This post is from The King's Fund Blog
Sustainability and transformation plans (STPs) are based on the notion that collective action is needed to address the significant pressures now facing health and care services in England. The logic of this is sound – but developing the plans has been far from easy, and implementing them will require leaders and organisations across a local STP footprint to work together in new ways. In our new report, Sustainability and transformation plans in the NHS, we make a number of recommendations as to how leaders and organisations might do this.
The development of STPs has acted as a catalyst for getting organisations together and establishing a shared common purpose. Typically, the leaders we interviewed from four STP areas – covering a total population of 5 million – are committed to working together and addressing some of the local challenges but understandably there are tensions. A central dilemma is the tension between being asked to collaborate with other organisations while still being held to account as an individual organisation.
This tension is most clearly expressed in relation to the accountability of NHS providers, which face strong incentives to improve their organisation’s own performance and few incentives to collaborate with one another. The lack of clarity over how organisations are to be collectively held to account for their performance in an STP is also hindering the degree of collaboration being shown by NHS organisations, and in some instances the nature of the decisions being taken. There is a danger that unless this issue is addressed we reinforce the principle of organisational self-interest as leaders continue to focus their attention on the part of the system most visible to them, and we lose the benefits of creating organisational wellbeing within a larger system.
Another key finding from the report is that the role of STP leads needs to be clarified. Leading the STP process -so far- has been challenging and time-consuming. Most STP leads have found it difficult to manage their existing responsibilities alongside their STP leadership role. Some leaders view the STP lead role as a convening role and are planning to ‘share’ leadership more formally in the future. This may be possible in STP areas where there is already a high degree of collaboration between local leaders and a small number of organisations involved, but in areas with a high number of organisations involved we would suggest alternative arrangements. Leaders in our study believe that the style of leadership is critical to success, and in our development work with system leadership groups we have seen the benefits of leaders collectively focusing on their leadership practices and processes. Acting together can magnify impact.
Another clear conclusion from our research is that much broader and deeper engagement of a range of different groups is now needed. It is particularly important to engage clinicians, though this won’t be easy, especially given the workforce pressures in many parts of the country. Clinicians we know are principal players in supporting or opposing change programmes in the NHS and so far few have been engaged in the development of STPs. The involvement of patients, families and the public is also critical and has also up until now been largely absent in the development of the plans. Although they should be key partners, our research also highlighted patchy engagement with local authorities. Addressing this must now be a key priority for local leaders, who will have a critical role in cultivating the conditions that will enable these different groups to be effectively engaged.
Some leaders in our report identified creating some headroom and collecting intelligence (wisdom) from different stakeholder groups as the key next steps in the process. This will require leaders to spend more time together in an environment that fosters reflection and more generative conversations rather than aiming to ‘get through the business’ in a couple of hours once a month. Taking some regular time out together in a protected environment – learning about each other’s organisational constraints and needs – can build trust. This in turn may foster some new creative solutions to longstanding problems – and secure real improvements in the care being received by local people.