STPs: Publish and be damned!

Three Councils have published their STP submissions, against the express wishes of NHS England and NHS Improvement. They may have done so for a variety of reasons but two have been repeatedly cited:

  1. Transparency – the belief that plans such as these should be openly available to, and discussed with, the public

  2. NHS bias – that plans are exclusively about balancing NHS books and not about finding sustainable solutions for health and care.

Does it matter?

Yes, it does – on both counts.

Transparency More than ever before (Brexit, Heathrow etc.) the public expects to be informed at least, but they also expect to be involved in decisions about things they care about. And the NHS is one of the things they care most about. It has great salience as the pollsters say. The local authorities know this, which is why they are the ones to publish. They know that this is what the public expects and that the public will only be angrier if they feel they have been excluded from decision making.

Local authorities know this because their leaders are subject to an inexorable electoral cycle and their officers must work with these elected officials. The power ultimately lies with the members. This is quite the opposite in the NHS where although ultimate accountability rests with national politicians, the real power at a local level lies with local NHS leaders, many in executive positions but a few in non-executive roles. It is certainly political with a small ‘p’ but not subject to any electoral cycle.

This means that all senior NHS leaders will pay lip service to public engagement (and many will sincerely believe in it) but it is not part of their organisational DNA. I might be pushing a point but it seems to me that many NHS leaders do not Trust the public to make the right decisions, or to be a little kinder, they think that they, as experts in a very complicated service, are likely to make better decisions than the public. This might be true, but the implications of it are not helpful – not least because it is often likely to set local NHS leaders against public opinion.

Might not this be the time to bite the bullet and seriously discuss the opportunities which greater local democratic accountability might bring? There are very significant problems to be overcome, the largest being that local control will inevitably lead to different decisions being made in different parts of the country with the inevitable ‘post-code’ lottery. But isn’t this the point? Let local people, through their elected officials, make these decisions.

Perhaps I’m jumping ahead? But at least we could open STPs to public debate, even when challenging reconfiguration plans are being proposed. There is little point in not doing so because public consultation is a legal requirement, and therefore STPs are not able to take a firm position on these questions in any case.

NHS Bias This has now been strenuously denied by Simon Stevens who has made clear that the STP process was designed to bring many parties in a health and social care economy together, not to solve all the (national problems) of health and social care. In fact, Simon has gone on record to say that any new funding should go first to social care. So far so good.

At a local level, however, the NHS has often been successful in protecting its interests whenever programmes have been designed to build better collaborative working. The Better Care Fund is a good example. Most councils may now be commissioning a wider range of services but they have not often been able to shift funding from service to service, except at the margins. So, it isn’t surprising that local councils feel this bias exists, nor is it surprising that local NHS leaders jealously protect every penny of their budgets because of the tightness of the financial regulation regime to which they are subject.

The fact is, as Sarah Woolaston, the Chair of the Health Committee, has said today, demand is outstripping supply dramatically and the government simply must think again about funding for health and social care. However, given that one is locally democratically controlled and one is not, a longer-term aim must be joining up the two. Health into social? Or social into health? More local democratic control or less? Discuss!

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