52.This chapter summarises key changes to the local planning of health and care services across England, including the development, and current status, of sustainability and transformation plans, as well as key issues concerning sustainability and transformation partnerships and integrated care systems, including the geographical boundaries of these areas.
53.The NHS planning guidance in December 2015 set a requirement for local areas to come together and develop blueprints setting out how they planned to deliver the NHS Five Year Forward View. As part of the plans, local areas were required to estimate the funding gap in their area and set out how they planned to fill this gap. This meant local bodies, often without a history of collaborative working, had to come together and make very difficult decisions about changes to health and care services locally. The process was made more challenging by the very tight timeline national bodies set for these plans to be developed.
54.Local areas had until the end of January 2016 to develop partnerships and submit proposed boundaries, known as footprints. The original deadline for the final plans was in June 2016. However, this was moved back to October 2016 following an initial assessment of the plans by national bodies. Areas with a history of collaborative working and a clearer, meaningful and more practical geographical boundary started with an advantage.
55.The tight timeframe placed significant strain on the resources of local NHS leaders and senior management. In many cases, management consultants were used to fill gaps in the capacity and capability of local organisations to develop these plans.
56.There was also limited time and capacity to involve all the key local partners. From the outset, representatives from local government expressed concerns that the process was inherently NHS-centric; many local councils and MPs had limited or no input into the original versions. Representatives from primary care providers also reported similar experiences and wider engagement with staff and local communities, including voluntary groups and members of the public, was also minimal in many places. Public engagement was also limited by instructions from national NHS bodies to “STP leaders to keep details of draft STPs out of the public domain.”
57.Sustainability and transformation plans for each of the 44 local areas were published by December 2016. These plans contained a series of proposals to redesign the shape of local health and social care provision, including controversial plans to reconfigure acute services and reduce bed capacity.
58.In many cases, proposals contained within the plans were not supported by robust evidence. An analysis of the 44 sustainability and transformation plans by London Southbank University found that very few of the proposals were based on a robust assessment of population need. Similarly, no detailed workforce plans were evident in two thirds of the original STPs, in which local areas set out how they planned to ensure they have enough staff to deliver the new policies and services proposed in the plans.
59.Over the course of 2016 the media portrayal of the STP process moved from relatively benign reports of progress locally within regional and trade outlets in the early part of the year, through to widespread negative portrayals of the plans in national media in July and August 2016. This reached a peak in late August, with reports of an investigation by 38 Degrees, a campaign group. The King’s Fund’s analysis of media coverage over the period in which STPs developed noted that:
On 26 August, the campaigning group 38 Degrees published an investigation into STPs that was covered by all major newspaper and broadcast outlets. News items focused on the ‘secrecy’ and lack of public consultation on the plans, as well as making frequent links to potential ‘cuts’, ward closures and the downgrading of A&E services.
60.In the run up to the final deadline, coverage about the secrecy of plans continued and was accompanied by reports of plans leaked to the press, in which the focus of the coverage was on proposals to close services, reduce bed capacity and reconfigure hospitals. The STP brand as a consequence was politicised and became seen as a smokescreen for cuts to services. As Professor Chris Ham described:
They were asked to produce a plan by whenever it was—October 2016—that showed how they would balance their collective budgets within the envelope that they knew they had available. That was behind the realistic concern that this was about a cost-cutting exercise rather than about transformation of care. Sadly, STPs got off to a very bad start, a very difficult start, because of that.
61.Professor Chris Ham described how “most STPs got to the finishing line of October 2016, submitted their plans and breathed a huge sigh of relief. No further work has been done on those STPs. The governance and leadership they brought together remains very weak by comparison with what is happening at the organisational level in most parts of the country.” The prominence given to the plans has diminished since the Next Steps to the NHS Five Year Forward View was published. The focus has now shifted from “plans” to “partnerships”. NHS England and NHS Improvement’s written evidence to our inquiry stated that:
it is partnerships–not plans–that matter most. Every local partnership is at a different stage of its integration journey, normally predicated on the strength of local relationships. The most mature partnerships are evolving further to become ‘integrated care systems.
62.Simon Stevens described the original plans as a “conversation starter”. He confirmed that NHS England is not expecting most of 44 areas to deliver on those plans, although NHS England is backing some of the local areas to make progress. Mr Stevens told us:
In some places, such as Dorset, they had a clear plan, and I think they are able to push on with that. We have backed it with capital and they are progressing well.
