingly underfunding the health and care service – stack up. Our analysis shows that every STP area is forecast to be in deficit by 2020-21, and these deficits total more than £24bn. For Theresa May and (somewhat more reluctantly) Simon Stevens to suggest that this financial gap can be closed through reform alone is disingenuous to say the least.
On the other hand, campaigners are wrong to argue that the reform agenda is simply about delivering dangerous cuts. The NHS cannot stand still as the world transforms around it. Instead, it must respond to growing demographic pressures; new evidence about what works and what doesn’t; and cutting edge technologies that can transform health and care.
Hospital reconfigurations are a perfect example of the need for a more balanced discussion. Campaigning groups have raced to uncover “secret” plans to close local hospitals, arguing that these changes are evidence of the government’s deceit. And, they are right to highlight that these changes are afoot: our research finds that up to 44% of STPs include hospital closures or reconfigurations.
However, the potential benefits of these changes have gone largely unnoticed. There is strong evidence for some services, in particular A&E and specialist surgery (pdf), concentrating care in fewer locations. This can save lives by ensuring people have access to the most highly trained doctors and the best equipment. Likewise, there are many examples where treatment could be moved out of hospital all together, saving money but also improving outcomes: for example, only 7% of people say they would prefer to die in hospital with the vast majority opting for home.
This doesn’t mean that all the planned changes are justified, some are likely to be driven by the need to cut costs but many are not and should end up improving health outcomes over the coming years.
Likewise, the wider health and care reform agenda is yet to get a fair hearing, with a number of initiatives likely to result in better care, for example new “community care hubs”, which will bring together GPs, mental health services and social care at a local level; “a truly seven-day health service” with GPs opening on evenings and weekdays; and the adoption of new technology that allows people to receive support remotely.
STPs are an opportunity to deliver these reforms – which will help to transform the quality of care delivered up and down the country – ensuring that the NHS is fit for the 21st century. However, there is no doubt that the NHS will struggle to seize these opportunities without three key changes.
First, the government must recognise that the health and care system needs more funding both to manage the immediate pressures of the winter crisis but also to properly fund the reform agenda. A good start would be a rise in national insurance. This could raise up to a further £16bn over the next five years, dramatically closing the funding gap.
Second, the government – in particular Theresa May and Jeremy Hunt – must start supporting NHS leaders in making the case for reform, in particular controversial and little understood hospital reconfigurations. This will give local NHS leaders the political leadership they need to argue for their proposals locally.
Finally, once central government has helped local leaders win support for their reform plans, they must be given the tools to deliver these changes and allowed to get on with it. This may well mean giving NHS leaders real powers to intervene in their local area, as well as devolving functions currently undertaken by central government as has happened in Greater Manchester.
STPs are an opportunity rather than a risk for the NHS, but without these fundamental changes, it seems inevitable the NHS will remain a 20th century system in a 21st century world.
Harry Quilter-Pinner is a research fellow on public services at the IPPR thinktank. This is an edited version of an article on the IPPR blog and is part of a wider project on STPs.
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Will NHS transformation plans kill or cure the health service?
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