In England, a sustainability and transformation plan (STP) is a non-statutory requirement which promotes integrated provision of healthcare, including purchasing and commissioning, within each geographical area of the National Health Service. The plans were introduced in 2016 but by 2018 had been overtaken by progress towards integrated care systems.
Establishment In March 2016, NHS England divided the geographical areas of England into 44 sustainability and transformation plan areas (or footprints) with populations between 300,000 and 3 million, which would implement the Five Year Forward View. These areas were locally agreed between NHS trusts, local authorities and clinical commissioning groups. A leader was appointed for each area, to be responsible for the implementation of the plans which are to be agreed by the component organisations. They were to "work across organisational boundaries to help build a consensus for transformation and the practical steps to deliver it".
Evolution During 2017 the use of the acronym STP shifted, so that it was used to signify sustainability and transformation partnerships. In February 2018 it was announced that these organisations were in future to be called integrated care systems, and that all 44 sustainability and transformation plans would be expected to progress in this direction. The ten pioneer systems were described as nascent and fragile by the Health Select Committee in May 2018.
By December 2020 only 13 sustainability and transformation partnerships still existed, with 29 transformed into integrated care systems.
Areas The geographical configuration differs in some respects from previous NHS arrangements – regional hospital boards, regional health authorities and strategic health authorities – because the configurations have been locally agreed, rather than imposed from the centre. When established in 2016, there were 44 STPs which varied considerably in size, the largest having more than ten times greater population than the smallest. By 2019 there were 41, after three STPs in the North East merged.
, the seven NHS England regions have 42 STPs which are at varying stages of progression into integrated care systems.
North East and Yorkshire
South Yorkshire and Bassetlaw STP Humber, Coast and Vale STP West Yorkshire and Harrogate (Health & Care Partnership) STP Cumbria and North East STP
North West
Cheshire and Merseyside STP Greater Manchester Health and Social Care Partnership Healthier Lancashire and South Cumbria
Midlands
Joined Up Care Derbyshire STP Staffordshire and Stoke-on-Trent STP Shropshire and Telford and Wrekin STP Nottingham and Nottinghamshire Health and Care STP Herefordshire and Worcestershire STP Birmingham and Solihull STP The Black Country and West Birmingham STP Coventry and Warwickshire STP Lincolnshire STP Leicester, Leicestershire and Rutland STP Northamptonshire STP
East of England
Mid and South Essex STP Bedfordshire, Luton and Milton Keynes STP Suffolk and North East Essex STP Hertfordshire and West Essex STP Norfolk and Waveney Health & Care Partnership (STP) Cambridgeshire and Peterborough STP
London
Our Healthier South East London STP East London Health & Care Partnership (STP) North London Partners in Health & Care (STP) North West London Health & Care Partnership (STP) South West London Health & Care Partnership (STP)
South East
Frimley Health & Care ICS (STP) Hampshire and the Isle of Wight STP Buckinghamshire, Oxfordshire and Berkshire West STP Kent and Medway STP Sussex and East Surrey STP Surrey Heartlands Health & Care Partnership (STP)
South West
Devon STP Somerset STP Cornwall and the Isles of Scilly Health & Social Care Partnership (STP) Dorset STP Bath and North East Somerset, Swindon and Wiltshire STP Gloucestershire STP Bristol, North Somerset and South Gloucestershire STP
Staffing , three of the leaders are from local government: Sir Howard Bernstein, chief executive of Manchester City Council; David Pearson, director of adult social care at Nottingham City Council; and Mark Rogers, chief executive of Birmingham City Council and president of the Society of Local Authority Chief Executives and Senior Managers. The remainder are NHS managers.
Finance The NHS planning guidance for 2016–17 stated: "For many years now, the NHS has emphasised an organisational separation and autonomy that doesn’t make sense to staff or the patients and communities they serve… System leadership is needed." It also suggested that the financial problems of individual organisations are no longer critical: "what is important is the financial situation of the organisations in each area considered together". Each area was required to produce a Sustainability and Transformation Plan by end of June 2016.
In February 2017 the National Audit Office produced a report suggesting that plans to save millions of pounds "may be optimistic", that there was poor oversight of the various initiatives and that progress with integration plans had been slower and less successful than planned. £5.3 billion spent through the Better Care Fund in 2015/16 had not delivered value for money. Furthermore, there was "no compelling evidence" to suggest that integration would lead to financial savings or less use of acute hospitals.
£325 million capital funding for the strongest plans was announced in March 2017 but Sir Robert Naylor concluded that at least £10 billion would be needed to deliver proposed plans and make NHS facilities fit for purpose. His review suggested that £6 billion could be raised by selling NHS land and buildings.