63.In other local areas we heard that the thinking has evolved since the plans were published, as the financial position in 2018/19 is, according to Mr Stevens, “more benign than it was when the plans were drawn up a couple of years ago.” Consequently, local areas may be revisiting their original proposals, especially given recent commitments of extra funding made by the Prime Minister at the Liaison Committee on 27 March 2018. However, while the NHS’ overall financial position has improved, it is still far from stable (see Chapter 8).
64.STPs got off to a poor start. The short timeframe to produce plans limited opportunities for meaningful public and staff engagement and the ability of local areas to collect robust evidence to support their proposals. Poor consultation, communication and financial constraints have fuelled concerns that STPs were secret plans and a vehicle for cuts. These negative perceptions tarnished the reputation of STPs and continue to impede progress on the ground. National bodies’ initial mismanagement of the process, including misguided instructions not to be sharing plans, made it very difficult for local areas to explain the case for change.
65.NHS England has rightly decided not to expect every area to deliver against the original sustainability and transformation plans published in December 2016. This is a pragmatic approach given the controversy surrounding the proposals contained within the original plans, and the constraints imposed on areas against engaging key voices locally. However, NHS England needs to learn from the mistakes of the initial roll out of STPs.
66.The STP footprints, or boundaries between services, were developed in a short space of time. Creating geographical boundaries is extremely difficult since, as Nigel Edwards from the Nuffield Trust described, “there is no real right organisational level for things as complex as healthcare.” Boundary issues are pervasive across many STP areas. Professor Chris Ham provided an example, saying that “Epsom and St Helier is part of the Surrey Heartlands integrated care system, but it is really part of south-west London and the STP there.”
67.A clear message from our inquiry is that the practical issues arising from STP boundaries have significantly affected progress so far. STPs are in a better position when their geographical boundaries, including sub-sections of the STP, make sense to local people, professionals and services. Unsurprisingly, STP footprints with a smaller population, a smaller number of partners, boundaries that align with patient flows between services and coterminous organisational boundaries between partners tend to be further ahead. Boundaries in the more advanced areas tend to align with pre-existing relationships, often built around a geographical area that is clear, practical and recognised locally. Julie Wood, Chief Executive of NHS Clinical Commissioners, told us:
The starting point in history and relationships is very important, also the geography. Some of the geographies the STPs were built on were the same as the places people were working in—for example, Nottinghamshire or Dorset. We heard from Greater Manchester that they have been working in that way for some time. Some of the other geographies did not feel as natural, so it has taken time to get to first base.
68.Councillor Jonathon McShane from Hackney Council, representing the Local Government Association, also argued that areas which are focused on patient flows around acute services, rather than wider community services and assets, including local authority boundaries, have struggled to make progress.
69.Despite the pervasiveness of boundary problems, the evidence we were strongly advised against any national intervention to reconstruct more cohesive geographies, even if, from the perspective of national bodies, this leads to a complicated patchwork of accountabilities. Instead, encouraging each local area to focus on developing clear, meaningful and practical boundaries, either at the STP level or in sub-sections of the STP, is considered to be the key.
70.It is not essential that the STP footprint as a whole corresponds to an area that might be recognised by local people, professionals and services. Instead, the clear, practical and meaningful boundaries to which we refer above could be set around a sub-section of an STP, where, as Professor Chris Ham described, “it makes sense to focus on the place, the population and how services in this area join up.” Ian Williamson from Manchester Health and Care Commissioning emphasised this point, saying “if there is one lesson I have taken from the last three or so years, it is place-based focus rather than organisational focus.”
71.Within South Yorkshire and Bassetlaw STP, for example, five separate sub-sections of the footprint (Sheffield, Doncaster, Barnsley, Bassetlaw and Rotherham) had been identified and alliances between providers were being built at this level. In South Yorkshire and Bassetlaw, the governance of the STP was built upon these five sub-sections, as local leaders operated on the principle that decisions would only be taken at an STP level where it made sense to do so.
72.NHS England, in the Next Steps on the NHS Five Year Forward View, made clear that boundaries, while initially imposed in some cases, are not set in stone, but can be adjusted, with national approval, where local areas present a clear benefit to doing so. In other words there has been an understanding that changes should be initiated at local level rather than imposed from above.
