Ten quick reflections on...

07 November 2016

...publishing sustainability and transformation plans

Chris Hopson and Daniel Reynolds

Sustainability and transformation plans (STPs) were submitted on 21 October. There has been some debate around whether, how and when they should be published. NHS England has published formal guidance on this issue. Over the last two weeks a number of plans have been published, some as a result of local councils publishing them on their websites, some as a result of simultaneous publication by all STP partners together. There has also been media coverage of the different perspectives of some local councils and NHS England on how effectively the STP process and the public engagement element, in particular, have worked.

  1. NHS services are a vital element of any local public services and there should be a strong sense of accountability to local communities for the shape and effectiveness of those services. NHS bodies therefore have a responsibility to engage and consult local communities about any possible changes to the pattern of services.

  2. All the evidence shows that it is better to engage local communities and their elected representatives as early as possible in the process of designing service changes, rather than present a “fully baked cake” in the hope of automatic support. The same applies to engaging staff and, in the case of foundation trusts, FT governors.

  3. Effectively engaging local communities in the process of designing service changes requires careful thought and preparation, including a clear articulation of the challenge and the case for change, and the right investment of both time and resource. Appropriate professional communications and engagement expertise is needed as well as public leadership from clinicians and senior managers. Public engagement and consultation needs to be conducted in a style and using a language that fosters genuine public understanding, debate and discussion of trade-offs. Collaboration with key partners is essential as is a willingness to listen and truly engage and consult. Risk increases if the NHS under invests in any of these elements. It’s also important to be clear who leads this process in each footprint from an NHS perspective: is it CCGs, providers or both acting collectively?

  4. We are still, in most places, a long way away from a final plan in some footprints. Many contain ambitious proposals that are unlikely to materialise. So there is a natural tension between the need to engage early and the desire to avoid setting unnecessary hares running. One way of resolving this tension is for STPs to set out the challenges and the need for change; articulate a top level vision; indicate the broad options being considered; and then lay out a process/timeline for public engagement and consultation. Detailed proposals can then be consulted on at a later date. Several STPs have successfully adopted or are about to adopt this approach.

  5. If public engagement / co-design is not a key element right from the beginning of a service redesign process (and the STP process has effectively prevented this), there is never an optimum time to start it. There will always be good reasons to delay until a later ‘better’ date. This is tempting but dangerous.

  6. It is telling that, at two different meetings of CCG and provider leaders late last week, there was almost unanimous agreement that STP footprints should start the process of public engagement and communication immediately.

  7. The way that some plans have been released over the last ten days suggests tensions between local government and the NHS. The NHS needs to reflect on why these tensions have occurred and redouble efforts to ensure local councils are full partners in the STP process.

  8. One obvious area of tension is that councils have found the process heavily driven by NHS England and NHS Improvement. This should give us pause for thought about how we run the NHS and whether we should be trying to devolve significantly more power to local health and care communities – as suggested in last week’s report fronted by Alan Milburn.

  9. Simon Stevens was right to argue last week that we should not pretend that STPs are a way of solving every problem in the NHS. They cannot, for example, solve the current mismatch between what is expected of the service and the funding available. They also cannot be expected to solve the current financial unsustainability of social care.

  10. The STP process is a vital and important one and we must do all we can to ensure its success. It is important that the current debates are a ‘bump in the road’ rather than a cause of derailment.
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