System working has evolved at pace since sustainability and transformation plans (STPs) were introduced in 2015. In a few years, we have seen 'plans' develop in to 'partnerships', and an aspiration that all STPs become integrated care systems (ICSs), taking collective responsibility for resource and performance management and accelerating integrated care models. But STPs are at different stages of development and there are mixed views about how they add value. As we approach the launch of a new ten-year plan for the NHS, we reflect on five key questions facing national policy makers, and system leaders, as we seek to embed system working.
Will all STPs become ICSs?
As the ICSs are demonstrating, system partnerships built on trust can enable partners to take a more ambitious approach to population health management, prevention and integration, maximise collective resources, and to improve pathways for patients. Despite this, not all trusts are confident that the partnerships they are involved in will achieve this goal - only 49% of trusts in a recent NHS Providers survey felt confident all STPs would become ICSs and three quarters of trusts were worried their STP/ICS would not support them to achieve A&E performance targets (NHS Providers, 2018).
Only 49% of trusts in a recent NHS Providers survey felt confident all STPs would become ICSs.Deputy Director of Policy and Strategytweet this
This raises a series of important questions about how we support partners within STPs to build the relationships they need - whether we accept that some STPs will not become ICSs in the foreseeable future and whether all STPs are therefore ready to take on all of the responsibilities they have recently been accorded, like allocating capital funding.
How much diversity do we want in a national system?
One of the benefits of the recent policy focus on system working is that it has allowed local partners to develop their plans 'bottom up' in response to local circumstances. But this has led to diverse models developing not least as STPs are still at different stages of development and cover a range of different geographies and population sizes. For example, in addition to the two devolution arrangements, some areas are driven by structural integration, others to establish a footprint for strategic commissioning, and others on fostering partnerships in smaller, place based footprints. If outcomes improve, the structural model won’t matter – but in the meantime, this raises interesting questions about which approaches will stay the course and whether we need a more unified approach.
In addition to the two devolution arrangements, some areas are driven by structural integration, others to establish a footprint for strategic commissioning, and others on fostering partnerships in smaller, place based footprints.
Can regulation keep pace?
The new NHS England and NHS Improvement regional offices are designed to be significant sources of influence and direction, with considerable delegated responsibilities but they will have to work with STPs/ICSs and local organisations to avoid creating too many bureaucratic tiers of activity. The results from our annual regulation survey endorse Sir David Behan’s views on the need for regulators to refocus their activities on system oversight, with 81% of respondents agreeing that NHS Improvement and NHS England need to develop new models of oversight to hold systems to account for collective performance.
How far can we push the boundaries of the 2012 Act?
While the focus on system working may be welcome, it also raises legitimate questions about accountability, consultation and scrutiny, nationally and locally. With parliamentary time tied up with Brexit, there remains no window for a substantial revamp of the Health and Social Care Act (2012) although we understand the government is minded to make minor amendments to legislation where it can. The existing legislation does not prevent collaboration between local NHS and care bodies, but nor was it designed to facilitate it.
And most importantly….what’s in it for patients?
Despite their differences, STPs and ICSs do share a focus on developing more preventative and integrated care models of care for their communities. It is early days but evidence from some of the first ICSs, like Frimley Health and Care, shows that collaborative working between primary care, hospital, community services and social care can reduce unnecessary hospital admissions and help patients return home more quickly when they are well again. Most, if not all, STPs are now focusing on developing more integrated models of care for neighbourhood populations of up to 50,000, and on developing 'place based' sub systems (or integrated care partnerships) for larger populations. This is arguably where the most interesting work takes place, often building on the work of the new care models, to facilitate multi disciplinary teams, develop shared intelligence, share data appropriately and ensure that patient journeys through the health and care system are much smoother.
Despite their differences, STPs and ICSs do share a focus on developing more preventative and integrated care models of care for their communities.
The promise of a new ten year 'vision' for the NHS and the social care green paper provide a pivotal opportunity to debate the role and function of STPs and ICSs in the future. Much of the work being led by ICSs is breaking new ground and forms real potential for a new relationship where local 'systems' and their component organisations seek greater autonomy and local flexibility in return for managing resource and performance collectively. The unanswered questions here are designed to explore how we support trusts, and their partners, to deliver the benefits of collaboration to local people.
This article was first published by the HSJ on 13 August 2018.