How can we rescue our NHS?

Photo: Steve Eason

In the last few days  Sustainability and Transformation Plans (STPs) have made it into the headlines after a statement from the Kings Fund  pointing that they have been kept secret. Despite this criticism, the Kings Fund seems to support the concept of the plans. Health campaigners on the other hand have been criticizing both the lack of transparency in how the plans are being elaborated – and also their overall direction. In an article in the new article of Socialist Resistance.  John Lister explains:

Since January NHS England has driven through a massive new reorganisation of the health service, carving the country into 44 “footprints” in which commissioners, NHS Trusts and local authorities are required to collaborate on 5-year plans to generate massive savings.

Each Footprint has to submit a “Sustainability and Transformation Plan” (STP) to NHS England by the autumn and be ready to implement the changes quickly to balance the books: only plans which satisfy NHS England will ensure access to £1.8 billion of “transformation funding”.

NHS England boss Simon Stevens has made clear he sees the reorganisation as a way to create “combined authorities” which pool their powers – making it possible to override any local “veto” that might prevent controversial cuts or closure of popular local hospitals and services. The little local influence and accountably there is in the NHS will be eliminated.

Only 9 of the 44 draft plans have so far been published: the remainder may not see the light of day until they have been rubber stamped by NHS England for implementation. From then on, any “consultation” over unpopular changes would be a purely token exercise: the 5-year plans would not be changed, but services could be subjected to far-reaching cuts, closures and changes despite vehement local opposition.

No basis

The system has no legal basis. Steven’s plan simply sidelines the 200+ Clinical Commissioning Groups established by the 2012 Tory Act to take charge of local budgets – but leaves them still obliged by the Act to continue to carve up services into bite sized, fragmented chunks to be opened up to “any qualified provider” or put out to competitive tender and potential privatisation.

The whole fragmented, wasteful costly market system remains intact, amid repeated expensive and disastrous failures of many of the contracts that have already been put in place. Our NHS is being broken up, run down and the choice sectors flogged off by a neoliberal government. The STPs speed up the run-down, though they use different rhetoric to mask the reality.

That’s why I want to put STPs into perspective in this article.

Let me tell a story. A sales rep is looking out of his hotel room one morning and he sees two men working on the side of the road. One man digs a hole, the other fills it in. Time and again, a hole is dug and filled in. Curiosity gets the better of the rep, and he goes over and asks them what they’re doing. One says “I’m Bill and I dig the holes: that’s Trevor, and he fills them in. We’re a team.” But then he adds … “of course normally Eric works with us as well: he plants the trees – but he’s off sick today.”

Teams only work with all the members working together. Plans only work when all the elements are brought together. One factor or person missing, and even the simplest plan goes horribly wrong.


 On STPs the question is to spot what’s missing amid all their jargon. Why can’t the teams deliver? What arent they telling us?

For the NHS, there are three missing elements:

  • the money,
  • the staff to do the job
  • and the evidence that the policies can deliver the expected result

There is a profound reluctance in the STP documents we’ve seen to engage with this reality. Nobody wants to talk about money. Everybody pretends it’s possible to get by without using so many agency staff – even while fearing that the current problems of recruitment and retention could get even worse. Some of the tens of thousands of EU nationals who are playing vital roles throughout the NHS may soon be effectively driven out by the Brexit vote.

And nobody, but nobody seems able to supply any evidence that any of the plans will work.

When I was growing up in the 1950s and 60s on Sundays my parents used to listen to the Light Programme on the BBC. One of the irritating songs that used to be played endlessly from that classic of patronising, racist stereotyping South Pacific was a song called Happy Talk:

“Happy talkie talkie,
Happy talk
Talk about things you like to do
You got to have a dream
If you don’t have a dream
How you going to have a dream come true?”

What we have in the STP’s is happy talk –  pie in the sky. The authors live in a fantasy world where dramatic changes in working patterns and cultures are achieved instantaneously – by publishing a plan, a strategy, or even a diagram.

NHS England has over a hundred directors and senior staff who are paid more than the Prime Minister. What are they all doing, what happens to what they do, and does it help?

