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Left hand, right hand… Sustainability Transformation Plans and devolution


Opinion: Why on earth do the NHS Sustainability Transformation Plan (STP) footprints not match with local authority or devolution areas?

The big news over the weekend has been the prospect of cuts uncovered in the draft NHS STPs. This is indeed shocking news, but it is no secret that savings must be made and that shifting patient care from hospital to community is one way of making those savings.

What I find more shocking therefore, is that the STP footprints themselves do not in the main match with existing local authority or devolution boundaries. The images to the left are taken from the NHS and the Local Government Association websites respectively. 

Furthermore, according to the House of Commons Library report Devolution to local government in England, Greater Manchester is the only devolution deal to contain health and social care integration to date. Under those groundbreaking plans the Greater Manchester Combined Authority and local NHS services will have much more control of the region's £6 billion health and social care budget.

One of the biggest problems facing both local government and the NHS is our ever growing elderly population and the lack of coordination between hospital and social care. Apart from the disparate organisational boundaries there is a cultural divide: people are patients in one building, citizens in the next. But rarely ‘real’ people.  

Costs and losses

Delayed hospital discharge itself costs the NHS in England £900m a year and rising according to Lord Carter’s recent report. The NAO says that bed space lost from delays in transfer of care have risen by 31% in the past two years alone. 

Pressure on bed space in turn puts pressure on staff to get patients home as soon as they are ‘medically’ fit to go. But when elderly patients are discharged without appropriate care cover they often end up back in A&E in remarkably short time, requiring acute care following a further accident or decline in health.

So the cycle continues. Good care in the home setting avoids this readmission. And joined up preventative care could even preveent crises from happening in the first place.

It is undoubtedly better for all of us to stay healthy, fit and out of hospital. It is definitely cheaper to the public purse if we do so. Which is why as someone with chronic health conditions and a child with disabilities I find the lack of join up between health and local government bewildering.

Housing is a lovely example: adequate housing, appropriate telehealth and adaptations - such as stairlifts for those in need - could keep vulnerable people safe and healthy – at a fraction of the cost of acute hospital admissions for falls or infections.

How much does it cost to mend a broken hip in terms of labour and parts, nursing and bed space? Surely less than the £6,000 it might cost for the stairlift that could have prevented the fall. A stairlift, I might add from personal experience, that could take up to two years to get from a local authority.

Fast coordination

Joining up health and care to ensure that: a) the vulnerable, the disabled and the elderly are well looked after in the community; and b) when crises occur there is a coordinated (and preferably fast) path from hospital to home is essential. Both for the wellbeing of our citizens and our public finances.

Undoubtedly the stated aims of the STPs and devolution plans to integrate health and social care are laudable and worthy. But if you were to design an organisation to deliver such an integrated service you would not start from our current 'accident of history' status quo of separate organisations. 

Digital technologies will inevitably provide the glue to get round this, but huge challenges exist not least in the ability to share basic patient information in order to help the patient – even though arguably data about the patient belongs to the patient.

Meanwhile, the historical issues of cultural, budgetary, technical and organisational differences between the NHS and local government across the country pose significant hurdles to the good folk striving to integrate health and care around real peoples’ lives.


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