STPs: moving from plans to programmes

21 October 2016

Amber Davenport

Born in December 2015 and described as a local health and care system’s “ambitious local blueprint for accelerating implementation of the NHS Five Year Forward View” sustainability and transformation plans (STPs) quickly became the new show in town.

You can understand why – in the current climate a place-based and whole population approach to planning has the potential to deliver a more collaborative approach to addressing the strategic challenges at local health and care economy levels.

Ten months in, and with STPs being submitted on Friday, now is a crucial time for the system to acknowledge and address some of the potential barriers to making the STP concept a successful reality, as well as considering how local areas can be supported to move from theoretical ambitious planning to realistic delivery programmes.

Clarity of purpose

STPs were initially described as the “holistic pursuit of the triple aim – better health, transformed quality of care delivery, and sustainable finances”. They have been an important vehicle in facilitating conversations that may not have previously taken place and have huge potential to overcome local systemic challenges that cannot be tackled in isolation by individual organisations.

However, rather than allowing local areas to identify and agree the best way of achieving this, the centre has pushed out a myriad of messages on what STPs should be prioritising.

Messages have included: explore how acute care reconfigurations can deliver savings, develop workforce and IT solutions to support working across organisational boundaries, and implement the recommendations of the national cancer and mental health task forces at a local level.

A key success factor of collaborative working is building trusting and constructive relationships

Over time however the triple focus of STPs began to morph into ‘money, money, money’ and more specifically - balancing the books at a local health economy level by 2020-21.

A message that has since been strengthened by the NHS shared planning guidance which announced the introduction of system financial control totals for STP footprints.

Failure to allow STPs space to deal with longer term strategic challenges, in favour of prioritising short term financial savings, may result in overambitious and undeliverable plans.

There will however be some STPs that submit locally-owned and deliverable plans. These may not balance the books by 2020-21, but are realistic in what they can deliver in the short term at maximum stretch and propose long term changes that have the potential to yield real benefits for patients. These areas should not be penalised for this.

Realistic expectations given the timescales

Compounding the challenges around clarity of purpose are the timescales local areas have been expected to work to, which have been at best ambitious and at worst unrealistic.

A key success factor of collaborative working is building trusting and constructive relationships. It is only then that hard conversations can take place and tricky challenges addressed – this, however, takes time.

Having recently worked on an NHS transformation project that spans two organisations I have seen first hand how difficult it can be to just find time for meetings at director level within trusts, let alone the time it takes to navigate through difficult and sensitive conversations.

Akin to investing time in building relationships is developing good governance arrangements that underpin these relationships

However STP footprints, which include a number of health and care organisations which may have not traditionally worked together or where the leadership of those organisations has recently changed, are being asked to come together and develop solutions with constantly moving goal posts in under 12 months.

In some areas relationships may just be starting to form and they will be making good progress at tackling vital short term challenges which have immediate benefits, such as sharing clinical staff and coming to sensible arrangements regarding patient flow, but may only be just starting to tackle some of the longer term strategic issues.

Again, these organisations should not be penalised for being at this stage – instead they should be supported to move forwards, be granted the time to engage with their local population and continue this positive work.

Of course there are some areas that are well underway with developing long term solutions that address strategic challenges and seem to be in a position to deliver on these plans, but a key enabler will have been the longevity and strength of their relationships.

Good governance

Akin to investing time in building relationships is developing good governance arrangements that underpin these relationships.

Local place-based planning feels instinctively like the right thing to do in the current context. However we cannot ignore the fact that STPs do not currently have a statutory footing and we must appreciate that their legitimacy is derived from the participating organisations.

For example, in some areas STPs have been a helpful and important vehicle to getting collective agreement on a way forward; however one of the crucial elements of keeping people at the table has been to agree that the STP process will not be another layer of organisational governance.

The recently published planning guidance states that STP leaders “will have strong governance processes to ensure clarity as to how different organisations are contributing to agreed system working”. There is therefore a need for clarity on the relationship between existing governance mechanisms at organisational level and the new emerging STP governance mechanisms.

Local leaders will need to be supported to develop local governance arrangements that support the delivery of their specific plan, while adhering to nationally agreed governance principles, rather than required to implement a one-size national blueprint that may not always fit all.

Moving forwards

Simon Stevens, NHS England chief executive, has recently stated at an NHS England board meeting that STPs will not be ‘approved’ and instead NHSE will be ‘reviewing and supporting’ plans. This approach is welcomed and aligned with the national bodies’ commitment to move towards a more supportive way of working.

However, with the introduction of system level financial control totals, it is likely that areas will be held to account for their delivery and the national bodies will need to think this through and provide some clarity on what this will look like quite quickly.

Given the challenges explored above it is important that NHS England and NHS Improvement recognise and appreciate that STPs are all at different stages. There will be some areas that submit strong and ambitious plans, but others may require more time and support to get to a similar place.

This blog was published by HSJ on 21 October