We know what they’re NOT doing; addressing some key issues arising in STP plans. The North-West London plan identifies a target saving of £188 million from Specialist Care, which is controlled and commissioned by NHS England. Except nobody knows how these savings can be achieved. No problem, they say. According to the STP:
“NHS England Spec Comm have not yet developed the ‘solution’ for closing the gap, however it is assumed that this gap will be closed“.

More happy talk. Assumptions with no evidence. Hoping for the best. Plans with bits missing. Teams with people missing.

STP plans are not written to be read. There is the famous NHS management ‘plan on a page’ – which begins with a childlike graphic, but gradually expands to the point of an enormous A3-page, jammed full of tiny type. In North West London the STP has page after page crammed with six point type. But it doesn’t add up.

The refusal to confront reality means that NHS directors bring in McKinsey or other management consultants to write a plan – since NHS managers don’t seem capable of writing a plan themselves any more. But despite being lavishly paid, the consultants don’t finish the job. Why would they when there’s more money potentially available? There are bits missing, and vague suggestions of additional research or information to be produced. So then the NHS pays them more money. But they still don’t finish the job.

Happy talk

In North-West London the plan known laughingly as ‘Shaping A Healthier Future’ has been running since 2012, promising for several years to publish a Business Case to explain how the money and services can work. The latest promise was that this would be published in September, which has been postponed again to the New Year. We’re not sure which year they mean.

Consultants have been paid tens of millions for this, with millions more still to come: for some reason it’s exempt from the normal limits on procurement of external consultancy. Nobody seems to have evaluated what the NHS has got for this money apart from 2,500 pages of repetitive and largely unreadable (and unread) early and incomplete drafts of the ‘Business Case’.

The plan, like the STP which has pinched much of its content, is full of wishful thinking, happy talk: assertions with no evidence, aspirations for rapid, miraculous improvements in public health that would somehow magic away the need for hospital beds, despite the absence of alternative services in the community, in primary care, and or in social care – and despite the lack of any funding to establish such services.

Nor have these consultants – for all their purported expertise and their resources – offered any evidence to support the assertions and proposals they’ve made.

In North-West London the STP is 54 pages and there is not one example of a working model of the type of new systems proposed to replace hospital bed provision in the area, or anything to indicate that the proposals might save anything like the amounts they suggest.

Of course there is nothing wrong with expanding Public Health programmes, improved health education, or preventive programmes aimed at keeping people healthy. We support such plans but note that Public Health budgets, never generously funded, have been heavily cut since 2010.

There is nothing wrong with wanting to integrate health services better with services such as social care – which has also been brutally cut back since 2010, and is now very substantially privatised, fragmented, and desperately underfunded. Integration seems a long way off, no matter what the plans say.

But if it to be more than happy talk, then plans that hinge on expanding intermediate care, on improving GP services and primary care, or increasing levels of success for prevention programmes like smoking cessation, and generous provision of social care, need to be upfront about the need for increased funding and capital.

Spending limits

Instead, the STPs are presented as ways of curbing health spending to live within the impossible spending limits imposed since 2010, even while the population and its needs for health services continues to grow.

In fact we could reasonably ask whether the real threat does come from STPs. Is our real problem these fanciful documents we keep seeing, which set out the ambitions and aspirations, the vision, the dreams of NHS managers?

Or is it in fact the cuts that are being driven through now on the ground, happening even as we plough through the small print.

Is the real problem the visible decline in the quality of care the NHS is able to deliver with the level of staffing and resources available? Is it the gaps emerging in the NHS workforce – which are being used in some areas as an excuse to close services on safety grounds – effectively pushing through closures of hospital services without consultation? We’ve seen this beginning in Lancashire, in Oxfordshire, in Lincolnshire and in London: this is a real threat that we have to confront, regardless of what’s in the documents.

These issues are crucial, but not always at the centre of attention. NHS England, the CCGs and the trusts have resources that campaigners don’t have: they can publish or leak plans, make statements that get reported and set the agenda – while in the main we have to respond. Our reports struggle for coverage: theirs can easily make headlines.

Their information is largely relayed uncritically in the media by journalists many of whom know no better, and accepted by a large audience which also knows no better. So if the NHS is able to create the impression that their plans are central, we have to deal with it. They pass down the stock line that “no change is not an option”, that the NHS must be cut back to the austerity levels established since 2010, we have to combat those arguments.