Development Simon Stevens described the progress made in December 2016, saying that the most advanced areas were "capable of combining the purchaser and provider, the commissioning and provider function, a la Frimley Health”. In some cases he expected a "governance partnership of the relevant statutory bodies" which in some cases might become integrated organisations. But in some areas there were only proposals, not yet progressed into plans. He proposed to give the most advanced money and authority to progress their plans. NHS England would organise national support programmes, particularly for “primary care provider development”, support urgent and emergency care systems, rather than to individual organisations, and set up clinical standardisation and productivity initiatives under professors Timothy Briggs and Tim Evans.
Plans released in March 2017 propose at that all plans should evolve into accountable care systems with "clear collective responsibility for resources and population health" and some control over devolved funding for mental health, cancer and general practice. Between six and ten STP areas are to be launched as accountable care systems.
A survey by the Chartered Institute of Public Finance and Accountancy in September 2017 found that of 56 organisations who responded to a survey, 55 did not believe that joint working between local government and health organisations would be fully achieved in the next 5 years. They also found that there was no funding for plans to increase preventative work.
Accountability Steven Broomhead, the chief executive of Warrington Borough Council, complained to NHS England in July 2016 that decisions were being made "without any local transparency". He said changes to where people receive services and what services they receive needed "local scrutiny and local community involvement".
Care in the community It is planned to transfer patients to care in the community. This may lead to improved care in some cases but the King's Fund claims not all community care plans are credible because there are insufficient services outside hospitals and there is insufficient money to provide more. The King's Fund fears reducing hospital beds will increase the strain on hospital services which were overstretched during the 2016–2017 winter. Professor Chris Ham of King's Fund maintains transferring services to the community is a potential improvement in many cases and plans should be considered on their merits. Ham maintains further transfer to the community cannot be done without extra funding and urges the government to invest in community services. The Nuffield Trust reported that some STPs were planning up to 30% reductions in some areas of hospital activity - going against trends which have persisted for the last 30 years. They conclude that out-of-hospital care may be better for patients, but it is not likely to be cheaper for the NHS in the short to medium term.
Reaction to proposals According to Dr Brian Fisher, "STPs are driven by the Treasury. They are focused on reducing NHS spend. (...) Unless STPs meet the funding demands of the Treasury, the plans will not be approved and areas will not receive any transformation money." An article by the King's Fund states, "Allocations from the fund for sustainability and transformation must be agreed in advance with HM Treasury and DH’." The same article states that the spending review, "is both ring-fenced and needs HM Treasury agreement to unlock."
The Nuffield Trust think tank claims many suggestions would fail to implement government financial targets and involve a "dauntingly large implementation task". Sally Gainsbury of the Nuffield Trust said many current plans involve shifting or closing services... "Our research finds that, in a lot of these kinds of reconfigurations, you don't save very much money - all that happens is the patient has to go to the next hospital down the road. They're more inconvenienced... but it rarely saves the money that's needed."NHS cuts 'planned across England' BBC There will be a shift from inpatient to outpatient care but critics fear cuts that could put lives at risk, that the plans dismantle the health service rather than protecting it, further that untested plans put less mobile, vulnerable people at risk. By contrast, NHS England claims that the plans bring joined-up care closer to home. John Lister of Keep Our NHS Public said there are too many assumptions, and managers desperate to cut deficits were resorting to untried plans.Plan to 'transform' NHS could lead to downgrade of major London hospitals The Guardian A survey of ninety-nine clinical commissioning group chairs and accountable officers conducted by the Health Service Journal in October 2016 found very little confidence that the plans would deliver.
An article in The Guardian by an anonymous NHS manager suggests possible substantial benefits from the plans. The system as a whole lacks money and an ageing English population has growing complex requirements. Health and social services need to be coordinated, STP's got people working enthusiastically together. The article suggests NHS England 'made up the policy on the hoof' and managers were under pressure to produce plans fast. NHS England gave fragmented guidance, coming in bursts with frequently insufficient time for responding to requests. There are fears secrecy within the NHS is hindering effective public discussion and without public discussion there is a risk of later delays, protests, judicial reviews. The author argues that full-time leaders are needed who will not put the interests of their own department before the needs of the whole and will send money where it is needed.NHS plans could bring benefits but we're barred from telling the public The Guardian Another Guardian article questions whether the plan might be to prepare for greater privatisation after 2020. Transferring services from hospitals to the community will only work if there is spare capacity in the community and GP's are already overstretched. There are too few NHS staff generally to enable the reorganisation.The NHS secret is out. And local communities won't like it The Guardian