NHS Sustainability and Transformation Plans
What Was Said
On September 14, the Opposition debate in the House of Commons took place on the NHS Sustainability and Transformation Plans (STPs). The motion was moved by Diane Abbott, Shadow Secretary of State for Health. We reproduce extracts from the debate, edited for continuity.
Diane Abbott: I beg to move,
That this House notes with concern that NHS Sustainability and Transformation Plans are expected to lead to significant cuts or changes to frontline services;
believes that the process agreed by the Government in December 2015 lacks transparency and the timeline announced by NHS England is insufficient to finalise such a major restructure of the NHS;
further believes that the timetable does not allow for adequate public or Parliamentary engagement in the formulation of the plans;
and calls on the Government to publish the Plans and to provide an adequate consultation period for the public and practitioners to respond.
I am glad to open this debate on the NHS sustainability and transformation plans. As the whole House knows, the NHS has a special place in the affections of our constituents. No other public service engages with us all when we are at our most vulnerable – in birth, death and illness – and the public and NHS staff are increasingly aware that the NHS is under severe financial pressure, a matter I will return to.
In that context of financial pressure and concern about the availability of services, the sustainability and transformation plans are arousing concern. They sound anodyne and managerial, and there is undoubtedly a case for bringing health and social care stakeholders together to improve planning and co-ordination. But the concern is that, in reality, the plans will be used to force through cuts and close hospitals, will make it harder for patients to access face-to-face consultations with their GPs, and, above all, will open the door to more privatisation. It tells the public how little the Secretary of State cares about their concerns that he is not in the Chamber to listen or respond to this debate. We know that recently he has missed all seven recent meetings of the NHS board. The public are entitled to ask how much he cares about their very real concerns.
One of the most alarming aspects of the STPs is their secrecy. England has been divided into 44 regional footprints, and it is worth noting that they are called footprints to distract from the fact that they are ad hoc regional structures – they are the exact same regional structures that the Tory health Bill was supposed to sweep away. Because they are ad hoc and non-statutory, they are wholly unaccountable. In the world of the STPs, the public have no right to know.
Initially, the STPs were discouraged from publishing their draft plans, freedom of information requests were met with blank replies, and enquirers were told that no minutes of STP board meetings existed. We are therefore bound to ask: if the plans are really in the interests of patients and the public, why has everyone been so anxious to ensure that patients and the public know as little as possible?
GP leaders in Birmingham said that it would appear that plans by the STP to transform general practice, and to transform massive amounts of secondary care work into general practice, are already far advanced. Only at this late stage have they been shared with GP provider representatives.
So when the STPs talk about efficiency, they actually mean cuts. Increasingly at the heart of these STPs are asset sales of land or buildings to cover deficits. No wonder the leader of Hammersmith and Fulham Council, Stephen Cowan, has said of his local STPs that
“this is about closing hospitals and getting capital receipts”.
He went on:
“It’s a cynical rehash of earlier plans. It’s about the breaking up and the selling off of the NHS.”
The Health Select Committee’s recent report on the impact of the 2015 spending review stated:
“At present the Sustainability and Transformation Fund is being used largely to ‘sustain’
in the form of plugging provider deficits rather than in transforming the system at scale and pace. If the financial situation of trusts is not resolved or, worse, deteriorates further, it is likely that the overwhelming majority of the Fund will continue to be used to correct short-term problems rather than to support long-term solutions”.
Other aspects of the STPs that relate to cutting expenditure involve a combination of factors, including the use of new technology such as apps and Skype, patients taking more responsibility for their own health, “new pathways” for elderly care, increased reliance on volunteers and the downgrading of treatment by skills, responsibilities and pay bands. It seems to me that while some of these proposals might have some merit in themselves, it is delusional to imagine that they will deal with the financial black hole in the NHS. There is no evidence that among the patient population as a whole, increased use of apps, Skype and telemedicine can produce the efficiencies required while beds, units, departments and hospitals are being closed.
I remind Members, many of whom speak to their constituents in their advice surgeries on a weekly basis, that the truth about speaking to people face to face is that it is often towards the end of the conversation that people will come out with what really concerns them. My concern about the increased use of Skype is that many patients will not get the familiarity and comfortableness with their interlocutors to enable them to say at the end of the Skype session what it is that they are concerned about.
The STPs talk a great deal about increasing preventative medicine. That would indeed have the effect of lowering demand for acute NHS care, but it would also require a very substantial investment in public health programmes – and this Government have just cut public health funding. The elderly, the poor and patients for whom English is not their first language are the least likely to use these apps, telemedicine and Skype. It is inappropriate and unrealistic to assume that elderly patients who, I remind Members, are the biggest users of acute care and the fastest-growing demographic, will want to use Skype for any sensitive matter. “New pathways” for the elderly is sufficiently vague as an idea to raise alarm bells, given the projected rise in demand for geriatric services and continuing cuts in social care funding.
It was the NHS England director of STPs, Michael McDonnell, who said that they
“offer private sector and third sector organisations an enormous amount of opportunity”.
