STPs: It’s not too late to have a say in plans for your local services
Nurses have been largely sidelined in the development of NHS sustainability and transformation plans (STPs), though they will affect thousands of jobs. But there is still time to influence local decisions.
Nurses have been largely sidelined in the development of NHS sustainability and transformation plans (STPs), though they will affect thousands of jobs. But there is still time to influence local decisions
STPs, the ‘secret’ plans for the NHS in England that will mean huge changes to local services, are now out in the open, and people in the know are worried.
In November the King’s Fund released a report based on anonymous interviews with NHS and local government leaders in a number of STP areas. The report revealed that the deepening financial crisis in the NHS had forced the plans to become more focused on costcutting than was originally envisaged. It also highlighted the lack of involvement from clinicians and members of the public, and the concerns of STP leaders about how the plans will be implemented.
The influential think tank’s chief executive Chris Ham said he was concerned there was not enough money available for the transformational element of the plans, with much of the promised additional funding being required to prop up trust deficits.
‘The only game in town’
However, he has also made it clear that the plans, which require local organisations to collaborate in the best interests of the population they serve rather than compete against each other, are the ‘least bad option’ for the NHS and ‘the only game in town’.
RCN regional director for the south east Patricia Marquis describes the STPs she has seen as a ‘real mixed bag’. ‘Some are vague and aspirational without many details of how they can be achieved.’ She adds that many of the plans' aims are impossible to argue against - but it is difficult to see how they will be delivered in the real world.
What is clear is that STPs contain proposals that will have an enormous impact on nurses’ working lives. Service reconfiguration is a major feature of some plans, with emergency department, maternity and paediatric services often prominent in these plans. This may mean some nurses with specialist skills being asked to work in different locations or take on more responsibilities.
For example, in Shropshire, there are controversial plans to concentrate emergency department services in one site, and also to move a newly-established women’s and children’s centre from Telford to Shrewsbury. Many nurses and midwives in Telford could find their job has moved 16 miles away. Similarly, Stafford Hospital may see its emergency department, which already closes overnight, replaced by an urgent care centre.
Several of the more radical plans for reconfiguration are likely to run into difficulties with local MPs. Cumbria - where a by-election will take place this month (23 Feburary) following the resignation of Labour MP Jamie Reed - could see the future of consultant-led maternity services in Whitehaven become a major issue. A number of local authorities have said they cannot support proposals that will see services downgraded.
Ms Marquis says some STPs propose using nurses across a wider area, for example, by requiring specialist nurses to divide their time between acute and community settings. This could involve significant travel, and nurses who are asked to move to a new site may decide to leave their jobs or may end up accepting other roles that are less appropriate for their skillset.
Most, if not all, STPs anticipate a step up in prevention and early intervention, reducing the number of people being treated in acute hospitals. Some patients may be supported at home rather than being admitted, and this presents a major challenge for the stretched and ageing community workforce.
All of these proposals will affect the shape of the workforce and the number of nurses required in each part of it. Some areas are looking to increase the skills of their existing workforce but others are looking to reduce staff numbers or to use lower-band staff to deliver care. For example, the Nottinghamshire STP suggests that ‘hundreds’ of band five posts could disappear, although it does recognise the need for a considerable increase in community and primary care staff.
A draft of the STP covering Buckinghamshire, Oxfordshire and West Berkshire said it would save £34 million through a ‘reduction in nursing grade input’ and the use of ‘generic support workers’. The RCN raised ‘serious concerns’ with the idea and warned on the impact on patient care. The plan may not become reality because NHS England and other bodies have now suggested they will be overseeing it and ensuring the ‘right skilled workforce’ will be in place.
Of more general concern may be what the King’s Fund report described as the ‘eye-watering efficiency assumptions’ contained in many STPs. In many cases, STPs are predicated on reductions in acute hospital use that seem fanciful, such as 30% drops in emergency department visits.
There is also widespread doubt that that the NHS has any fat left to cut, or can transform the way it works sufficiently to deliver the anticipated savings.
In some regions, there is already intense pressure on community budgets. In the Liverpool area, RCN steward and former council member Mike Jarvis is concerned the break-up of the local community provider will lead to less money being spent.
He is also concerned about the impact on staff, pointing out that some nurses could find themselves moved to a non-NHS community services provider, which he fears could affect their pensions.
Despite all these reasons for concern, the level of engagement of nurses with STPs so far has been low and many still do not realise the extent of the changes going on. ‘As a branch, we have not been involved in any oversight of the plans,’ says Mr Jarvis. ‘Jobs will be affected but we are not able to hold people to account. It is a dangerous time for the NHS.’
Ms Marquis has a broader warning. She is worried that the plans will make it harder to recruit and retain health and social care staff, reducing the chances that the NHS will be able to rise to the many challenges it currently faces.
‘At the moment many of the suggestions in STPs are about making jobs less attractive, not more. That does not bode well,’ she says.
What should nurses be doing now?
It is not too late for nurses to influence STPs. Most of the published plans are fairly undeveloped and in some areas look more like aspirations or wish lists. The first step for nurses should be to read their local plan and think about how it will affect them and their patients.
Some of the proposals, for example on reconfiguration of services, will have to go through formal consultation, where there will be opportunities for nurses to raise issues, both individually and through representative organisations.
Other schemes won’t be subject to the same restraints but nurses can still make their voices heard, pressing for inclusion on working groups and acting as a ‘common sense check’ for some of the more unrealistic proposals. This may be particularly true for nurses working in the community, mental health and primary care, areas where involvement in STPs seems to have been light but that will be expected to take some of the strain created by reduced acute beds and the shift of services into the community and the patient’s home.
A particular challenge for nurses will be ensuring that where doctors have been consulted in STP development, this is not seen as having engaged the whole clinical workforce. Nurses will have a different perspective to doctors on STP proposals and, in some cases, will be much more directly affected.
Ms Marquis says in her area the RCN and other trade unions have already approached Local Workforce Action Boards and asked to attend their meetings. The RCN has also asked for meetings with trusts to explore what the STPs will mean for nurses.
King’s Fund progress report on STPs – key findings
- Cutting costs has become a more important part of STPs. The original focus was more on improving care, quality and efficiency but pressure has resulted in a shift towards financial stability in the NHS.
- Developing STPs has not been easy: some local authorities felt sidelined, and mental health and community trusts were less likely to engage than acute ones. Primary care engagement has been low and patients and the public ‘largely absent’ from the process.
- In areas with little prior experience of joint working, engagement with the process has been a challenge.
- Leaders in all STP areas are concerned about their ability to implement them. They will need different skills and a focus on managing change.
- Despite the problems, STPs offer an opportunity to improve service through collaborative working, rather than the ‘fortress mentality’ where organisations are only concerned about their own future.
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Alison Moore is a freelance health writer