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The Royal College of Psychiatrists Improving the lives of people with mental illness

STP or not TP - that is the question

Let’s start with a little warm up exercise. I give you some initials, you tell me what they stand for. For example, I say NHS, and you say “outmoded concept that we cling to only out of nostalgia for the past and the sooner we get into a proper market driven system the better”, because you have been reading that Oliver Letwin again. OK, not the best example. Let’s try again. BMA. ECG. USA. Easy.

How about STP?

I am betting that caused some problems. But it might be something that you really need to know about.

STP stands for Sustainability and Transformation Plans (STPs). Some of you will be none the wiser, which is exactly the point of most initials that emerge from the NHS bureaucracy.

STPs are the brain child of Simon Stevens. I’ve mentioned him before because he is a Very Important Person. He also has a Very Big Brain (no, really he does) and for unknown reasons also now a rather fetching beard. Simon is the boss of NHS-England, high on the list of “Impossible Jobs that no-one in their Right Mind would Contemplate”. Simon wrote the NHS Five Year Forward View which I have said nice things about because it is indeed sensible, short and rather well written.

In the plan, Simon outlined the future of the NHS. He talked about how the NHS would survive in times of financial hardship, the importance of transferring care from expensive secondary care hospitals to primary and community care, why social care mattered, and why we needed to integrate physical and mental health care. All stuff we agree with.

But it was a bit light on how these things might happen. And after Lansley’s Monster, otherwise known as the Health and Social Care Act, getting things done in the NHS has not proven easy.

So he came up with the STPs. Every health and care system is now required to produce an STP, showing how local services will evolve and become sustainable over the next five years. These plans cover all CCG and NHS commissioned activity meaning commissioners and providers must come together to jointly plan services for a larger population. That’s an exercise in itself - since it becomes a bit like a version of the Prisoner’s Dilemma - everyone needs to co-operate to try and maximise the resources they can get, but equally need to compete to make sure that their own organisation gets the biggest slice of whatever cake there is.

In short, STPs are about trying to improve health and getting more care where it is needed. Nothing wrong there. But there is a sting in the tail in the words “sustainable finances”. We all know what that means, just like we know what cost improvements are. Don’t be fooled, part of the agenda is saving money. And as the NHS finances get worse this part of the agenda gets larger and larger.

So what about mental health? Well we know that NHSE is serious about making sure that CCGs spend more money on mental health, and we know that STPs are supposed to reflect it, with nine “must do” priorities, one of which is implementing the 5YFV for mental health.

But are they? When we look at what those who are drawing up the plans think it’s all about, mental health doesn’t seem to get a look in. Although NHS England has published an aide-mémoire for mental health and dementia to try and concentrate minds but this is only guidance. Which means that local areas don’t have to articulate how they will meet all of the targets of the Taskforce Implementation Plan.

And that is a bad thing. The things that the CCGs will be measured on - access standards for Improving Access to Psychological Therapies (IAPT), Early Intervention in Psychosis (EIP) and eating disorders are limited in their scope. Other priority areas - like child and adolescent mental health services - will continue to be variable across the country. And that’s certainly what we have been hearing from some of our members.

Now NHSE is not oblivious to these concerns. There is an impressive team now working on getting some results. Tim Kendall of this parish has taken on the mantel of national Clinical Lead, Karen Turner is the senior civil servant, the person who knows how the system works, and Claire Murdoch, the CEO of Central and North West London, is tasked with knocking heads together on the delivery of the 5YFV (please tell me you now know what this is).

We know that the party line is now that no STPs should be approved by NHS England that do not include a clear articulation of how they will achieve the priorities of the mental health taskforce, including the access and waiting time standards, as well as a clear demonstration of how local areas will increase their spending on mental health.

The problem - as ever - is that money is tight. History tells us that’s not good for us. We know that lurking in your local A and E or cancer centre are a host of Dick Turpins - ready to spring out, draw their pistols and shout “Your money or your life”, and for once I don’t mean that metaphorically. It will be phrased in exactly those terms. And whose money are we talking about? Ours. Unless we are careful, and perhaps even if we are, Dick Turpin and his fellow highwaymen may be able to shift money allocated for mental health improvements to supplant existing spend or balance reductions elsewhere in the system. And this is not far fetched. A recent survey found 61% of CCG leaders cite “organisational priorities” (ie balancing the books) trumping “whole system plans” (ie improving the way we deliver care) as a significant barrier to success.

And we are not talking about a few gold sovereigns. The Sustainability and Transformation Fund (STF) currently has a pot of £1.8bn for 2017/18 and 2018/19 respectively. Gosh, that’s a lot. Surely no one can steal all of that? Well, it may have been stolen already. The plan is for £1.5bn of this to go into a general fund allocated on the basis of emergency care; a £0.1bn general fund allocated to non-acute providers; and a £0.2bn targeted fund. I am losing you, I can sense it. OK, back to plain English. The providers - ie the acute trusts - have to balance their books by 2017/18. So if it all goes to them to do just that, there won’t be much left for real changes in services.

So our Three Musketeers (Claire, Karen and Tim) have a job on their hands to stand up to Dick Turpin and ensure that the mental health money allocated through the STF must is protected appropriately and local areas held accountable for delivering what they promised. We will be cheering them on.

Professor Sir Simon Wessely

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Re: STP or not TP - that is th
Apart from 'mantel' (?piece) typo -- three cheers - informative, and amusing as always.
Re: STP or not TP - that is th
Nothing has changed since I came into psychiatry in 1958.
Re: STP or not TP - that is th
The NHS-powered by acronym.
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Professor Wendy Burn

Professor Wendy Burn FRCPsych


Professor Wendy Burn became a consultant old age psychiatrist in Leeds in 1990 and now works fulltime in a community post. Her main clinical interest is dementia.

She has held a regional leadership role in this area from 2011 and was co-clinical Lead for dementia for Yorkshire and the Humber Strategic Clinical Network between 2013 and 2016.