We know that PricewaterhouseCoopers has been heavily involved in the formulation of a large number of these plans, and we know that – as was mentioned earlier – GE Healthcare Finnamore, which was taken over by General Electric in the United States, has been heavily involved in the formulation of plans in the south-west and possibly more widely. The strong suspicion is that a combination of cuts, the reorganisation of services on a geographical basis, and the growth of hospital “chains” will facilitate greater privatisation of the NHS.
Heidi Alexander, Labour, Lewisham East:
I am grateful for the opportunity to speak in this debate. Sustainability and transformation plans – what are they, should the public be concerned, and are the plans good, bad or a mixture of both? As we have heard, over the last eight months or so STPs have been drawn up in 44 areas in England by a range of people involved in the running of the NHS and local government. As far as I can work out, they have come about because NHS England could see that in the chaos following the previous Government’s Health and Social Care Act 2012, there was no obvious body responsible for thinking about how best to organise NHS services at a regional and sub-regional level, so NHS staff and local government officials were tasked with assessing the health and care needs of their local populations, considering the quality and adequacy of the provision to meet those needs, and developing ideas about how those needs might be better met within available resources.
So far, so good, we might say, but there are three big problems. First, the current financial pressures on the NHS mean that the plans are likely to be all about sustainability, not transformation. Secondly, this is a standardised process to define and drive change, so we run the risk of good proposals being lumped in with bad ones, and of some plans simply focusing on the achievable, as opposed to the necessary and the most desirable. Thirdly, it is an inescapable fact that these plans are being developed when there is huge public cynicism about the motives of a Tory Government when it comes to change in the NHS. If the Government want to deliver change, the debate with the public needs to start in the right place – not behind closed doors, and not using jargon that no one understands. It needs to be focused on patients and their families, not on accountants and their spreadsheets.
I think most people understand that the NHS cannot be preserved in aspic. They understand that compared with the 1950s, we now use the NHS in a very different way. At the moment, they simply see an NHS under enormous pressure. They are waiting longer for an ambulance, to see a GP, to be treated in A&E and for operations. They see staff who are stressed out and who are on the streets in protest. When Ministers and NHS leaders talk about sustainability and transformation, the public are therefore dubious. For sustainability, they read cuts, and in some cases they will be right – it will mean cutting staff, closing services and restricting access to treatment. No matter good the plan, how thorough the analysis or how innovative the solution, we cannot escape the basic problem of inadequate funding for the NHS and social care.
As a country, we have a growing and ageing population. The reality is that in the last 10 years, the number of people living beyond the age of 80 has increased by half a million, and the NHS and social care are buckling under the strain. Although we should never give up on trying to organise the NHS in the most efficient and effective way possible, we have a choice. Do we want to cut services to match the funding available, or do we want to pay more to ensure that our grandparents and our mums and dads get the sort of care that we would want for them? If the NHS is to provide decent care for older people we need not only to fund social care adequately, but to find better ways of organising services to keep people out of hospital for as long as possible.
That leads me to the next problem. STPs are being used as a catch-all process to bring about change in the NHS, but many run the risk of focusing on the wrong things. They are being used as a vehicle to do different things in different places, and although some may lead to better treatment and better outcomes, the danger is that there will be knee-jerk, blanket opposition to everything. Some proposals will inevitably be controversial – the closure or downgrading of an A&E or maternity department will never be easy – but, in other cases, the plans may end up focusing on something that is not the burning issue.
Let me take my local area as example. The STP for south-east London proposes two orthopaedic elective care centres. The sites for them have yet to be decided, and the STP plan has yet to be signed off by NHS England. On the face of it, there is little wrong with the proposal to create centres of excellence so that all hip and knee replacements are done in one of two places. The problem is that when the front page of a national newspaper talks about the “secret” STP plans under which A&Es will close, my constituents fear the worst. “We’ve been here before,” they will say. They will smell a rat, even where one might not exist.
My constituents ask me these questions. What happens if Lewisham is not the site of the new centre, its elective work is shifted elsewhere and the hospital then struggles to staff the emergency department? Is orthopaedic care really the burning issue in south-east London? What about the queues of ambulances outside the Queen Elizabeth hospital? What about the homeless young man who pitches up in A&E because he has nowhere to sleep and there is no support for him in the community?
Where will the money come from physically to redesign the NHS buildings that such a care centre would entail? With £l billion taken out of capital budgets and switched to revenue last year, it seems fanciful to think that there will money lying around for such projects. The NHS is on its knees. Everyone knows that hospitals ended up £2.5 billion in deficit last year. We have all seen the reports of A&Es closing overnight because they have not got the staff. We all know that GPs are run ragged, that ambulance crews are stressed out and that nurses are demoralised, and that is before mentioning the junior doctors.
This is the main problem for the Government: if you do not fund the NHS adequately and if you do not staff it properly, do not be surprised when the public do not trust your so-called improvement plans. There is deep public cynicism when it comes to anything this Government wants to do to the NHS. People believe Ministers are trying to privatise it. They believe services are contracted out to the private sector to save money, not to improve quality, and in many cases they are right. The problem is not STPs as such, but the context in which they are being developed – inadequate funding, an inability to make the case for change, a workforce crisis that is leading to overnight closure of services and, as a result of all of these, a deep public mistrust of the Government’s intentions.