The chief executive of NHS providers, Chris Hopson, has been all over the media stating the obvious case that many trust bosses fail to make: that there is not enough money to sustain services on the current level and meet increased demand over the next four years.

He has spelt out a grim series of options in the likely event that no further funding is forthcoming from Theresa May’s government. He warns:

“No trust board wants to depart from the key principle of NHS care being available to all based on clinical need not ability to pay. But, faced with this clear, national level gap, the logical areas to examine would be:

  • reducing the number of strategic priorities the NHS is currently trying to deliver [such as seven day services]
  • formally rationing access to care in a more extensive way
  • relaxing performance targets
  • closing reconfiguring services
  • extending co-payments or charges
  • or reducing or more explicitly controlling the size of the NHS workforce which accounts for around 70% of the average trusts budget.”

‘Hopson’s choice’

In other words ‘Hopson’s choice’ is whether to abandon NHS principles … or cut the service to vanishing point. It’s a choice between being hung or garroted.

In fact most of these things are already happening. CCGs or trusts. have effectively abandoned serious discussion on 7-day services, many are beginning to ration care, starting with soft targets like IVF, performance targets are routinely being missed, even for cancer care, reconfiguration plans are being hatched up, and some trusts are planning to slash their workforce while NHS Improvement has set new limits on nurse staffing levels.

Only charges remain taboo, and Hopson is trying to engineer a public debate that could enlist the ill-informed to create conditions to undermine this principle.

Meanwhile, in the background, the private sector is wondering – six years into a decade of unprecedented freeze on NHS funding, designed to reverse Labour’s decade of increased investment and reduce the share of GDP spent on health – whether there is enough money left in the elective care kitty for them to make profits.

Many STPs plan to establish Accountable Care Organisations, the new magic incantation that is seen as the way forward. ACOs are an American model, in which a provider accepts a contract paying a fixed amount per head of population to provide an agreed package of services. If they can do so inside the budget they make a profit, taking the risk that if the money runs out, they will carry the excess costs. These schemes have been losing a packet in the US because a number of them have taken on delivering subsidised insurance plans to people on low incomes; and these people tend to get expensively sick –  not what the insurance companies want or expect. Many have gone bust.

The nearest equivalent we have seen in England was the very controversial Cambridgeshire CCTG plan for a single £150m a year contract for Older People’s and Community Services. It went out to tender: but a number of private bidders withdrew, arguing that there was not enough money in it. The contract eventually went to two local foundation trusts: and within 8 months collapsed – because there was not enough money. In Staffordshire attempts to develop a cancer care contract have also struggled because most private bidders pulled out, and once the contract had been allocated even the local NHS trust pulled out … because there’s not enough money on the table to sustain services.

These schemes don’t save money – especially if they are to draw in the private sector. They are just a new type of cash limit. So if there’s not enough cash in the pot, there won’t be a sustainable service. Nor will ACOs be effectively accountable to the communities they are supposed to serve.

Hopson says we should debate how the NHS should be sustained. I say no – let’s not have a debate in which one side, backed by the media, right-wing think tanks, and the Tory right urge us to turn the clock back to the 1930s, drop the NHS principles and adopt a combination of charging for treatment and private health insurance.

Let’s instead fund the NHS properly from general taxation: it’s already underfunded compared to almost any comparable country, with fewer staff fewer beds and less modern equipment.

Hopson puts the points bluntly, but the cash squeeze is the reality behind the happy talk and charades of STPs. We can’t choose between fighting the cuts on the ground and challenging the STPS – because they come from the same source.

We have to fight both, demanding proper funding and the renationalisation of the NHS to strip out the crazy, wasteful, fragmented, bureaucratic market system that was massively expanded by Andrew Lansley’s 2012 Health and Social Care Act.

We need to raise public awareness of the danger of STPs now, to challenge them consistently while still keeping a close eye on the cuts taking place.

Together we are strong. Let’s develop fighting policy at locally and nationally to challenge the cuts that are being proposed through STPs, expose the happy talk, the doubletalk and hot air of the STPs, while keeping our services together – and keeping our NHS public.

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