20 Feb Will STPs ever be implemented?
Will STPs ever be implemented?
This blog is based on a debate held at a junior doctor training event in Bristol. The motion was ‘Are the proposals in STPs sufficient to ensure an effective and sustainable NHS?’ I was asked to make the case for ‘no’, while Dr Sean O’Kelly made the case for ‘yes’. I lost, having stated that I didn’t want the answer to be ‘no’, given the lack of an alternative strategy! I was heartened by the optimism in the audience when a ‘yes’ vote triumphed. Below I consider arguments for both sides and strategies that could facilitate an efficient change.
We know where we are, and we know where we need to get to, so the question is ‘how will we get there?’
The Sustainability and Transformation Plans (STPs) are, of course, the means by which the Forward View will be put into practice across the 44 ‘footprints’ that cover the English NHS. All are now published and, unsurprisingly given the prescribed format, all aspire to similar models of care once the differing terminology is taken out.
In my experience, the NHS is generally good at setting direction and writing plans, but rather less effective at implementation and delivery of the intended benefits. Some of this is due to over-promising, because of a perceived or real pressure to do so, and some is due to operational and other constraints that hinder progress. Will the STPs be any different?
Service reconfiguration often hits difficulties during public consultation, even assuming that staff support for the change has been achieved. Public trust in NHS leaders who promote change, even when medical staff are fronting the meetings, is low. Members of the public recall previous experiences where the real reason for change was unclear, and in the absence of constructive long term relationships with local NHS leaders they are understandably suspicious. Public opposition usually leads to local political opposition, which further raises the barriers.
Open communication is key
If the STP plans are to be different, we need to have learned the lessons of history and started to engage with both staff and public in a more constructive, open and transparent way. I do not see this happening at any scale.
STPs were drawn up behind closed doors, which was unfortunate. By the time the public saw them, they were well advanced. Clinical staff involvement was variable. Very few GPs were involved, other than those in commissioning roles. Given that the new integrated services will be built on a foundation of strong general practice, this is an unfortunate omission.
If you look up any authoritative work on how to manage change, you will find that engaging all those involved, early and genuinely, is essential. The other prerequisite for successful change is adequate resource. There is real doubt that resource will be sufficient, for perhaps understandable reasons given the constrained economic circumstances. If radically different new care models are to be created, then a period of ‘double running’ will be essential to cover the period before downstream savings (from the acute sector) are achieved. This will be costly.
Challenges and solutions
If relevant clinical staff are not fully engaged, the public are not supportive, and they are likely to be insufficiently resourced, then it is difficult to be optimistic about the implementation of STPs. This is worrying. The STPs describe changes that are essential for the continued survival of the NHS. We all want them to succeed.
It is not too late to turn this around, but it will require a real determination to break with the past and operate differently.
1. GPs should be supported (with backfill funding) to work on defining the local neighbourhoods that will define their future pattern of working.
2. Local public councils should be set up, giving real influence over the implementation process to lay people in every health economy. These should be senior groups in the hierarchy.
3. Local leadership responsibilities and accountabilities must be clearly delineated. CEOs are accountable officers of their Trusts and they cannot simply set their statutory responsibilities aside in the interests of joint working, however much they may wish to do so.
4. Financial planning will need to be done over a period of 3-5 years, in order to cover the double running costs and allow the necessary re-balancing of finance across sectors. Control totals will need to be realistic during the period.
5. Hospital doctors in specialities that will move towards a holistic, community-wide service model, should be actively planning these new services.
Some may say these things are happening already. If they are, then we should be optimistic that real and sustainable change will occur. But where they exist on power-point slides only, then an honest reappraisal is urgently needed.