The NHS is being reorganised - this time quietly and without bothering our sovereign Parliament
We are not supposed to notice it, but the NHS is being reorganised again - and once again it is starting as a top-down process.
Just to recap briefly: before the 2010 election the Conservatives promised 'No more top-down reorganisations of the NHS.' Within months of coming to power with the LibDems, Andrew Lansley was left alone in the toyshop and began not just a top-down rearrangements of the chairs, but a root and branch reorganisation of key parts of the NHS.
This had not been mentioned in the 'Coalition Agreement' that fluttered across the Downing Street rose garden. But when it came to the crunch in Parliament, the junior coalition partners did little to stop Mr Lansley opening up the NHS to root and branch privatisation - more roots, more branches.
Some of the current problems the NHS is facing can be sourced directly to the Lansley plan - as well as to the decision to make good the promise of 'real term' rises in NHS funding by staying the wrong side of the decimal point.
This new reorganisation is called STP - an NHS acronym that sounds unfortunately as though it belongs to a sexually transmitted disease. It stands for Sustainability and Transformation Plans.
STP involves two basic notions:
1. It creates units that are larger than the Clinical Commissioning Groups (CCGs) which Lansley created to replace Primary Care Trusts (PCTs). These new areas are called 'planning footprints'.
2. Lansley concentrated on the commissioning of health care and left hospitals at the mercy of rising demand, lack of trained staff, commissioners trying to save money and two regulators each with different priorities. This time it is very different:
Although the Lansley legislation was called the Health and Social Care Act and included the formation of local Health and Wellbeing Boards to promote integration, he did not properly build bridges between health and social care. And anyway his colleague at the Treasury was busy reducing - if only indirectly - local councils' social care budgets.
STP 'footprints' will include not only the commissioners (CCGs) but also acute hospitals and local authorities - with all the latter's social care responsibilities. They aim at real integration. But they will not include any of the private providers which have a growing stake in the NHS.
On paper these STP 'footprints' look suspiciously like re-heated Strategic Health Authorities - one of the many NHS bodies Lansley abolished.
Wiltshire will join Swindon and Bath and North East Somerset (BANES) to become an STP 'planning footprint'. The great advantage of the 'footprint' the Marlborough area finds itself in, is that it includes all three acute hospitals (RUH, Salisbury and GWH) which serve Wiltshire's population.
Another advantage of this new system is that Wiltshire CCG are quite a distance along the road to transformation - notably with the rising success of their policies to treat many more of the old and frail at home rather than in hospitals.
A probable disadvantage for this STP footprint is that it yokes together three very different cultures (mainly urban and mainly rural) and demographics.
A broader disadvantage of the whole STP scheme is that it may be seen as a distinct slap in the face for the 'clinical leadership' of the CCGs. They have been driving change in the CCGs and, under the Lansley regime, replaced the commissioners of the PCTs who were referred to by many politicians as nothing but bureaucrats - or worse.
The speed with which NHS leaders and local authority leaders now have to move to achieve this nation-wide reconfiguration is eye-watering. The timetable of key stages began last week (week beginning February 29) and ends in July.
The power these footprints will wield comes from the capitated budget each will receive. But this will almost certainly provide them with their main problem: as the population ages and treatments get more costly, affordability will become the watchword. They will have to decide on reductions in treatments they can afford.
And, unless people are properly informed and prepared, that will open them up to a welter of local 'rationing' controversies and they will have a lot of explaining to do to patients, families and their MPs.
However, do not get too alarmed: because STP is not put in place by legislation but by NHS dictat it may not create permanent structures. If they do not work, they can be shunted off to a rehabilitation home.
Each 'footprint' area has to have "a named person who will be responsible for overseeing and coordination their STP process" - this could be a CCG chief officer, the chief executive of a hospital or of a local authority.
The letter spelling out 'the process' is from the heads of the six main, national NHS organisations - NHS England, Care Quality Commission, Health Education England, NICE, Public Health England and a new body - NHS Improvement.
This new kid on the block is symptomatic of the sleight of hand with which this reorganisation is being carried out. NHS Improvement joins together the Trust Development Authority and Monitor which each regulated different layers of England's hospitals.
However, joining them together would require primary legislation - and that might frighten the horses. So they have simply been yoked together under one boss, but still with separate offices and staffs. Many people hope that NHS Improvement will work towards real improvements rather than merely delivering the slaps on the wrist associated with its forebears.
The chief problem will be sorting out the governance of STP: who reports to whom and who can force change on what, and how to deal with a complex cocktail of conflicts of interest. Another issue will be that while the CCGs and hospitals carry on their vital day jobs, there will need to be some sharing of staff and resources towards the greater good of the 'footprint' - and ultimately themselves.
Another issue will undoubtedly be fitting various existing oversight and other committees into this new 'footprint' geography. For example the Health and Wellbeing Boards (of which there are three in our 'footprint' - joining each CCG to its local authority) may well become redundant. That would be tricky as they were created under Lansley's Act of Parliament.
As the NHS letter to all heads of CCGs, hospitals and local authorities, spells out engagement and communication will be one of the main jobs the STP will have to achieve:
"If we get this right, then together we will:
• engage patients, staff and communities from the start, developing priorities through the eyes of those who use and pay for the NHS.
• develop services that reflect the needs of patients and improve outcomes by 2020/21 and...close gaps across the health and care system...
• mobilise local energy and enthusiasm around place-based systems of health and care, and develop partnerships, governnance and capacity to deliver.
• provide a better way of spreading and connecting successful local initiative, providing a platform for investment from the Sustainability and Transformation Fund..."
So we will be watching this space to see whether STP is the cure or the disease. We should all expect to hear about STP sooner rather than later as one of its key aims will certainly be telling 'those who use and pay for the NHS' what the service can no longer afford and what services will be combined or moved elsewhere.
This Friday (March 11) a cross-party (not, we note, 'all-party') NHS Bill will be debated in Parliament. This aims to bring back the NHS as a national universal service and get rid of the expensive, chaotic internal and external market.
In other words it seeks to de-Lansley the NHS - ending fragmentation and privatisation. Were that to pass it might do more in the short term to save the NHS than hurtling forward with STP.