STPs: collaboration makes sense, but it needs leadership and direction

16 November 2016

John Coutts

Just as many decisions are best made locally, a good few are better made at regional or local health economy level. And if we are making decisions at a regional or sub-regional level then it is best that they are taken by the organisations that make up that health economy, those with a stake in the game, than it is to have them taken by an otherwise unnecessary regional bureaucracy.

So the development of sustainability and transformation plans (STPs) at health economy level makes absolute sense. Without that level of interaction it will be difficult to realise the financial and quality gains implicit in delivering new models of care. It will also make the delivery of economies of scale necessary to bring NHS expenditure into line with budgets even more challenging.

So my starting point is that STPs are, for the most part, a good thing and are probably a necessary next step in the development of the NHS provider sector.

The thorny issues of leadership, direction and governance

Of course there are practical problems such as some STP areas not corresponding with other ‘footprints’ including some trusts’ patient flows, some new care model projects going across several STP areas and issues that need to be resolved ‘across borders’. None of this is insurmountable, but, and there is always a ‘but’, there are also more thorny issues of leadership and direction, and dare I say of governance, that if ignored are likely to lead to fundamental problems.

First and foremost, we need to take account of the fact that STPs have no legal status. They are not unlawful, but they have no standing in law and no legitimacy other than that which the participants bring with them. This means that in making decisions they need to be mindful of where they derive their authority to act. There are difficulties around direction and control because the process of leading STPs is unwieldy. They cannot delegate and involve meetings of representatives of all participants, which is likely to mean cumbersome groupings.

We need to take account of the fact that STPs have no legal status

Secondly, decision making processes warrant significant attention if they are to deliver good outcomes. STPs have no legal powers and decisions can only be made by in accordance with the delegations allowed to the chief executives that make up the STP leadership. The only way to make those decisions binding is through contracts between the participants, but putting contracts in place will be time consuming, comes with a cost and is therefore not practicable in most cases. So participants will need to rely on trust that partners will not renege on agreements, but also accept that circumstances will change and that there will sometimes be legitimate grounds to reopen negotiations.

Thirdly, there has been little non-executive input into STPs to date, so there are likely to be cases across the country where decisions are not being challenged and tested properly. If that is the case then there will be problems with risk management because the absence of strong challenge leads to weak risk control and a greater likelihood of risk coming to fruition. There will be a challenge for STPs in developing a common, robust risk culture.

Fourthly, to date the conduct of business has been carried out largely in private and their plans have been confidential. This raises important questions around engagement, and could prove detrimental if CCGs, councils of governors and local authorities opt to halt plans in their tracks in part because they have not had the chance to understand and gain ownership of the business case for change. Similarly there is a need to ensure timely and appropriate public engagement prior to formal consultation. Sooner, rather than later, there will be a need for much greater transparency if implementation is to be as uncontroversial as possible. We have already seen four councils publish STPs and criticise the NHS for not being more transparent.

There has been little non-executive input into STPs to date, so there are likely to be cases across the country where decisions are not being challenged and tested properly

Finally, those leading STPs have been charged with ‘getting on with it’ and with being seen to play well with others. There are dangers when like minded people are gathered with a collective mind-set that promotes making progress above diligence and caution. The possibility of group think, where talented and able people make decisions that they believe to be right, but are in fact wrong is well known, but often ignored.

With the drive from the centre to get things done, the lack of NED challenge, cautiousness over sharing early thinking more widely across local partners or the public, the homogeneity of the group and the pressure of not to be the one standing out against an agreement represents an almost perfect storm. If we had attempted to design a system where group think was likely to occur it might look a bit like the one set up for STPs. But in knowing that is the case, we can do something about it.

None of the issues identified above constitutes an insurmountable problem. It is true that some of them might be better solved by legislation – the issue of legitimacy for example – but all of them can be addressed and dealt with, however imperfectly, within existing flexibilities and by applying the principles of good governance. And collaboration is without doubt superior to a return to command and control. The challenge for the sector, nationally, and locally, is to recognise that proper leadership, control and direction need to be designed into new forms of service delivery from the outset and to act accordingly.

NHS Providers will be working with partners to produce a guide on how local areas can deal with some of the issues outlined above and ensure the implementation of their STPs is underpinned by good governance. This guide will be launched at our annual conference and exhibition on 29-30 November 2016.

This blog was published by National Health Executive on 16 November 2016

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