Andrew Slaughter, Labour, Hammersmith:
I hope that I am in a position to assist some of the Members who feel that they are in the dark or confused about what is in their STPs. That is not because my own sub-region, north-west London, is one of the two, I think, that have officially published their schemes – I fear that, like most NHS documents, it is written in a style and language that make it difficult for the ordinary public to understand. Rather, it is because, for north-west London, this process has not mushroomed overnight, as has been the case with STPs generally, but has been developed over four years. In the wonderful Orwellian language that is used, we have had something called “Shaping a Healthier Future” since the middle of 2012, and that has simply morphed into the STP, so I can perhaps give a little insight in the few moments that I have.
What did “Shaping a Healthier Future” mean? It meant the loss of 500 acute beds. It meant that of around nine major emergency hospitals two would, effectively, be downsized to primary care, and four A&Es would lose all their consultant services – and that, as far as I am aware, is still the plan. What has become clear with the transformation into STPs is that this is very much about money. The original language four years ago was that unless we implemented these cuts to acute services, we would “go bankrupt”. When that language did not go down very well – not surprisingly – with the 2 million people affected in west London, the language changed, and it was all about clinical care.
I am pleased that at least the honesty is now back in the system, and the proposals are now very much about money. One sees why when my own hospital trust – a very important, prestigious trust called Imperial, which runs three major hospitals – is over £50 million in deficit this year alone. The CCGs are flatlining on funding. The importance of that is that the only possible justification for these major cuts in acute care is that social care, community care and primary care funding will be increased. How that is possible with budgets that are, at best, standing still, I really do not know.
The other interesting factor is the delays that have occurred over this time. We had this proposal in the middle of 2012 and a slight revision in February 2013 – and then silence. I have lost count of the number of times I have been promised that a full business case will be published. I act as the unofficial shop steward for the 11 Labour MPs in the sub-region, and I summoned them all to a meeting and said, “You’re going to get the business plan this month.” It was going to be next Tuesday, and we were all coming in in the recess to look at it, but, guess what, it has been put off until at least after the new year.
Moreover, the plan is now thought to be so unwieldy and so difficult to achieve that it has been split in two. My own hospital – Charing Cross – was due to lose 90% of its acute beds and its consultant emergency services, and we simply do not know when the proposals will now be published, but it has already been taken outside of the STP process. In other words, it is beyond the five-year horizon, and nothing will happen until 2022. Now, in one way, of course, I am delighted that the demolition balls are not going into Charing Cross for that period, but in the meantime the lack of support the hospital is getting worries me greatly.
These STPs are a Trojan horse for cuts. They are about cuts in acute services before there are compensatory services. For that reason, Members should be extremely concerned and worried about them, and I am happy to share my pain and knowledge on the subject if any Members wish to hear about them.
Emma Lewell-Buck, Labour, South Shields:
We have all become accustomed to the Conservative party’s disdain for our NHS since the shambles of the top-down reorganisation that began in 2012. Now we have the stealth introduction of sustainability and transformation plans – secret plans that would bring yet more unjustifiable and drastic reforms to cash-starved hospitals. Instead of being given the funding they so desperately need, hospitals are being asked to make £22 billion of efficiencies to compensate for this Government’s total mismanagement of our NHS. The audacity of making hospitals themselves pay the price for that by threatening them with closure or the reduction of acute services is the final act of treachery in a tragic and deliberate play to decimate our NHS.
South Shields is part of the footprint area of Northumberland, Tyne and Wear, an arbitrarily created boundary. By 2021, the health and social care system in that footprint area is projected to be £960 million short of the funds it needs to balance its books while maintaining the same level of care for patients. Make no mistake: these plans are about cuts. They are nothing to do with transforming our NHS for the better. The NHS has been set an impossible task by the Government; the endgame is to see it in private hands.
The Government have said that the initial STP submissions to NHS England are
“for local use, and there are no plans to publish them centrally” – a nice touch to put the onus once on to our hospitals again, so that the Government themselves do not have to deal with the flak.
I was born in South Tyneside hospital. I am the local MP for the area, and I have not seen a single plan. Not even the governors at my local hospital have, let alone the people of Shields, whose vital acute and emergency services could be devastated by these changes.
I am told that the timetable for implementing these unseen plans begins this autumn, yet the first we will see of them in my area is at the end of this month – that is, in the autumn. I am extremely alarmed at the lack of accountability and transparency with which the plans are being pushed through. There is simply no time at all for consultation. I make a plea to all NHS leaders not to be complicit but to stand up for their hospitals and the communities that they serve. The Government have no mandate for such a radical reconfiguration of our NHS, one that could involve the closure of accident and emergency and acute services up and down the country.
Last week, the Prime Minister called in NHS leaders to order them to stop any hospital mergers or closures that risk causing local protests. There is already a protest in my constituency.