73.An STP area, or areas within it, work more effectively where they are meaningful to partners, local health professionals and most importantly the public. STPs, particularly those with more complex geographical boundaries, should be encouraged and supported to allow local areas to identify, define and develop meaningful boundaries within their patch in which local services can work together around the needs of the population.
74.STPs should be encouraged to adopt a principle of subsidiarity in which decisions are made at the most appropriate local level. NHS England and NHS Improvement should set out in their planning guidance for 2019/20 advice and support to achieve these recommendations.
75.The Next Steps in the NHS Five Year Forward View shifted the focus and the name of STPs from sustainability and transformation plans to sustainability and transformation partnerships. These partnerships were described by Simon Stevens as being on an “evolutionary and developmental journey.”
76.Despite getting off to a difficult start, many local leaders conveyed the benefits they have already seen and the potential of more place-based working. This potential extends beyond the NHS’s traditional role in healthcare. For example, partnerships have facilitated conversations that may not have taken place in the same way before. Ian Williamson from Manchester Health and Care Commissioning explained:
from my background largely as an NHS person, this has given us the opportunity to have conversations about, for example, how we try to reduce childhood obesity, or how we work on emissions in our atmosphere in a way that we have not previously been able to do. Those are real things that impact on people’s health and wellbeing, and it has given us a way to address them.
77.Many local leaders also spoke with enthusiasm at our visit to South Yorkshire and Bassetlaw about the positive contribution the NHS can make to wider social issues and local economic growth. Rob Webster from West Yorkshire STP described how, with a strong life science sector in his patch, the NHS locally has a potential role to play as a catalyst for innovation and growth. Senior leaders in South Yorkshire also told us how the NHS, as a large employer, could play a critical role in providing career opportunities for young people locally.
78.Increasingly STPs have become the vehicle for delivering national priorities and targets, improving financial management across the system and managing demands, particularly on acute care, despite the governance and infrastructure being fragile and in development. NHS Providers argue:
There needs to be far greater clarity and discipline over what STPs are intended to deliver. There is an increasing tendency for STPs to become the default footprint for delivering national policy initiatives, but they do not currently have the mandate, statutory authority, or infrastructure to deliver these.
79.National leaders should not lose sight of the fact that local leaders, as well as the wider workforce are rightly far more enthused and motivated by what can be achieved for patients through joint working than by the prospect of how this delivers national policy objectives.
80.NHS England and NHS Improvement have published an STP dashboard which rates the progress in each of the 44 sustainability and transformation partnerships. Each area is rated on the following 4-point scale: Outstanding, Advanced, Making progress and Needs most improvement. The written evidence we received identified a series of concerns about the utility of the dashboard and the indicators chosen. In particular, the indicators selected in the dashboard add further weight to concerns that the national bodies have narrowed their focus away from the original aims of the Five Year Forward View: the indicators chosen to measure the progress of STPs focus on their ability to reduce demand on hospitals, manage financial resources and deliver national priorities in the short term. In future there needs to be greater emphasis on what these deliver in improving the experience and outcomes for patients.
81.Sustainability and transformation partnerships are mechanisms for delivering the NHS Five Year Forward View, which in part, was a vision for making the transition to more integrated models of care. However, the STP Dashboard has no indicators to measure integration or the progress local areas have made in transforming care, such as progress made against their STP plans.
82.Integrated care is difficult to measure and, as noted in Chapter 2, national bodies are still developing their understanding of how to do so. However, it seems surprising that there are no indicators to measure integration or transformation in the dashboard, particularly given statements characterising STPs as part of the greatest move towards integrated care in the western world.
83.A central part of the NHS Five Year Forward View is the shift to more proactive and preventative delivery of health and healthcare. However, we heard that the indicators chosen to measure prevention narrowly define prevention in terms of reducing demands on acute services. This is unlikely to help to build the case for change with the public.
84.There is also no measure of how local areas have engaged with key partners and local communities. Engagement with local groups, who are understandably active and vocal about local service changes, is critical for STPs as they begin to transform services.
