Could plans for NHS shake-up collapse?

As winter approaches, NHS managers in England will be even busier than usual.

Handling the increased volume of emergency admissions to hospitals and juggling demands for beds will be as tough as ever.

On top of that will be a raft of meetings discussing the potentially most radical shake-up of health services in decades.

The sustainability and transformation plans (STPs) being produced in 44 local areas of England are seen as vital ingredients in the redesign of care to cope with increasing patient demand.

The plans will focus on trying to moderate that demand and treat more patients away from hospitals.

But there has been no denying that some of the plans will see closures of accident and emergency units and hospital wards, concentrating services on fewer sites.

The STP process has got off to a difficult start.

Accusations of cover-ups and stealth cuts have been fuelled by the King's Fund report, external that said local health teams had been asked by the NHS nationally to keep the plans out of the public gaze.

Local campaigners, fearing closures, are gearing up to take to the streets to defend local hospitals. There could be a winter and spring of discontent ahead.

A bigger question raised by the King's Fund report was whether the STPs would be deliverable.

Local health leaders have enough on their shoulders with the day-to-day running of services, never mind managing ambitious and sometimes controversial transformation plans.

Investment for a shake-up of local care provision will be hard to come by in stretched budgets.

I am hearing there is a big variation between the best and the worst STPs and the way they are being handled locally.

One source close to the process said that while NHS managers were always good at setting out healthcare challenges and aspirations, it was much harder to get agreement on concrete action plans.

Egos, money and jockeying for leadership positions often get in the way of difficult decisions on change.

Sustainability and transformation plans are are aimed at overhauling NHS services and saving money.

Each area of the country has been asked to come up with its own plans, and so local NHS managers have divided the country into 44 "footprints".

It is all part of NHS England's five-year strategy to release £22bn of efficiency savings by 2020. As health is devolved, the plans do not affect the rest of the UK.

The 44 areas started reviewing local services in early 2016, and all have now submitted proposals to NHS England and NHS Improvement.

Consultations on major changes are expected to take place early next year, with implementation following soon after.

Sustainability and Transformation Plans explained, external

The STP process has brought together hospital bosses, community health organisations, GPs, commissioners and local authority social care leaders, often for the first time.

In some areas, tensions have emerged and local council leaders have hinted that the NHS is dominating the process.

Reading Council has gone public with criticism of its local STP, claiming the local authority view has not been properly heard: "we have serious reservations about a process in which a five year plan for local health services can be drawn up behind closed doors and without proper public, or indeed political scrutiny."

This has been compounded by confusion over publication and public involvement, with some plans released unilaterally by local authority representatives.

Some of the STPs already published have plenty of predictions about anticipated increases in activity and how they need to be tackled.

But they are short on detail and run the risk of being dismissed as pie in the sky.

On the other hand, plan teams know that specific references to closures will spur local protests.

At a Kings Fund discussion Caroline Clarke, chief finance officer at Royal Free London Trust, was supportive of the STP work and noted that it was galvanising efforts on system-wide problems.

The fund itself has made clear that it sees STPs as the best hope for improving health and care services, even if they are controversial.

NHS England has made clear that more plans will be published in the weeks ahead and the public will have a chance to have their say.

As the debate gathers momentum, the Department of Health will watch closely.

Government sources indicate it is supportive of the process but needs to see and assess the plans.

There is a sense of keeping things at arms length at this stage. Downing Street is known to be taking an interest, keen no doubt to assess the likely political fallout.

The head of NHS England, Simon Stevens, has made clear to the service that the STPs are an essential part of his much heralded Five Year Forward View strategy.

For Mr Stevens personally, there is a lot riding on these plans. If they get derailed, it will be a serious blow.

Success could see a major shift in health and social care management, with the STPs blueprints for a new devolved care model.