Sustainability and Transformation Plans (STPs)

NHS England has now published all of the 44 Sustainability and Transformation Plans covering the different geographical footprints across the country. Taken together, the plans envisage profound changes to the way care for patients is conceived, delivered and resourced. STPs are hugely important to the future of the NHS, but why? What are they and what do they mean? Below is our short guide to what an STP is and what they likely mean for emergency medicine.

*Please note, the below focuses on emergency medicine - for a more in-depth guide about the plans and what they mean for the wider NHS please visit NHS England’s website. More links to further reading are at the bottom of this page.

What are STPs?
Sustainability and transformation plans (STPs) is the name for the locally developed plans for delivering NHS England’s Five Year Forward View

The plans have been developed by NHS organisations and local authorities in 44 geographical ‘footprints’ across England to deliver ‘place-based plans’ for the future of health and care services in their area.

They are viewed by many as offering the best hope for the NHS and its partners to sustain and transform the delivery of health and care.

What do they aim to do?
The plans aim to address three headline issues: improving quality and developing new models of care; improving health and wellbeing; and improving efficiency of services. 

Put simply they aim to reorganise services in a way that most suits the needs of the local population in order to deliver the best care possible. 

Where can I find the plan for my local area? 
All 44 of the plans are available here

Are they just about cutting services?
It is very likely that there will be some cuts to some services across the country and the desire to save money is very much a key driver of the plans. 

However, there is also a clear need to improve and integrate services to provide more co-ordinated services to patients – for example, by GPs working more closely with hospital specialists, district nurses and social workers to improve care for people with long-term conditions.

With an ageing and growing population, and limited funding, the NHS is under pressure like never before. These plans aspire to the best use of resources to create a service that is financially viable in the long term and provides the best care for patients. 

Will A&Es be affected and if so, how? 
As Emergency Medicine is in many ways the front line of the NHS, Emergency Departments (EDs) are not immune from these changes. Many plans envisage service reconfiguration or closure, or are in part predicated on the assumption that they can deliver significant reductions in ED demand.

What is the College doing about the plans?
Because of the significant implications both for the patients who visit our departments and the staff that work within them, The Royal College of Emergency Medicine is seeking to encourage the engagement of Emergency Medicine clinical professionals in the development and delivery of Sustainability and Transformation Plans in their local areas.

To facilitate this process, we have created reconfiguration guidance, which, when taken with the information and questions here, is intended to help inform a critical, constructive and patient centred approach to STPs. However, given the nature and sheer variety of the different STPs, this guidance is not exhaustive and close examination of the details of individual plans is strongly advised.

STP Analysis

Are the plans themselves written in a way that means that what is being proposed is clear and comprehensible to either clinicians or patients?
Among a range of commentators the Plain English Campaign have said that the language of these plans is ‘vague enough to hide all manner of changes’.  Similarly, members of the Healthier Lancashire and Cumbria umbrella group complained that one of the major problems they faced when assessing their local STPs was simply their inability to understand it in the first place.  However, it should be noted that the plans are an ongoing process and will be further refined subject to clinical and patient feedback.

To what extent are the funds available for STPs being spent on sustainability or transformation and does this compromise their viability?
A BMA investigation into the 44 STPs in England has revealed the vast sums needed just to create the infrastructure to deliver the projects, with costly building projects and investment in community facilities vital to the plans. Following a series of Freedom of Information requests, the BMA has found that NHS leaders are unlikely to have anything like the capital required to deliver the projects, with budgets under ‘significant pressure’.  Similarly, a recent report by the National Audit Office on health and social care integration, concluded that of the £2.1 billion made available to fund STPs, £1.8 billion had already been allocated to cover trust deficits rather than transformation

To what extent is the STP in question actually proposing to cut ED attendances and admissions?

Taken as a whole the 44 STPs – if properly implemented – forecast cuts to admissions ranging from 0 to 30%. However, 25 of the 44 plans leave the proposed level of reductions unspecified.  A clear understanding of these changes is vital to assessing future levels of resource provision or the potential impact on neighbouring EDs.

If ED closures are being proposed, has the impact on surrounding ED facilities been adequately considered?
Both current and previous Royal College of Emergency Medicine reconfiguration guidance cautions that ‘the key issue is the impact on patients and patient care at the site from which services will be removed or reduced. Secondary, though important, are the consequences for services at sites that would be required to absorb the diverted patient flows.’ 

Are levels of financial savings being proposed realistic and can they be achieved without compromising patient care?
While some of the STPs are proposing relatively modest financial savings, other are very considerable. For example, the Cambridgeshire and Peterborough STP envisages savings of £504 million by 2021 from an annual budget of £1.7 billion

If prevention is being proposed as a way of cutting ED attendances and admissions, are the resources devoted to this likely to be sufficient, and are the measures being proposed likely to have a significant impact on patient demand?
While preventing illness is valuable in itself, a number of plans acknowledge that there had been considerable successes in this area in recent decades (tackling heart disease for example) while demand has continued to rise, and then go on to predict that further success in the same area will mean that demand will begin to fall

If promoting self-care is being proposed as a way of cutting ED attendances and admissions, are the resources devoted to achieving this sufficient or, in your judgement, likely to have the intended effect?
While organisations like Patient Voices have many anecdotal examples to offer to show where this has been helpful  it remains to be seen whether this can be scaled up in a way which makes a significant impact on demand. NHS Choices and other trustworthy information sources to facilitate self-care have been available for some years without tangible reductions in demand.

If placed based care is being proposed as a way of cutting ED attendances and admissions, are the resources devoted to achieving this sufficient or, in your judgement, likely to have the intended effect?
Although the Chancellor’s recent announcement of additional funding for social care is welcome and should help with social care provision,  the Institute of Fiscal Studies has shown that these and other measures will only return social care spending to a level of 2.5% higher than was the case in 2009-10 just before government austerity began.  In the intervening period both the demands made of services and associated costs like the minimum and living wages have substantially increased. Moreover, the Nuffield Trust and others have cast doubt on whether this approach will yield cost savings. 

If improved primary care provision is being proposed as a way of cutting ED attendances and admissions, are the resources devoted to achieving this sufficient to have the intended effect?
It has proven to be difficult in the past to deliver 7 day GP services and recent figures show a significant shortfall in the number of GPs. While NHS England is committed to an uplift in GP numbers as part of the Five Year Forward View, delivering this uplift could prove to be challenging

What happens to services if these plans fail to work? Is there an alternative approach?
In 2015, the Royal College of Emergency Medicine endorsed ‘Safer, Faster, Better’ published by NHS England. This offered ‘good practice in delivering urgent and emergency care’ and was, in our view, a constructive step forward.

This document put forward a number of principles, ‘to improve safety and flow, and help reduce unwarranted variation and manage demand’. The first of those principles states:

“Emergency departments (EDs) should be resourced to practice an advanced model of care where the focus is on safe and effective assessment, treatment and onward care. While it is essential to manage demand on EDs, this should not detract from building capacity to deal with the demand faced, rather than the demand that is hoped-for.”  

On this basis a realistic alternative to STPs would be to start planning for the continuing growth in the demand the NHS is almost certain to see based on England’s growing population and increasingly elderly demographics.