85.The public and voluntary groups are not only important constituents to engage, but play a critical role in the delivery of the NHS Five Year Forward View. Ian Williamson from Manchester Health and Care Commissioning referred to the importance of situating these partnerships in their wider communities. Mr Williamson stressed:
it cannot stop at just the statutory sector or public-sector bodies; it has to reach out to neighbourhoods, community groups, be they communities of interest or geographical communities, and the voluntary and community sector. It is crucial that this is a journey we go on together, so to speak.
86.Chapter 2 of the Forward View emphasises the need to empower people and communities. However, the prominence given to the role of people and communities has not been carried through to the STP Dashboard. Simon Stevens, in response to a question from Anne-Marie Morris MP at a meeting of the Committee of Public Accounts about whether NHS England should have a target to assess engagement with local voluntary groups, stated that:
we have been discussing, as recently as this morning, the extent to which we should try to build some of that into the processes we use to assess and check how well the STPs are working.
87.We heard that engagement with local voluntary groups was very limited in the development of sustainability and transformation plans, although it has improved in some areas. Cuts to voluntary sector funding have meant that many charities have struggled to engage with STPs, particularly smaller charities that do not have the same infrastructure as the larger national charities.
88.Involvement and engagement of local communities, representatives and voluntary groups are pivotal to realising the changes described in the NHS Five Year Forward View. Progress of STPs, as one of the key mechanisms for delivering the Forward View, should include an assessment of how effectively local communities are involved and engaged.
89.For most local systems, the focus has been on building trust and relationships between local leaders and services. National support and funding for transformation has been directed predominately towards the 10 integrated care systems which are further ahead (discussed in more detail in Chapter 8). These areas, in contrast to those further behind, often drew on a history of collaborative working locally. NHS Providers’ written evidence identified the following factors that have affected progress of sustainability and transformation partnerships:
90.The strength of local relationships is pivotal to the process. According to NHS Providers, where the factors outlined above are less evident, more time is necessary for local areas to form relationships, build trust and agree local aims and objectives. Rob Webster, STP lead in West Yorkshire, characterised the importance of relationships in saying that “change happens at the speed of trust.” This message was expressed by Simon Whitehouse, STP Director for Staffordshire and Stoke-on-Trent, one of the more challenged local areas:
There is also recognition that as we sit here now STPs in their widest sense are not statutory bodies; they do not exist in an organisational form. It is literally the strength of the relationship and the collaboration that sits underneath it that drives it. We have to keep coming back to why we are here and what we are trying to deliver for the population we serve. For me, you can change the three letters as many times as you want, but we need to serve the local population, improve health outcomes, bring a real focus to rigorous continuous quality improvement at local level and get partners to work collaboratively to drive that change.
91.Sustainability and transformation partnerships provide a useful forum through which local bodies can come together in difficult circumstances to manage finite resources. However, they are not on their own the solution to the funding and workforce pressures on the system. We are concerned that these pressures, if not adequately addressed, may threaten the ability of local leaders to meet their statutory obligations let alone transform services. Overwhelming and unrealistic financial pressure drives them to retreat back to organisational silos. This would seriously undermine the progress local leaders have made in already difficult circumstances.
92.Sustainability and transformation partnerships have no legal basis, and so depend on the willingness of local leaders to participate. These relationships are fragile: national bodies must be careful not to overburden these partnerships by increasingly making them the default footprint for the delivery of national policies, especially while their relationships, governance and infrastructure are relatively weak in comparison to other parts of the system.
93.We recommend that the national bodies, including the Department, NHS England, NHS Improvement, Health Education England, Public Health England and CQC, develop a joint national transformation strategy. This strategy should set out clearly how national bodies will support sustainability and transformation partnerships, at different stages of development, to progress to achieve integrated care system status. This strategy must not lose sight of patients. National bodies in this strategy should:
c)consider whether, and if so how, support, resources and flexibilities currently available to integrated care systems could be rolled out to other areas to help them manage pressures facing their local areas;
d)develop a more sophisticated approach to assess the performance of STPs and their readiness to progress to integrated care status. This should include an assessment of local community engagement, the strength of local relationships and the progress towards preventative and integrated care. An assessment of prevention should encompass a broader definition than preventing demands on hospitals and integration should focus on how to improve patients’ experience of and outcomes from services.
94.Integrated care systems are advanced forms of sustainability and transformation partnerships, in which “commissioners and NHS providers, working closely with GP networks, local authorities and other partners, agree to take shared responsibility (in ways that are consistent with their individual legal obligations) for how they operate their collective resources for the benefit of local populations.”
