Unlike the healthcare system in which they sit, the sustainability and transformation plans (STPs) cannot attempt to fix every problem. “We mustn’t see them as the panacea for everything,” warns Julie Wood, chief executive of NHS Clinical Commissioners (NHSCC). “It’s the notion of subsidiarity. We need to take the right decision, at the right level, to get the right outcome.”
When the 44 STPs were drawn up in January 2016, they were tasked with closing three gaps: a funding and efficiency gap of £22 billion by 2020 across the NHS; the care and quality gap between the best and worst performing organisations; and the health and wellbeing gap by reducing avoidable illnesses through promoting self-care and mental health services.
But nearly 10 months later, many of the plans are still under lock and key. So what can CCGs expect as they implement STPs from next year? How are they planning to stabilise funding for mental health services and community pharmacy? And how will the practice of commissioning be altered in the process?
Q: What are the next steps for CCGs in terms of implementing the plans?
A: The next steps are about getting support for the plans. STPs are just that: plans. So we need to ensure we are able to move from plans into implementation, which for some may be a smooth transition. For others it may not.
You have to remember that we have 44 different footprints, which are currently at 44 different stages of development. They need to connect up all the different bits of an STP. We are bringing together all the people who have a critical role to look at how they can make the best use of the collective pound they have in their footprint.
Q: To what extent have the nurses and GPs involved with CCGs been involved in STP talks?
A: They have been involved - because they are involved in governing bodies. We feel strongly that we need clinical leadership and engagement throughout.
We know that having clinicians in those processes is really powerful in successful implementation.
We also need the engagement of the wider clinical community. If we are looking at doing things differently and bringing in commissioners and providers in a much more collaborative way, we need clinicians owning the issues so we get commitment and buy-in for implementing the issues, whatever they are.
It is about clinicians and managers working together to get this symbiotic relationship to deliver change.
Q: How confident are you that STPs can deliver efficiency savings?
A: It is early days. Much depends on support for the proposals. Some of those proposals are likely to be controversial. If they are supported and can move towards implementation, my confidence levels will be higher.
Given the amount of expectation that the STPs will deliver on all three fronts, we need to make sure they do.
Q: What challenges do you expect for CCGs as they implement the STPs?
A: Getting engagement with all the different bits of a footprint is fundamental to success because we’ve got to bring the population with us.
The demand on resources is increasing, so there might be a trade-off between doing things differently here, in order to liberate the gain here. Getting the buy-in and the understanding for that is big.
And then getting the commitment to work with those plans and implement them will be fundamental. It is vital to be clear about who is to take decisions and how they will take them in a way that they can implement their plans once you have the engagement and buy-in.
But there is a danger that STPs are becoming the be-all-and-end-all. They can’t be that or they won’t deliver. It will still be business as usual in terms of what is being done in some areas.
Q: The GP Forward View says investment in primary care is likely to grow even further than the promised 14% increase ‘as CCGs build community services and new care models’. In light of the deficits that CCGs face, is this likely to become a promise that can be fulfilled?
A: STPs have to work through how to deliver the GP Forward View, commitments on mental health and cancer, eliminating the deficits and closing the care gap. But it’s like a balloon – you squeeze it at one end and the air has got to come from somewhere else.
So we absolutely need a commitment to ensure that general practice is both sustained and transformed.
But equally we need to ensure that we deliver parity of esteem for mental health. And when you list all those absolute needs, you’ve got to see that in the context of the available resources.
Q: For the final three years of the STP, how will the commissioning process change to accommodate the STP vision?
A: Contracting will be set for the next two years. NHS England is bringing forward the planning process so that the way is clear in the new year to implement the plans. That is fundamentally important because next year we’re looking at a growth of between 4.4% and 4.8%, which is less than we’ve got this year. So we really have to spend all our energy on implementing the changes and transformation.
The two-year operational plans are the first two years of STP implementation. Then at a certain point in 2018/19 we will be set a new task. Whether we would be setting rolling contracts, I don’t know, but we then move into implementing years three, four, and five of the STP.
Q: Commissioning contracts could become rolling at that stage?
A: I have not had any conversations about what it would look like. It’s not good to have start-stop contracts. It gives people uncertainty.
We have been calling for longer planning cycles because doing everything on a one-year basis isn’t good. We don’t need to have a contract that ends in 2018/19 if we have been through a procurement process. Some places might have longer contracts; it is about trying to get that blend right.
Q: We are seeing more CCGs announcing mergers, like North, South and Central Manchester CCGs most recently. Is that the future of commissioning?
A: We have started to see the commissioning system evolve. CCGs in some places will want to formally merge. If that’s the right thing to do with their population and they have clinical buy-in from the member practices then we will advise NHS England to enable that to happen.
What we don’t want to see is a forced merger from the top down, as we lurch from the idea that small is beautiful to big is beautiful. CCGs must be the right size to do the right job. That will look different in different parts of the country.
Q: Graham Jackson (co-chair of NHSCC) wrote in the Health Service Journal that NHSCC would be publishing a ‘road map’ in July of what the future of clinical commissioning should look like. This still hasn’t been published. How do STPs feature in the publication?
A: No, that hasn’t come out. It won’t be called a roadmap. That is old language. We hope to be publishing it in the next couple of weeks. It will be a relatively brief document, describing how the clinical commissioning landscape is evolving and what needs to be enabled.
Q: What is being done in CCGs to ring-fence funding for mental health?
A: There’s some work being done. It’s important that we don’t just look at it through the lens of a provider trust. So investment in mental health needs to look across the piece. As we are looking at new models of care for mental health it might mean investing in the third sector in a different way, or in provider trusts.
We absolutely need to make sure we can deliver on the expectations that have been set out for mental health commissioners.
We must put all those absolute commitments against one another and ask how we do that in the totality of the resource we have at our disposal.
Q: How will the cuts to pharmacy funding impact on CCG efforts to bring more services into the community?
A: Community pharmacies are important partners in helping CCGs deliver. Many CCGs are already working with pharmacies and pharmacists, getting more clinical pharmacists working in primary care to do more for patients.
The community pharmacy spend is part of this big picture and the NHS budget is under extreme pressure as we know, so community pharmacy cannot be exempted from a look at what the system gets in return for investment.
The whole system must play a part in changing and making sure the system gets the best return – including community pharmacies.