Hugh Alderwick: Tracking the development of sustainability and transformation plans in England

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  • Posted:Thursday 17 November 2016

Hugh Alderwick, Senior Policy Adviser to the CEO at The King's Fund, shares findings from our report on how sustainability and transformation plans have been developed in four parts of the country.

This presentation was filmed at our conference, Sustainability and transformation plans: from planning to implementation, on 17 November 2016.


So I’m going to be talking through this report which we published on Monday about how STPs are being developed in practice and so before I start, I’ll summarise what I’m gonna say in three main points. What our report really says is that STPs first are the right thing to do, the idea that improving care and managing resources is best done across systems. It’s something we support.  So the concept is a good one but nonetheless I think most people in the room will recognise there’s been some pretty big issues with the process so far.  So the third point is how do we learn from what’s happened over the last nine months, to improve the process to make sure that STPs reach their potential. I had some ideas about that in the report.

So I’ll very quickly run through what STPs are and why I think they matter before heading into some of our findings. A very brief summary, what are STPs? So put simply, these are plans for the future of health and social care services across 44 different parts of the country and those 44 different parts of the country are equal in size and complexity. They range from 330,000 people at the smallest, all the way up to 2.8 million in the biggest.  The organisational landscape is also very different at one end, we’ve got one CCG covering the STP footprint. At the big end we’ve got 12 CCGs working together in a single STP footprint.  So all STPs are the same and that context really matters and I’ll talk about that later.

The scope of the plans is broad. They cover all areas of NHS spending including primary care specialised services as well as back to integration with local authority services. They matter to everybody. The plans are long term, covering the next five year period and most importantly they are place based.  Essentially a jargon means, organisations in an area working together to meet the needs of the local population.

And stepping back, STP leaders were asked to do three main things in their plan. Of course lots of detail underneath that. The first is improving health and social care quality, the second improving broader population health and wellbeing and the third was reducing gaps in NHS finances and it really was focussed on NHS finances rather than local government finances too, and some areas weren’t happy about that.

So in case you’ve not been around the last twelve months, here’s a very brief and quick headline summary of the process so far, so STPs were announced in December last year, right at the end, a good Christmas present for STP leaders. First drafts of the plans were due around June time, they were going to be the final drafts but the deadline got pushed back till October so now final, although final in inverted commas, STPs have been produced in 44 areas and they’re now being publishes, so we’ve got around half and the rest are soon to come.

Anybody who’s been involved will know that the process has been somewhat fluid but that’s perhaps unsurprising given the scale of the task and the complexity, and no-one’s really complaining the deadline was pushed back.

So why do STPs matter. I think I won’t bother explaining this because David did in such a compelling way, in the first presentation. We set out why we think place based systems of care are important.  In the report I’ve put on the slide that Chris and I wrote last year, and essentially we argue that improving care and managing resources given the challenges facing both services, also local populations is best done across systems.  The challenge of course is, how we’re trying to work across systems in an NHS environment that was fundamentally not designed for working in collaboration.

So what did we do in our research, just very quickly, I won’t spend long on this. We focussed on the process of how the plans were being developed in different parts of the country, so the story of developing the plans rather than their content, although of course process and content overlaps. So we chose four very different parts of the country to follow over the last nine months or so.  Those sites are anonymous and we chose different areas based on complexity, history of collaboration, so we’d get a relatively representative sample.  We chose around 7 to 10 leaders in each of those patches to be involved in a series of interviews and those leaders represented different parts of the health and social care system.

And whilst it was only four areas, they cover around five million people, so just under 10% of the population, so quite a good chunk of people.

The first report which I put on the slide, published on Monday, is based on about 35 hours worth of interviews and we were interested in asking the questions that I’ve listed on the slide, so at high level how were STPs being led, governed, managed? What was the role of national bodies, other external advisors? And really how was the process being perceived and experienced at a local level.

The idea to focus on the process is that we think the process, lot to be learnt from how the plans are being developed, but also it has implications for the content of the plans.

So what did we find? I’m going to go through six or seven of the headline findings, there’s lots more detail in the report which I would encourage you to read, but happy to take any questions on the detail.

The first big point that I want to emphasise is that context we found, was fundamentally important in understanding how the plans had developed in different areas. So for all areas based on the same set of challenges, growing pressures on finances and services, everybody is working within the legacy of hand holding and the challenges that creates and everybody was working to the same, very tight timescales and big expectations. Those three things made the process difficult for everybody.  But then underneath that we’ve got understand local context and we found that played a major factor in how well the plans had progressed, so things like the history of collaboration, how long had leaders and organisations been at it in terms of cooperation and what was the geographical context, what’s the size of the system and how well do people get on? Both at a senior level and at a frontline level, do they work together?  And unsurprisingly, in areas where they’ve been at it for a long time, they were making the best progress.