95.The benefits of ICS status for STPs include greater autonomy over funding, such as resources earmarked for transformation, and for services currently commissioned nationally (e.g. primary care and specialised services). However, to qualify for ICS status local areas must demonstrate that they have robust mechanisms for collective governance and decision-making, deliver horizontal and vertical integration across services, have robust measures to continue to provide choice to local residents and are capable of managing population health.
96.The recent NHS planning guidance published by NHS England and NHS Improvement introduced a series of changes which seek to foster greater system-wide management. These changes include a requirement for each ICS to produce a system-wide plan to deliver the system’s control total, in other words the limit on its spending, more streamlined oversight from national bodies, and a series of financial incentives to support system-wide management of funding. NHS England and NHS Improvement will only assure system-level plans, leaving ICSs to review plans of individual organisations within their area.
97.The first wave of integrated care systems are expected to pave the way for the remaining local systems by developing a pathway to full ICS status, leading on the implementation of specific system-wide efficiencies (e.g. consolidation of back-office functions), and providing lessons, and possibly support, for future cohorts moving to ICS status.
98.Since the Next Steps to the NHS Five Year Forward View announced the creation of accountable care systems (the former title of ICSs), the focus in the first cohort has been on building the capacity of these systems to take collective responsibility for their local system. In doing so, these areas are grappling with complex changes, such as how to align the work of CCGs with wider system plans. The landscape within these areas is also changing rapidly, with the emergence of integrated care partnerships and changes to local commissioning (mergers of CCGs, joint executive teams between CCGs and integrated commissioning between CCGs and local authorities).
99.Like STPs, ICSs vary significantly. Greater Manchester covers a population of 2.7 million, whereas Blackpool and Fylde Coast has around 300,000. The number of bodies also varies widely between these areas. The 10 integrated care systems face similar problems to the rest of country, but have been able to demonstrate positive progress in the changes they have made and some of the outcomes they have already achieved.
100.Despite examples of progress, organisational roles and accountabilities within these areas still cause tensions and difficulties. Local bodies in these areas have competed for many years and, in some cases, may not have worked together for long. Partners within integrated care systems in 2018/19 have flexibility to move funds between organisations to balance the system control totals. However, organisations are having to reconcile system control totals with their own individual controls and use of the provider and commissioner sustainability funds (see Chapter 8). The King’s Fund has warned that:
if control totals are not realistic, they could create significant financial disincentives to partnership working and bring into question the commitment of NHS organisations to continue working in this way.
101.Even in the more advanced areas, local leaders were worried about how to maintain the cooperation between all the relevant players. Pressures on even the most advanced areas are far from sustainable. South Yorkshire and Bassetlaw had made excellent progress and the areas’ financial position was more benign than other local systems, yet the area is not immune from some of the pressures. Primary care in the area, notwithstanding excellent examples such as Larwood Practice, faces significant workforce challenges.
102.While very supportive of the principle and potential of integrated care systems, Professor Chris Ham from The King’s Fund, who has been working with NHS England and the first wave of integrated care systems, provided a word of caution, saying:
the 10 integrated care systems are beginning to show what is possible through place-based working that goes beyond STPs. Let’s not underestimate how nascent and fragile those systems are. They depend on the willingness of organisations to come together in the same room and collaborate, in a system that was not designed to make that the easy thing to do.
Professor Ham went on to say that:
There is clearly a risk that some of them will not be able to build on the progress they have made so far because, with the growing pressures, the focus will be on organisations dealing with their deficits, which may get in the way of systems playing a bigger part in supporting organisations to do that collaboration. I do not want to exaggerate, but I do not want to adopt an overly optimistic view either.
103.A lot of pressure is being put on these frontrunners. The King’s Fund argue that they are “writing the manual for system working rather than being readers expected to implement a blueprint written by others.” National bodies need to pay careful attention to how they support these fragile and nascent systems to maintain the progress they have made so far, as well as pave the way for future cohorts.
