With Sustainability and Transformation Plans (STPs) aimed at delivering multi-billion savings, being carried out secretly in 44 areas nationwide, this is a seminal moment for the NHS. Leaders need to engage the public in addressing the country's health and social care crisis; come clean about what STPs can realistically deliver; and acknowledge that in some areas STPs could actually be asking the wrong questions.
Nine months ago NHS England announced that every health and social care system would produce a STP, the first drafts of which have now been submitted to NHS England. On one of August's quieter news days they made major news, with STPs flagged as the means health bosses would save billions by closing hospitals and other services.
Let's be clear. The principle of the STP is sound. After the disastrous destruction of planning arising from the Coalition's 2012 Health and Social Care Act, the notion of bringing together providers and commissioners within a recognisable geographical area is a good one. STPs offer opportunities to explore options and collectively find solutions to various health and social care challenges. They also give the chance to join up health and social care, and involve local authorities much more - potentially key in an era of wider devolution.
So what's the drawback? More money will be needed and transparency is key. STPs are being undertaken in the context of the greatest financial squeeze ever experienced by the NHS, and between them they have to deliver at least £20bn of savings. It's fanciful to think they can do this without hard choices being made by the government about what the NHS will now stop doing.
And the plans are being drafted in secret as the STP's geographical footprints have no statutory basis, no clear governance or decision-making processes or obvious way for members of the public - or indeed their local Members of Parliament - to know what they contain.
Public engagement
Like other MPs my focus is on my own constituency. For Bristol South residents the STP is formed of Bristol, North Somerset and South Gloucestershire CCGs, a recognisable planning area (BNSSG) based on hospital catchments but covering three local authorities very different in their political and social demographic.
In 2004 the same geographical area joined together to produce the Bristol Health Services Plan. Then it comprised four Primary Care Trusts and the two acute Trusts. These six NHS bodies described the need for changes to 'transform and modernise' local health services largely by moving services closer to home, improving quality of care, bringing together specialist hospital services and improving the quality of old hospital buildings.
After scores of public meetings and a wide range of engagement with the public a plan was produced, agreed by all six Trusts and overseen by a joint scrutiny panel of the three local authorities. It resulted in the closure of one hospital, the building of a new large acute one, new community hospitals, GP surgeries and rationalising of other estate. Most of the promise was delivered.
What hasn't been achieved since these agreements is the delivery of the assumptions that underpinned the plans in terms of how many beds would be needed, how long people would stay in hospital, and the substantial increase in community services including urgent care centres to reduce pressure on A & E. And that means that 12 years on largely the same population, in the same geography, with the same health and care needs, will now be getting a new Plan, its STP.
What will it reveal when we eventually see it? My own view locally is not very much. Old sites have been closed and old buildings replaced with newer more efficient ones. One hospital has a £50m annual deficit and there could be an additional £30 - 50m deficit in the wider BNSSG system.
Where can BNSSG find £80 - 100m worth of further savings? It doesn't take an accounting genius to work out it can only be done by cutting staff, continuing the pay freeze, dissuading people from attending A&E, crude rationing of services to cut demand, reduction in attendances and admissions to hospital, and the recurring talk of prevention. None of these have worked before.
GP recruitment
It's worth stating that in Bristol South the major NHS issue residents face is the sustainability of primary care - getting a GP appointment, for example. GP recruitment to south Bristol, with its high levels of health inequality, has long needed support, and sadly in the current world of NHS England organisation and GPs having the pick of more convenient or lucrative placements it is hard to see prospects of improvement. This problem cannot be solved by reducing hospital activity to save money. So from the perspective of my Bristol South residents, the STP is missing the point.
What will happen next? We can speculate but many who know the NHS predict:
•Government will finally bow to the inevitable and fund health systems that shout loudest or are in the most favoured locations.
•Staffing problems across all disciplines will continue to worsen with services gradually becoming unsustainable.
•Waiting times and lists will increase and targets will disappear.
•The NHS Constitution, which specifies our right to treatment within set times, will be watered down or voted away by the Tories' huge English majority in Parliament.
•People who can afford it will choose private treatment so slowly a two tier system evolves.
Involving taxpayers in finding solutions
Make no mistake, in some areas major changes will be necessary. But the only chance NHS leaders have of securing public confidence going forward is involving taxpayers at the earliest possible stage, as we did in BNSSG 12 years ago, so they appreciate the challenge and help produce the solution.
In the absence of NHS leaders proactively involving the public, what can those who care about our NHS do to bring influence? Firstly, pressure must be applied to local leaders and NHS England to publish STPs, as I'm doing locally.
Other options, in the absence of a change of Government and or immediate Government policy, are:
•Lobbying local and national NHS bodies
•Attending Trust board and CCG governing body meetings
•Reading the public papers. Actually very little is secret - sometimes it is just hard to piece together.
•Demanding your £350m. Don't let the Brexiters off the hook. In Bristol South 47% people voted out in the EU Referendum.
•Asserting your rights as laid out in the NHS Constitution and Handbook.
But it takes time, energy and capacity to take on large institutions. Busy people shouldn't have to, especially when they are vulnerable as any patient is likely to be. Getting good quality healthcare, and the ticking timebomb of the scandal and silent misery of access to social care are prominent in the minds of the people we seek to represent.
So this is where the Labour Party should come in, speaking up on their behalf. Labour should be campaigning, ensuring people know their rights, enshrined in law by the last Labour Government under the NHS Constitution, and supporting the people who are being denied treatment.
Labour should welcome the way place-based planning can draw people together to find solutions, as a potential means to resolve some of problems caused by the Health and Social Care Act.
Karin Smyth MP
Labour Member of Parliament for Bristol South
@karinsmyth