Now the important point to make is that all four areas we tracked, were making very good progress but from very, very different starting points hence that has implications when you read the plans but also for Ben and his colleagues about the sort of support that areas get from now in terms of further developing them and putting them into practise.

So a big theme running throughout our research was that local leaders we spoke to were really supportive, like we are, of the idea behind STPs and wanted to collaborate to improve services but they were highly critical of the process so far and how it was being managed at a national level. So at the start of the process in particular, leaders talked about the intervention from NHS England and NHS Improvement in defining STP footprints and their leaders, which they didn’t always find helpful, there’s a quote on the slide from one leader, anything in purple is not from me, that’s from one of our interviewees, and that intervention wasn’t just important at the start, it had lasting impact on leaders perceptions of the process, perceptions of their own ability to make change happen. Some leaders talked about how it was disempowering.

Over time national guidance seemed to sometimes shift in focus, some of the requirements seemed to have conflicted and expectations have grown over time and in some cases the approaches of national bodies themselves has not always been consistent in how they’ve supported local areas, both between different national bodies but also between national teams and regional teams.

So this led to the people we interviewed to conclude that STPs were the right thing to do, but as one summarised, the right thing being done badly. So supportive of the idea but recognised that improvement is needed in the way the process is being managed.

So important point as the process went on, as we revisited the sites for our second round of interviews in particular, we heard that while the three gaps that I mentioned at the start of the presentation remained important, so care quality, health and wellbeing and finance, is a third of those gaps and closing gaps in NHS finance as quickly as possible became much more important. Now of course national context is important there too, NHS leaders themselves are under pressure from No. 10, the treasury, department of health, to reduce gaps in NHS finances but that’s been translated into pressure on STP leaders to show how their plans can close gaps in NHS finances as quickly as possible.

Now that’s understandable, and closing gaps in finances is the right thing to do, but the big risk is that work on new care models, prevention and public health, things that are unlikely to save money next year, and might require upright investment, take a back seat and that’s obviously an issue.

We also found that leaders in our areas weren’t always confident that they could close the big financial gaps in their area and often questioned the assumptions underpinning the plans, particularly around bed reductions and we might get into that in the discussion.

So again, unsurprising for the first category of hand holders, they’re managing the process has not been simple at a local level. Leaders told us about the challenges they faced managing the day job of commissioning, delivering health services, complicated enough already, on top of other strategic initiatives like Van Guard, Evolution pilots and then work on the STP. They thought all of those things were the right thing to be doing but finding time to do all of them was not easy and it often meant that somethings had to stop.   So there’s a quote on the slide from a very senior leader in one of our footprints who said “It stopped, yes it’s literally stopped” when talking about their integration programme they’ve been working on for the last two years, so they could work on their STP.

Now of course, you could argue they were trying to do the same thing at a bigger level on their STP but that caused some frustration. So at the moment it seemed to us like the process was running on good will, intrinsic motivation, long hours and the commitment of staff which is a great thing, but our leaders questioned how long that would last without additional resources. Leaders themselves, the 44 named STP leaders, that role seemed particularly difficult, people trying to do that on top of their day jobs and actually saying they were doing three jobs at the same time, one leader describes the job like operating in a sea of fog.

Areas were often using management consultants to help make their plans, filling perceived gaps in capacity, so working on the PMO for instance but also perceived gaps in capability doing financial modelling work for instance.

We found, based on our research that meaningful involvement from a range of stakeholders was difficult to achieve within the timescales available. It wasn’t that people didn’t want to involve, patients and the public for instance, or local authorities, getting it done in the timescales was hard. Across our four areas, involvement really varied but stepping back and looking across all four, within the NHS we found that the main voices, it seemed to missing were GPs and primary care staff more broadly. Clinicians and clinical teams broadly speaking too.  So a problem about depth of engagement not just breadth of engagement.

The local authority involvement also very widely, in one of our patches we found really strong partnership between the NHS and local government, the local leaders worked well together. They saw the plan as about health and wellbeing and collaboration was strong. We had the other extreme too, where they’d been almost no local authority involvement in the plan, whatsoever and some issues about relationships between senior leaders.  Also issues about how local authorities were being involved.  So an important nuance was that sometimes local authority leaders were at meetings but were being consulted on adult social care or prevention and not seen as core partners in the development of the plan and of course they wanted to be core partners in the development of the plan and that again wasn’t always seen as helpful way to engage.