104.Another dilemma facing national bodies is how they approach areas in which the concept of integrated care systems, as currently envisaged, does not work or is unlikely to work. A lesson from the foundation trust pipeline is that it is quite possible that the eligibility criteria local areas need to meet to attain ICS status will be outside their reach. While this is entirely possible, an even more likely scenario is that some local areas which manage to achieve ICS status may struggle to maintain their performance, resulting in a scenario where the ICS badge becomes tokenistic. Such a scenario would see a similar pattern to the one that emerged between NHS trusts and foundation trusts, which Simon Stevens described as a “distinction without a difference.”
105.We support the development of integrated care systems, including plans to give greater autonomy to local areas as part of their ICS status. We are encouraged by the positive progress the first 10 integrated care systems have made in the face of challenges on the systems. However, like STPs more generally, we are concerned that funding and workforce pressures on these local areas may exacerbate tensions between their members and undermine the prospect of them achieving their aims for patients.
106.NHS England and NHS Improvement should systematically capture and share learning from areas that are furthest ahead, including their governance arrangements and service models, to accelerate progress in other areas and also to provide clarity about what is permissible within the current legal framework.
33 NHS England, , December 2015, pages 4–7
34 The King’s Fund, November 2016, pages 67–79
35 The King’s Fund, November 2016, page 5
36 The King’s Fund, November 2016, page 43
37 The King’s Fund, November 2016, pages 31–38
38 The King’s Fund, November 2016, page 23
39 The King’s Fund, , February 2017
40 London Southbank University, , May 2017
41 The King’s Fund, November 2016, page
42 The King’s Fund, November 2016, pages 14–15
43 Q274 Professor Chris Ham
44 Q261 Professor Chris Ham
45 NHS England, , March 2017, page 31
46 NHS England STP0107, page 1–2
50 Oral evidence taken before the Liaison Committee on 27 March 2018, HC 905 (2017–19), Q76 [Prime Minister]
51 Q256 Nigel Edwards
52 Q260 Professor Chris Ham
53 NHS Providers STP0050
54 Q203 Julie Wood
55 Q203 Cllr McShane
56 Q256 Nigel Edwards
57 Q256 Professor Chris Ham
58 Q194 Ian Williamson
59 NHS England, , March 2017, page 34
60 The NHS planning guidance in December 2015 required local areas to come together to develop sustainability and transformation plans: blueprints for delivering the NHS Five Year Forward View. These plans were originally intended to contribute to filling the gap between patient demand and resources between 2015/16 to 2020/21. 44 plans, one for each local area, were published in December 2016. The Next Steps to the NHS Five Year Forward View shifted the emphasis of from the original plans to partnerships, focusing on driving efficiency and improvements through more collaborative working locally than rather making progress with the proposals described in the original STPs.
61 See Annex
62 Q194 Ian Williamson
63 NHS Providers STP0050, Q261 Professor Chris Ham
64 NHS Providers STP0050
65 NHS Providers STP0050, Local Government Association STP0027, NHS Clinical Commissioners STP0064
66 National Audit Office, , HC 1011 Session 2016–17 8 February 2017.
67 Local Government Association STP0027
68 Q194 Ian Williamson
69 Oral evidence taken before the Public Accounts Committee on 21 March 2018, HC (2017–19) 793, Q118 [Simon Stevens]
70 Q143 [Don Redding]
71 Q144 [Don Redding]
72 NHS Providers STP0050
73 NHS Providers STP0050
74 Note on SY&B visit
75 Q194 Simon Whitehouse
76 NHS England and NHS Improvement, Refreshing NHS Plans for 2018/19, February 2018, page 12, para 5.2
77 NHS England, , March 2017, page 36
78 System control totals are overall financial targets for an STP. Each NHS body within an STP also has an individual control. ICS areas, unlike STPs, are able to move resources between partners as long as the system control total is met.
79 NHS England and NHS Improvement, Refreshing NHS Plans for 2018/19, February 2018, pages 13–14
80 , Health Service Journal10 July 2017
81 The King’s Fund, A progress report on integrated care systems, March 2018
82 The King’s Fund, A progress report on integrated care systems, March 2018
83 The King’s Fund, A progress report on integrated care systems, March 2018
84 The King’s Fund, A progress report on integrated care systems, March 2018
85 Q253 Professor Chris Ham
86 Q253 Professor Chris Ham
87 The King’s Fund, A progress report on integrated care systems, March 2018
88 Q226 [Saffron Cordery]
89 NHS Chief backs Monitor and TDA merger, Health Service Journal, 10 February 2015
Published: 11 June 2018