STPs – How serious are the proposals and can they work?


Can Sustainability and Transformation Plans deliver a sustainable NHS?

This week we publish a review of the 44 STPs (1) – the actual plans, to find out if they provide a credible basis for sub-regional (population based and place based) transformation. The report is not a commentary on whether there should be STPs but on how they are set up to deliver the level, pace and scale of change required.

There are a few fundamental requirements in my view for the plans to be useful:

  1. The plans should be based on real data about the current actual starting position – capacity, finances, quality BECAUSE you can’t plan ahead from a false starting place.
  2. The plans for change should be evidence and intelligence-based BECAUSE for many changes it is known what works.
  3. There should be plans to reduce demand as well as increasing access BECAUSE many of the best solutions for longterm health needs are citizen-led and community owned.
  4. The proposals should demonstrate accountability to the population they serve BECAUSE these are local people’s services.
  5. The process should develop collaboration between health and social care BECAUSE they are interdependent for some services and people need a more integrated person-centred approach.
  6. There must be a change in the current legislation which was built for the market BECAUSE you can’t collaborate and compete at the same time on the same services.
  7. Leaders need to cede territory BECAUSE the evidence from high-performing health systems demonstrates that this is what this scale of change requires.
  8. Plans for change must use the right process for the type of problem BECAUSE applying fragmented simplified solutions to complex problems doesn’t work.

The report finds many of these key requirements lacking. The report is not a commentary on the leadership of STPs locally, but on the process by which they have been put in place, and on the lack of capacity to do this work in such a short timeframe. The report finds that:

  1. It is unclear whether the STPs are the actual plans, the people implementing the plans (usually a ‘Board’), or a generic terms to cover all. There is lack of clarity about the authority and accountability of the STPs. THIS MEANS that given the ‘old world bites back’ the NHS will tend to a hierarchical approach, whereas local government has to operate through a local mandate.
  2. The starting place for the plans are often not grounded in reality – for instance the actual financial position of the health system (the report identifies over £23bn deficit for a do nothing scenario which excludes efficiency savings in the NHS; with individual STPs varying in the scale of the problem from £1.4bn to £131m ), or a needs analysis, or the funding gap in social care; and there is real variation in how open they are (with key information hard to find), and the level of risk assessment (if any at all). THIS MEANS that some plans cannot be realised, and there could be solutions implemented that make things worse.
  3. Collaboration is really hard when there are very different accountabilities for the NHS and local government; and when the STPs nationally came from NHSE not from both health and local government at the outset. THIS MEANS the STPs are not ‘owned’ at the outset by local government which is a key partner in deciding what can be done and how, including how it uses its own resources.
  4. 50% of the STP publications cited reductions in acute beds and A&E departments. THIS MEANS collaboration with local government will be even more difficult as these require local consultation.
  5. There is lack of clarity of boundaries for plans – at what level of population/ geographical footprint the solution resides – whether the work is best undertaken at a borough level, across a particular health system (CCG or group of CCGs), at sub-regional footprint; and who has managerial control for each type of system. THIS MEANS that change plans will tend to be sucked up to a higher scale by the NHS rather than devolved to the lowest scale.
  6. It is unclear how much the STPs are costing to develop and implement. There is the possibility of the plans costing 5m per STP per year (based on the ones that have declared their costs).
  7. One area with immediate gain is collaboration over workforce, but two-thirds of the Plans had no detailed workforce plan.

Here are some examples of how the work could be distributed appropriately:

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Overall the report demonstrated that the STPs are not ready for implementation.

Moreover the literature on leading systems demonstrates that in times of increased complexity, without robust and hard-earned relationships between the leaders, they will fragment (2).

