Tensions and conflicts are emerging between health bosses and their town hall counterparts over STPs
Serious tensions are emerging between the health service and local government.
There are three sources of conflict – centrally-imposed secrecy over the sustainability and transformation plan (STP) process, whether the aim of STPs is to fix the NHS or develop an integrated health and care system, and disputes over whether the financial plans being sent to NHS England are fact or fantasy.
At least five councils have now published the STP, despite NHS England asking local areas to keep them hidden until the central bodies have given their verdict.
This pointless subterfuge has put local politicians in an invidious position; if they do as they are told they run the risk of being accused of conniving in a cover-up of plans to shut services. Faced with incurring the wrath of either NHS England chief executive Simon Stevens or local voters, it is not a difficult choice. The surprise is that more councils have not taken the same step.
The first local authority to reveal one of the plans was Birmingham city council. Its chief executive, Mark Rogers, articulated publicly the frustrations many in local government express privately. He complained in the Health Service Journal that Stevens and NHS Improvement chief executive Jim Mackey were pressurising NHS organisations to sort out the health service debt crisis rather than make the entire health and care system sustainable.
At the Ncas social care conference on Friday, NHS England operations director, Matthew Swindells, was forced to apologise after he said that councillors needed to be “managed” in the STP process.
“When I said ‘managed’ I meant brought into the whole of the conversation,” he responded to angry lead members for adult social care, who protested that they had been shut out of local STP discussions. “That was not our intention. If that has happened, that is not satisfactory and I apologise for that.”
Swindells admitted that NHSE’s handling of the STP process had been “not our finest hour”, explaining that while “most” of the 44 plans were good work, “a lot” needed rewriting before they were understandable by a wider audience. They would all be published before Christmas.
The Five Year Forward View held out the prospect of moving the centre of gravity of the health and care system at least a few inches towards primary and community services. But the STP process is now in danger of reinforcing the domination of the hospital sector rather than reforming it. The implications of that are far more serious than simply maintaining a system that is failing to cope; it will require even more money to be pumped into hospitals to expand the number of beds.
Arguably the biggest weakness of the STP process is that the pressure on hospitals to get their finances under control is so intense that some are offering up plans for savings that have virtually no chance of being achieved. One council chief executive said a local deeply-indebted hospital was claiming that it would save millions but did not have a credible plan for making it happen.
On Tuesday, Rogers took to the Today programme’s airwaves to ram the point home, pointing out that the funding gap will not be closed by “simply using the transformation word endlessly”.
Another local government chief I spoke to was visibly angry at the failure of his local hospital to take even the most basic steps to improve their estatesmanagement, back-office systems and procurement, while his authority was being eviscerated by another round of cuts – with public health taking a big hit.
There is a cultural chasm between the NHS and local government when it comes to handling public money. It is illegal for local authorities to run a deficit on their services spending, so they are compelled to make tough decisions to live within their means. Chief financial officers have extensive powers to intervene if they believe unlawful expenditure is going to be incurred.
In contrast, in some trusts there appears little connection between the financial decisions of the board and what actually happens. It is that disconnect which lies behind scandals such as the financial collapse of St George’s in Tooting in 2015.
Local government is no nirvana, of course. Several authorities – including Birmingham and Manchester – are still struggling to deliver effective child protection services, and although councils face severe increases in demand, these are not on the scale confronting the NHS. But local government’s financial management is far more effective.
Despite the inevitable tensions, the good news is that local government and the NHS are learning to work together, marrying up clinical services with a stronger sense of place and beginning to develop a clearer vision for integrating health and care.
