NHS planning guidance: an opportunity for collaboration across places?

The new NHS planning guidance arrived just in time for Christmas. As well as asking NHS organisations to produce their own operational plans for the coming year, it also asks them to work together to make joint plans for their local health and care services – a ‘sustainability and transformation plan’. The focus for NHS policy-makers is shifting from organisations to places. But how will sustainability and transformation plans work in practice?

More detail on the process has been promised later this month, but the initial guidance gives NHS leaders plenty to think about in the meantime. After agreeing the right geography for their plan – their ‘transformation footprint’ – health service leaders are asked to develop five-year plans covering all areas of NHS-commissioned care in their area (including by working closely with colleagues in local government). These plans will then become the new assessment process for accessing NHS transformation funding, with the best plans set to receive funds soonest.

What should the plans include? Annex 1 of the guidance helpfully reminds local leaders just how many ‘national challenges’ there are to keep them awake at night, setting out more than 60 questions (counting those containing multiple questions separately) for the plans to respond to. These questions (very) broadly fit within three themes: improving health and wellbeing; improving quality and developing new models of care; and improving efficiency. The guidance also asks that sustainability and transformation plans describe how they will deliver the objectives in the NHS Mandate – so there’s a lot to cover.

Taking a place-based approach to planning and delivering health and social care services is the right thing to do. As Chris Ham and I argued in our recent report, Place-based systems of care: a way forward for the NHS in England, the challenges facing public services in England can only be met by collective action across local areas. Put simply, this means organisations working together – in partnership with patients and the public – to govern the common resources available for improving the health of the population they serve. We set out ten ‘design principles’ for this approach in our report.

But developing sustainability and transformation plans will not be simple. The first task facing local leaders is working out how to define the ‘place’ that their plan relates to. Is their local system defined by the boundaries of the clinical commissioning group, the local authority, NHS England’s local area team, the area covered by a major local provider, or in some other way? In some places, say, the Isle of Wight – the answer to this question will be pretty simple. But in others – say, London – it won’t be. The added challenge is that leaders have been asked to submit proposals for their ‘transformation footprint’ by the end of January. So the clock is already ticking.

A related task will be defining the relationships between neighbouring and overlapping ‘places’ in England. Take an organisation like the Royal Free London NHS Foundation Trust, whose footprint spans the London boroughs of Camden, Barnet and Enfield and extends into Hertfordshire. How many plans will the trust end up being involved in? And where will the lines between them be drawn? In cases like this where the boundaries between places are blurred, it is likely that different sustainability and transformation plans will need to be knitted together – or at least closely co-ordinated.

And all of these questions come before the real task of developing the content of the plans themselves, which need to be submitted by the end of June this year. While the guidance focuses mainly on NHS services, developing a credible plan will require the NHS to work closely with social care, public health and other local government services, as well as third sector organisations and members of the local community. It’s odd that the meat of the guidance doesn’t focus on these aspects of integration in more detail.

This is where the big problem lies – namely, that doing all of this properly within the timescales provided will be difficult even for those areas with a long history of working together. For others, simply developing the co-operative relationships needed between leaders more used to competing than collaborating will be a challenge in itself. Either way – and as the planning guidance itself hints – the right answer won’t be to outsource the problem to external consultants.

Instead, the requirement to write these plans should be used as an opportunity for local organisations to invest time in working together where this isn’t happening already. The task here isn’t simply to write a good enough plan to pass muster with NHS England and the other national bodies in the summer. Done well, the process of developing these plans could provide the right stimulus for long-term collaboration based around places and populations – things that really matter. If this doesn’t happen, the risk is that NHS organisations revert to an all-too-familiar ‘fortress mentality’, fighting for their own survival regardless of the impact on others. The ultimate losers in this scenario are NHS patients.

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#545656 Remy
Retired medic

Surely nhs needs to reform but not the way it has been dismantled over the last three decades.
We still could be the best but what is lacking is fairness and critical evaluation to put patients first in an effective manner. Cuts and changes politicians ,some other relevant office bearers are making and already made are mostly destructive, sadly cant explain why in most instances.
I would join quite happily if allowed to be part of a new venture to save nhs constructively with core values remain at the heart,ethos.

#545658 Pearl Baker
Independent Mental Health Advocate and Advisor/CARER

Having just returned from LONDON after being denied any status as a Carer, yet doing absolutely everything, I learnt that the person I care for has a Liver function that is so 'bad' I wonder how much longer they will be on this Planet Earth. NOT alcohol related, but medication.

I will refrain from commenting further, because I have said it all. No 'Aftercare' at all, and no support for Carers, there are many like me.

I have 'fought' this system so long, that decided to go it alone, and seek help from those who CARE.

#545662 James Bunt
Gordian Management

I agree that this is a huge task. I have worked in several guises to foster co-operation between Trusts. A big issue is that organisational boards view is framed by their organisation and not the system. It will take a paradigm shift in mindset to put the interest of the system over the interest of the organisation. Its not impossible but it will take work prior to the STPs being produced.

#545672 Terry

Great to read but I should feel most embarrassed at having to quote the obvious - yet again.
Not your fault but reports now are so predictable and nothing of any substance results.
To tell professionals for instance, that they should talk with one another is going back to primary school.
Your Fund does great work but just how long do we have to put up with this general non sense by those key figures employed in the NHS to serve us?

#545675 Christine Pattison
Action Hampshire

Voluntary organisations very happy to work with health and care. But may I comment that health professionals, especially managers, need to change the language they use. Who wants to have to go through some sort of initiation ritual because they talk about 'burning platforms' and 'value propositions'?

#545677 Tony Fuqua
Business Development Manager; VCS rep to Health & Wellbeing Board; Board Member local VCS Infrastructure
YMCA Plymouth

The VCSE is a vital infrastructure and is only modestly supported. It is rich in creative talent, leadership, specialist skills and years of cross-sector experience. It can also provide effective community engagement, particularly with those hardest to reach and at risk. It also forms a very important part of the the NHS and PH workforce.

This VCSE resource needs to be valued by public sector officers; local VCSE infrastructure should be financially supported to deliver mechanisms for community and stakeholder engagement; and integrated into planning, commissioning and delivery processes.

Yet, the VCSE is rarely identified as a stakeholder in NHS England reports and frameworks; and often only mentioned in the margins.

Transformation is change; lets include changing ineffective behaviours with the VCSE.

#545808 Peter Turner
Clinical Auditor

The place based approach for the NHS has echoes of an approach Government imposed on local authorities around 2008/9.

This was enforced by the Comprehensive Areas Assessment (CAA) inspection process of the now defunct Audit Commission. The CAA applied to all outcomes delivered by local authorities acting alone or in partnership with other local service providers. How local partners work together was seen as key to delivering tangible results.

The approach didn't survive the consequences of the financial crash so who knows if it would have been beneficial and organisations improved joint working. It is difficult to overcome organisational boundaries because there are real differences in the priorities and needs for local areas.

With a June 2016 target date for these latest plans I suspect they will be at best a re-packaging exercise. Getting all the relevant people around the table will be a job in itself. Perhaps ultimately the Manchester devolution / mayor approach is the model for everywhere.

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