System inertia may thus be a rational response to interventions that seek to reform when individuals and organisations have to manage other competing demands. If the benefits of a reform come at the cost of other important organisational goals, then organisations and the individuals in them will necessarily do what they have to do at minimum. In a system that is over constrained with competing demands, the human attention and physical resources needed to make a new intervention succeed are just not available ”. (3)

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In order to have a fighting chance of taking the NHS to a place where it can provide the level of quality expected, through a very different type of provision, the STPs need:

  1. Clarity on the starting point – needs assessment, financial position i.e. intelligence informed baseline
  2. Evidence-based plans for change with scenarios on the impact of these plans on health and social care, with developed workforce plans for these
  3. Structural support for collaboration across health and social care – including legislative change
  4. Time to build relationships between leaders
  5. To agree about the ‘system boundaries’ for the range of problems they are facing, and the appropriate accountability process. Some issues are solely the domain of the NHS, some require borough or HWBB level collaboration, and some need sub-regional level collaboration but that needs agreeing at the outset.

The STP’s role is therefore best clarified as:

  • Strategic Planning: for the long-term balanced with short-term reaction.
  • Generating Shared Purpose: across members with definable impact for all.
  • Intelligence: Providing business intelligence and evidence to inform STP-wide plans and to inform and challenge local strategies and plans
  • Fostering Innovation and Spread: Sharing and spreading best practice and new approaches across partners; collective learning.
  • Managing Up: Advocating for the population
  • Determining the level of action: Place-based local system; cross organisation system (not place based); Sub-regional system.
  • Managing: transformation that can only take place at sub-regional footprint.
  • Coordinating: resources (e.g. workforce), for a common purpose.

This is best realised through a network leadership model than an organisation hierarchy model. You can find out more about network leadership here

Leading STPs

In my experience STP leaders are confused about:

  • Which system takes responsibility for which issue (i.e. at what level of system does solving the ‘problem’ reside)
  • Where accountability lies
  • What mode of change is required and is possible for which issue
  • How decisions are made and who buy
  • The congruence of leadership behaviours across partners

The Kings Fund (4) suggests that systems leadership requires

  • A compelling shared vision of transforming the health and well-being of communities across England
  • A shared commitment to work together for the medium and long-term (not only the short term) to transform the health and well-being of those communities
  • Frequent contact between leaders who need to work together to build trust and make real progress in order to deliver for their communities
  • A shared covenant to surface and resolve conflicts quickly, fairly, transparently and with a commitment to collaborative problem solving
  • An overt commitment to behave altruistically towards each other’s organisations, mutually supporting system success in transforming the health and well-being of communities

The difficult for STP leaders is that when the going gets tough, old patterns of behaviour assert themselves. They will need to watch out for:

  1. Culture eats strategy for breakfast.(5)
  2. Tendency to turn wicked problems into tame – segmenting and setting up project groups who find they can’t solve the problem and the issue then goes round and round.
  3. Tendency to structure as a hierarchy/ bureaucracy rather than a network – with:
    1. Lack of clarity of accountability in partnerships/ collaboratives/ networks – unclear meeting purpose and function, leading to longer and longer agendas.
    2. Lack of clarity on what change process is required/ at what level – defaulting to project management.
    3. Lack of clarity on role at system level/ lack of clarity on delegated authority – leading to expanding workgroups
  4. When the going gets tough the NHS reverts to performance management, while Local Government reverts to local differences.

There is no doubt that STPs at least for the NHS are seen as a good development (6), but they wont solve the significant problems facing health and care without support -legislative changes, business intelligence, collaboration at national level, funding, development in capacity to lead as networks not hierarchies, and time.

You can find the full Report into Sustainability and Transformation Plans here Sustainability and Transformation Plans_LSBU_31_May_2017

And the individual reports here:

(1) Boyle, S., Lister, J., Steer, R. (2017) Sustainability and Transformation Plans. How serious are the proposals? A critical review. London South Bank University, London.

(2) Oshry, B. 2007. Seeing Systems: Unlocking the mysteries of organizational life. Berrett-Koehler Publishers

(3) Coiera, E. (2011).Why system inertia makes health reform so difficult. BMJ 2011;342:d3693. 

(4) Hulke, S., Walsh, N., Powell, M., Ham, C., Alderwick, H. (2017) Leading across the health and care system. Lessons from experience. The Kings Fund

(5) Widely credited to Peter Drucker

(6) BMJ (2017) Next government should not ditch STPs, says policy expert. 357:j2591