Crunch time for local system plans: five things to look out for

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I tend to agree with the view that ‘Plans are worthless, but planning is everything.’ Written plans, particularly those covering a long period, are rarely followed to the letter. The sustainability and transformation plans produced in 2016 are a prime example – many of their proposals have since been adapted, delayed or (for better or worse) abandoned altogether.

Why, then, should we pay attention to the new system plans that are currently being developed by sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) across England? The answer, I believe, is that beyond the detailed proposals they contain, the overall objectives set out in these plans and the process by which they are agreed could have a lasting impact

The first key milestone in developing these plans is fast approaching. At the end of this month, local systems will submit their draft plans for agreement with their regional teams before final submissions in mid-November. So, what might we learn over the coming months, and what should we look out for? I’m going to pick out five things here.

'There is a clear lesson from 2016; pushing systems to produce unrealistic plans doesn’t work and comes at a cost, undermining trust and relationships and setting back genuine efforts to plan for improvement.'

The first relates to the last round of system planning in 2016. The big question is whether lessons have been learnt, locally and nationally, from the significant difficulties with that process. Will systems be able to put forward realistic assumptions around activity, funding, performance and service change? It is no secret that many systems were under pressure in 2016 to produce plans that balanced financially, even if the changes needed to achieve this were not realistic. The good news this time around is that the context is more favourable in some respects; the financial outlook is better (but still challenging), systems are not starting with a blank sheet of paper and are not having to begin with the tricky task of defining the geography their plan will relate to. On the other hand, performance against key standards has deteriorated and the shortage of staff has become more acute. Either way, there is a clear lesson from 2016; pushing systems to produce unrealistic plans doesn’t work and comes at a cost, undermining trust and relationships and setting back genuine efforts to plan for improvement.

Second, it is worth looking out for what systems choose to prioritise in their plans. All must set out how they will deliver the priorities of the long-term plan, so it is a given that these will feature. But there is also scope for systems to set out their own ambitions based on local need. The long-term plan said disappointingly little about how the NHS will work with communities and other partners to achieve wider improvements in population health. In particular, it underplayed the role of local government and the potential for the NHS to work much more closely with local authorities to improve health and wellbeing. It remains to be seen whether local systems will look beyond the narrow lens of the NHS to set out genuine place-based plans grounded in the needs of their local populations.

The third thing to look out for relates to workforce. The crippling staff shortages in the NHS are high on the national agenda and the full NHS people plan is due for publication later this year. But much of the action to address this crisis needs to take place locally through changes to training, new roles and improvements to working lives. The Interim NHS people plan set an expectation for ICSs to take on greater responsibility for workforce planning, supported by regional teams. Systems’ plans will give a sense of their readiness to take on the greater role envisaged for them, and the scale of the gaps they are facing. Given the extent of national shortages, this is unlikely to be a rosy picture. It will also be an indication of whether ICSs are taking a whole-system approach, looking across the workforce in the voluntary and community sector, social care and other local providers alongside the NHS, recognising the interdependencies between them.

Fourth, the process of agreeing plans over next few months will be the first real test of the relationship between systems and the seven regional teams. How prescriptive will they be? Will they live up to the rhetoric around supporting local systems to improve? Will they manage to give a coherent message now NHS England and NHS Improvement have come together? Of course, the answers may not be the same across the seven regions, and the process may reveal variation in the approaches they are taking.

'The real opportunity in this process is to bring partners together around shared, system-wide objectives, and to build trust and relationships through the process of doing so.'

The final thing to look out for is the reaction of local partners as plans are released. The publication of plans in 2016 sparked widespread criticism and active resistance in some areas from local citizens, politicians and frontline staff. This didn’t only reflect the contents of the proposals, but a lack of engagement and transparency throughout their development. If a different approach has been taken to produce plans that represent views and engagement across whole systems, including the patients and users they will serve, we should expect to see a different reception this time around.

Returning to the point that the planning matters more than the plan, the real opportunity in this process is to bring partners together around shared, system-wide objectives, and to build trust and relationships through the process of doing so. Given the variation in the maturity of local systems and the leadership and relationships within them this will have been much easier in some areas than others.

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james robertson

Hospital Gov Medicolegal expert witness, ex district/parish cllr,
Salisbury F T
Comment date
19 November 2019

Here there is a general agreement re HWB/STP?IC. Locality or place matters , patients cannot be forced to go to places. Locally we have a complementary relationship with Southampton , over many years. We have regional and supra-regional services that Sthn doesn't, and vice versa. We are part of a regional (Wessex) medical school. Our Catchment patients mostly go to Southampton, and will not wish to go to Bath. We have a good DGH and I personally find it wrong to recentre on Bath who may wish us to take additional hospital patients . We had a regional authority and no new change will deal with clinician /nurse shortages.

Gethin Williams

Retired Academic Researcher,
Dr Gethin Williams
Comment date
27 September 2019

Enjoy reading your output which I find illuminating and balanced. I totally concur with your assessment of plans and planning and a piece read recently on the pivotal roles of PCNs and ICSs in the NHS organisational 'architecture', despite lacking a statutory basis. I am very interested to see how Chris Ham leads the Coventry & Warwickshire Health & Care Partnership, which is my own patch (Leamington Spa).

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