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
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
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
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
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
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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