Accountable Care Health Care Public Health Healthcare Reform STP

 where next for STPs

So they are all in. 

Simon is going to be busy over the summer reading them.

No trashy novels by the poolside for him.
What next is anybody’s guess.
I was having a think about what next. 

Some reflections below.

Don’t know whether I’m right and I’m happy if you want to disagree and argue with me….that would be fun……


Have we got the macro incentive structure right?
Not until we abandon PBR, and have a serious think about some of the less helpful targets we aggressively performance manage that drive odd behaviour.

Is the system (and I mean system not individual orgs, though that would be adecent start) on capitated contract 
But starting with hospitals (who to be fair don’t have the incentive nor much control about demand coming in to their part of the system)… Capitation contract should fix the incentive part of the above statement and automatically incentivise prevention of stuff to keep folk out of increasingly unprofitable hospitals.
May be interesting to increase the acuity of the incentive by 

a) introducing two sided risk share (as per the ACO) or more brutal,

b) decreasing the size of contract decreases by x% a year (value of x is debatable)….accelerates the shift (but risky re stability)

The decrease doesn’t have to be in cash… 

Could be in sessions of hospital docs not actually working in hospital but working in non hospital. So say diabetes docs, or maybe better generalists – getting geriatrics out of hospital (this is the community extensivist model). 

This is financially less risky for hospital.


Concentration of power in one sector

There might be an argument that there’s a danger that concentration of power in larger hospital chains – as is happening in many STP models – may make the above less likely rather than more.

Will need strong muscle from both CCG, local govt and NHSE to make it happen. 


Money and spreadsheets vs story and vision

By necessity the rules to date have led to an Over emphasis on the technical description of the challenge, not the story and the vision. 

Under emphasis on practical wisdom, management of relationships and winning hearts and minds.

The next step has got to be getting buy in up and down the system

This has got to be done with stories not spreadsheets


We focus on the money not the other aspects of transforming 
Danger that when the centre sees the collective sum of STPs across the country and it doesn’t add up to the required sum, the default response will be standard centralist management – dear NHS get a grip and try harder……

This will be the wrong response, but……


Lots have said to me ‘where’s the GP leadership’

My stock response is that they are mighty busy keeping the show on the road and that part of the system is arguably under the most pressure – demand hike with at best flat funding. So it’s sort of hard to get nose away from the grindstone etc

That said, point stands we absolutely need GP to be at the very top table here and having an influential voice.


Where are the creative service models
Some examples


Getting geriatricians at front door or hospital with right non hospital networks to actually enable those that don’t need hospital bed to be cared for at home (thus avoid hospital being the default etc).

Exploring the notion of alternative forms of GP contract

Specialist GP contracts so as only focus on urgent care, or LTC management

Danger of turning generalists into specialists

Who is playing with say direct access physio to avoid unnecessary GP appts.

Good evidence here.

Get on with.

Only a few random reflections. 
What’s your view.

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