A recently endangered trade deal between the EU and Canada offers some pertinent thoughts on balancing the interests of the new partnerships, writes Chris Ham
Sustainability and transformation plans are here to stay, despite the many problems that have accompanied their birth.
The task now is to strengthen their governance and leadership as well as to build capacity and capability for implementation. This means finding a way of STP partners taking decisions together while also being held to account for their own performance.
The recently agreed trade deal between the EU and Canada illustrates the challenges of marrying collective action with the sovereignty of partners. The deal was almost scuppered because of objections from Wallonia, the French speaking region of Belgium, even though it was supported by all other members of the EU. This happened because the governance of the EU requires agreement by all member states before a trade deal can be signed.
Veto powers undoubtedly gives huge leverage to those whose agreement is needed for deals like this to be ratified
The objections of the government of Wallonia, and it appears some other Belgian regions, seemed likely to veto the deal at the eleventh hour. In the event, a way was found of overcoming these objections, enabling the deal to be signed. How this was achieved is not clear but the existence of veto powers undoubtedly gives huge leverage to those whose agreement is needed for deals like this to be ratified.
The implication for STPs is clear. NHS leaders will need to agree a way of working that allows decisions to be made while respecting the autonomy of partner organisations. They must do so without enabling each partner to exercise a veto if they object to a majority view. They must also avoid those holding minority views feeling they are being railroaded to accept decisions with which they disagree.
This means putting in place governance that commits partners to decisions once they have been taken. In other words, decision making must be ”collective and binding” if STPs are to become an effective part of the governance landscape. Organisations must be willing to cede some of their sovereignty to work in this way, while also being held to account for their own performance.
The alternative is for STPs to remain a forum for promoting partnership working but without the ability to enact decisions. If this were to happen, they risk withering on the vine as partners decide that the considerable time and effort involved is not justified by what STPs deliver. The opposite also applies with senior organisational leaders more likely to take STPs seriously if they have ”skin in the game”.
Whatever governance arrangements emerge for STPs, their effectiveness will depend on the underpinning relationships and trust between partner organisations and their leaders. It will also depend on STPs developing their own leadership by identifying senior and respected teams able to commit full time to work on STPs without the distractions of their day jobs. The appointment of independent chairs may help in this process in some cases.
The current organisation of the NHS in England is fragmented with many potential Wallonias seeking to protect their own interests
The most advanced STPs are beginning to work in this way. Examples include Greater Manchester, whose strategic plan was approved before the idea of STPs was born, and Devon, where there is combined leadership of the success regime and the STP. This leadership is centred on a respected foundation trust chief executive who has stepped out of her role, with support from organisations across Devon, to concentrate on the STP.
The current organisation of the NHS in England is fragmented with many potential Wallonias seeking to protect their own interests rather than work for the common good. Regulation by national bodies often reinforces Wallonian tendencies, as when providers are put under pressure to deliver their control totals and get back on trajectory for key performance targets.
The implication, sometimes unspoken, is that it is a higher priority for organisations to get their own house in order than commit to partnership working.
The other big question is how to involve local authorities in governance and leadership of a process which, for the most part, has been led by the NHS both nationally and locally. Local authorities have made clear their unhappiness with this process and there is much work to do to engage them more fully in STPs in future as health minister David Mowat has emphasised.
Finding a way of doing so while also reconciling the local accountability of councils and the national accountability of NHS organisations will be a challenge.
Serious thought needs to be given to how to overcome these and other barriers without adding unnecessary complexity to an already confusing system or imposing a governance model that is not sufficiently flexible to be adapted to the needs of different areas.
This year’s contracting round will test to the limits the strength of relationships between organisations and their leaders and the ability of national bodies to act in a way that is consistent with the priority now given to STPs.
Chris Ham is chief executive of The King’s Fund. The King’s Fund’s new report Sustainability and Transformation Plans in the NHS: how are they being developed in practice can be downloaded here.