For the cynical, it may have started as “just another planning exercise” but the creation of 44 health and social care footprints and the push for Sustainability and Transformation Plans (STPs) that address the Five Year Forward View’s fabled three gaps now looks increasingly set to be a genuine game-changer. Whilst deadlines have been tough and the task of turning around the NHS’s financial gap is daunting, the STP process is driving collaboration and system-wide thinking, and looks set to shake up health and social care for good. Whether it was originally intended this way, or has happened as a consequence of the process, the STP is becoming a vehicle for establishing system-wide governance and ways of working; although the ultimate destination, and its implications for service delivery, organisation, leadership and finance flows, remains unclear.
This was a key conclusion reached by the 10 STP leaders from the health and social care system who attended a debate “Closing the sustainability gaps – surviving and thriving with your STP” hosted by PA Consulting.
Challenges: scale, cynicism and status
As they battle to meet October’s final submission deadline, many participants acknowledged that they will struggle in an ever-tightening funding environment to close the finance, quality and health and wellbeing gaps; and that earlier initiatives have not succeeded in addressing these.
This is leading to cynicism among clinicians, carers and others in vital patient-facing roles, whose engagement and ownership is so crucial to delivering improvements. Many are questioning whether the STP process will prove any more transformative than its predecessors, before the next ‘big idea’ comes along.
Not surprisingly, the requirement for local authorities to play an active role was cited as a particular challenge. As one participant said, “Local authority teams are being asked by a fully funded, protected public service to play a part in a compliance exercise commissioned by a Government department that is not their own at a time when they have taken the brunt of austerity.”
Some of the attendees also regarded the budgetary control regime as crucial, feeling that transformation funding needs to be handled at STP area level for the greatest long-term benefit. According to one participant, “If funding is distributed by NHS England or NHS Improvement direct to Trusts, it will be used to plug in-year gaps rather than make those changes necessary to close gaps for the future.”
All the while the October deadline looms, doing nothing to lighten the spirits of those responsible for delivery.
Benefits and solutions – a collaborative catalyst
Yet, despite the seriousness of such concerns, most attendees felt that they were seeing benefits from the STP development process. Most common was an improved ability for those directly involved to communicate and collaborate effectively across organisational boundaries.
As one participant said, “It’s a question of using the process to get people together and then letting them get on with it.” Another added, “You can use the STP process to take away barriers. If you incentivise teams to work together to develop manageable and scalable front-line solutions, the STP can give them the ‘air cover’ they need to get things delivered without management getting involved. It means clinicians can come together to look at things in a constructive way, share best practice and innovate. Under the STP’s protection, we can then rapidly scale up successful ‘green-shoot’ pilots to achieve effective change.”
Another person reported a significant improvement in culture. “The NHS had turned into a culture of ‘no’ – we couldn’t talk to GPs and we couldn’t talk to providers. But now, under the STP, we can talk to all our colleagues as we need to. It’s creating a culture of ‘yes’ that allows us to put back on the table things that were previously off it.” As another put it, “We’re getting the right people in the right places having the right conversations.”
The way forward
A new era of cross-system, ‘whole patient’ service design and delivery is emerging, driven by the STP process. This provides a fantastic opportunity to make significant and radical improvements to health and social care. Experience, though, suggests that this will be tough to realise and the implications for health and social care are huge.
In the face of such challenges, a new type of leadership is emerging. It will need leaders who unite their peers by establishing a clear vision that transcends organisational barriers; leaders who have the energy, resilience and determination to see through complex, long-term changes without losing sight of the ultimate goal; and leaders who have the experience, insight and confidence to support front-line innovation, quickly spotting and exploiting the ‘winners’ that will make a sustained and positive improvement to patient care.
Each system will need a number of such leaders representing the various parts of the system to work together to establish the ‘powerful guiding coalition’ required to drive such complex change.
Kate Woolland is a healthcare expert at PA Consulting