From our experience, patients and the public seemed to be largely absent from the process, of course there was different processes at a local level that were being used to engage patients, so there was not no engagement, but of course now NHS England have called for areas to engage patients and the public in the plans and they’re now being published but from our experience, this quote sums it up, someone describing being in meetings and asking where are the real people in all of this? So I won’t go into detail on this point but leaders faced impractical challenges to working together in the timescales available. Partly that was due to the number of people round the table in some footprints, so one leader in the first quote describes it a bit like the Eurovision Song Contest, where you want to make a decision it goes round the table and by the time you’ve agreed it you’ve lost an hour, it’s madness.

So in some areas, the problem of simply getting round the table and talking and agreeing was hard. Now again, context is important. In areas where you’re used to working together and you’ve got established processes for making decisions, it’s far easier, but when areas were coming together for the first time, those practical challenges were a pretty big obstacle and of course the tight timelines made everything more difficult; draft plans being sent round late at night for comment by the next morning wasn’t always the best way to engage people in the plans.

As well as practical challenges, leaders talked about the more fundamental policy barriers to working together. So for STPs to work in practice, leaders, organisations are going to have to find ways of making collective decision about the use of resources and how services should change, but of course STPs are being designed in an environment that was not designed to do that. Organisations are held to account for individual performance no collective performance, decision making powers and authorities sit with those individual organisations and of course local government has a separate set of accountability arrangements altogether to the NHS, and so working out how you can make decision collectively in practice was very difficult.  That wasn’t just a theoretical barrier, it was a very real barrier that was being experienced in all four of our areas and recognised by colleagues from NHS England too who told us about the barriers that their approach and regulation performance management created for working in system.

So the final point about our findings is that quite understandably the process so far has been on planning, this has been about writing a document but of course the real challenge is implantation so I think these two quotes rather long but worth reading, if you can read quickly in your head, the first one really saying that look we’ve got a very good history of working together, we’ve made lots of plans in the past, our better care fund plan was fantastic, won prizes but look can we actually put it into practise, can we actually deliver it and not only do we have the skills, resources, have we worked on the underlying relationship and cultures, but also have we made the difficult decisions, a lot people recognise that their plans looked good but the hard choices about where are we gonna spend the money, which services are we gonna stop, which services are we gonna start hadn’t really been taken yet, and that’s what seemed to be keeping people up at night rather than meeting the October deadline for their submission.

So those are some of the key findings. As I say, lots of detail underneath that but we also focus in our report on learning from those lessons. What should happen next.  We make quite a few recommendations under six big categories.  I won’t go into all of them.  I think in the immediate term, the top recommendation is perhaps the most important and that’s to ensure there’s meaningful and deep involvement, not just to patients and the public, but the staff who are gonna be expected to deliver these changes in practice.   Without that, particularly clinical engagement, can we expect anything to change.  We’ve got a very good history of writing five year plans, but how good is our history of implementing them in practice.

The second is about governance and leadership, so I don’t wanna repeat what Ben said, but I think it’s really important to recognise that this isn’t gonna be done by a single organisation, we need to find ways of multiple organisations working together and actually making decisions together, because at the moment that really isn’t happening in practice and where it is happening, we just share the lessons of how it’s happening and so that’s both local action but also national bodies have a role to play here in how they regulate and govern at a national level.

The final one again is to focus on the skills and relationships needed for making the plans happen as well as the focus being on planning, leaders talked about a lack of focus so far on the underlying relationships and behaviours across systems and that’s clearly gonna be an important component in the future.

So final slide, to conclude I want to reiterate the same three points that I started with. STPs based on the idea that collective action is needed to improve care and manage resources is no doubt the right thing to do. We all know there’s been big issues with the process so far, but is it any surprise.  STPs are imperfect and complicated work around to a set of rules and structures that weren’t designed for doing what we’re trying to do.  So big credit needs to be given for anybody in the room who’s been involved so far, because the progress is down to you in a very difficult environment and the process will continue to be really, really difficult but we’ve quite simply got to make it work.

So to conclude, from people much wiser than me, Nick Black and Nick Mays wrote a BMJ editorial this week about STPs and they concluded in line with us, that with no obvious alternative the public and the health and care system need STPs to succeed.

So really important day to day and I hope you enjoyed that.

Thanks very much.


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