In spite of the short timetable, Sustainability and Transformation Plans (STPs) are taking shape and programmes of action are being defined very quickly. It is striking how many actions are required across so many different areas in a very limited timeframe. History suggests that the problem the NHS has with this process is less the thinking and planning (although optimism bias is common), and more with delivery – in particular dealing with opposition and resistance to change.
Some footprint areas are having to work hard to create new relationships and ways of working in the absence of previous experience of working together; sometimes in groupings that they are not keen to be a part of. Others have been able to build on work that has already been developed. This means, unsurprisingly, that progress has been mixed. Having said that, a history of working together does not always guarantee progress.
Participants in our workshop held with the Healthcare Financial Management Association (HFMA) thought that there were big risks around implementation and governance that needed to be addressed.
Firstly, it is important to avoid the temptation to give STPs the responsibility for fixing everything and to be clear about the rules of subsidiarity. STPs have little infrastructure and many of the jobs to be done need to be addressed at a more local level.
Another critical risk is the level of engagement from local people. This has been limited by the speed of the work. Later in the process, some of the proposals may come as an unpleasant surprise to patients and communities. We have already had a small taste of this with today’s news coverage following a report by campaigning group 38 degrees.
Lessons from all previous large-scale changes have always stressed the need to bring the local population, politicians and others along with the thinking, rather than presenting a fait accompli. There is definitely a concern that the 'centre' underestimates the difficulty of the changes ahead, the political hazards of major change and the extent to which they require time and relationship building that are difficult to accelerate.
The importance of time and relationships is also an issue with less contentious changes – such as the development of new primary care models and the alphabet soup of new integrated care systems being developed.
The availability of managerial and clinical capacity to deliver this and meet all the current requirements – both financial and performance – are a source of concern. The number of projects, their complexity and the extent to which they often require rigorous attention to detail means that the size and complexity of the change programme will be very great.
The enabling strategies – particularly around estates, workforce and digital technology – are crucial and are all areas where the availability of the right sort of expertise and vision are in short supply.
The absence of capital is an issue. There will be a temptation to draw up deals with the private sector in a way that prevents the money generated from counting towards NHS spending limits, but may come at the cost of getting a good deal. This might be a complex, difficult to manage and expensive fix. There is also a view that simply selling assets rather than turning them into income would be short-sighted. Exploring the opportunities offered by working with housing associations and local government are seen as a potentially useful route to securing capital.
The governance of the STP and its implementation is seen as one of the most challenging areas. Local government has elected members, while clinical commissioning groups and foundation trusts are membership organisations. They have different objectives and, in the case of local government, quite different decision-making criteria. There is a concern that the machinery to oversee the STP and the mechanisms for holding people to account and for preventing defection from agreed positions are very underdeveloped. The way that current accountabilities work means that it is difficult to hold a large number of organisations to agreements and there is a fear that the STP will become the sort of ‘talking shop’ that has failed to deliver similar changes in the past.
Worse, it may become a distraction from changes that people could be getting on with locally. Effort is going into behavioural rules, agreements on collaboration and developing the levers – for example through controlling access to funding. However, these are all in their early stages, relatively weak and reliant on the different regulators and other parts of the national system holding the line and supporting local decisions.
A key idea is that there is only one sum of money. Mechanisms to maximise income or shift activity without a plan to reduce provider costs simply move the problems around the system. At best this is futile and at worst it will undermine the success of the system. Several STP leads suggested that there needs to be a shared financial framework – with transparency about costs and how the financial flows work – and that this needs to be agreed by all stakeholders.
Moving from talk to action is always a challenge. The machinery that has had to be constructed to restore some sort of planning system is something of a compromise. A lot of effort will be needed to make it work.
Edwards N (2016) ‘So much to do, so little time: turning STPs into action’. Nuffield Trust comment, 25 August 2016. https://www.nuffieldtrust.org.uk/news-item/so-much-to-do-so-little-time-turning-stps-into-action