If STPs are given the support they need to flourish – and equip themselves with the expertise they need to avoid failure – there is every chance that they might deliver the holy grail of better quality health and care services, writes Sarah Brooke

Sarah brooke

Sarah Brooke

Sarah Brooke

When the concept of Sustainability and Transformation Plans (STP) was first introduced to the NHS in the planning guidance last December, some would be forgiven for thinking it was the latest manifestation of NHS initiative-itis.

In the preceding 12 months, after all, the vanguards programme, “Devos” and then the “Success Regime” had been heralded as the next big thing – and now STPs were being added to the mix.

In fairness to NHS England, all of these proposals – though distinct – do pull in the same direction. There is, for example, the blurring of the distinction between purchasers and providers. There is also the desire to dispense with the prevailing activity-based payment systems.

And there is inherent in all the initiatives a focus on sharing budgets – or at least financial risk – between distinct organisations. At first glance, STPs appear to be simply another route to meeting these objectives.

The next big thing

But there is a clear reason why STPs might actually be the next big thing in the NHS – and might even outlast and supersede the other initiatives we hear so much about today. This is because of the clear involvement of the Treasury in STPs: in their origin, their design and their desire to see STPs fully implemented.

Looking back, the involvement – and direction – of the Treasury in the STP process seem obvious. There was, for example, the throwaway declaration in the Spending Review that there would be, “an ambitious plan so that by 2020 health and social care are integrated across the country”.

STP leaders will have one of the most difficult jobs in healthcare over the coming years

This was followed by the Planning Guidance and its unveiling of STPs, to be signed off centrally. Then came the carrots: providers will only be eligible for STP funding – and commissioners will only be eligible for real-terms increases in their allocations – if they work in support of the STP they are a part of.

All £1.8bn of the Sustainability and Transformation Fund is ring fenced and allocations from the fund are subject to the prior approval of Treasury.

The breakneck speed of the process has all the hallmarks too of being externally driven. There are few in the NHS hierarchy who would feel that designing a geographic “footprint” of STPs in one month, appointing a leader inside three months and finalising a five-year plan within six months would be a particularly achievable timeframe.

But to date, the NHS appears to be coping admirably with the task.

Time will tell if the NHS copes with the task of implementing STPs as well as it is with the task of setting them up. The ultimate objective of STPs appears to be to achieve across the NHS the trinity of financial stability, access, and high quality care that has proved challenging even in the best of times.

Although the scale of the task is daunting, there are reasons to be hopeful. The calibre of those STP leaders revealed is impressive.

STP leaders will have one of the most difficult jobs in healthcare over the coming years – for a whole host of reasons – and the quality of the individuals in the roles is critical.

Leadership skills

Not least, STP leaders must herd the efforts of multiple organisations without having any legal authority to bend them to their will. The “power” of STP leaders relies on the hard ability of the Treasury to withhold money from recalcitrant organisations – and perhaps more importantly the will to make use of it.

It also relies on pressure being exerted by Simon Stevens and by Jim Mackey to ensure organisations not willing to play ball fall into line.

These are significant levers, but it remains to be seen whether they are sufficient ones. The different organisations that are party to each STP will have their own legal objectives – and sometimes competing ones. STPs will need to find a means of discussing these objectives – and establishing governance arrangements which clarify who the final decision-taker is when conflicts need to be resolved.

Replicating the geographically contained successes more widely across the country will improve care significantly

They will need to ensure that all their constituent organisations are adequately sighted on their decisions and the rationale for them – managing their upwards relationship with NHS England but also their downwards relationship with clinical commissioning groups, all of whom might be pulled in different directions by their legal obligations and their members.

Even if all of these internal decision-making hurdles are safely navigated, STP leaders will find themselves facing external ones too. When STPs seek to implement service redesigns that engage procurement laws, they will need to involve all interested parties – inside and outside the STP umbrella – right at the outset.

They will need to pay heed to the need for consultation with their local populations, and determine who is accountable to their local authority’s health overview and scrutiny committees for the decisions made in pursuit of the plan.

If the leaders of STPs tread their way safely through this minefield, the prize that awaits them may be a great one. The opportunities offered by Greater Manchester – the part of the system that resembles most closely a fully-functioning STP – are widely known.

The North East – the part of the NHS that has seen probably the most collaboration over a prolonged period of time – is arguably one of the most resilient parts of the healthcare system. The successes of the integrated Isle of Wight system have featured in national newspapers.

Replicating these geographically contained successes more widely across the country will improve care significantly.

There is a prize too for the organisation that has driven this process to date. For around a decade, the Treasury has been philosophically consistent in championing place-based budgets – estimating, in 2010, that billions of efficiencies could be achieved simply through streamlining the administration of different organisations alone.

If STPs are given the support they need to flourish – and equip themselves with the expertise they need to avoid failure – there is every chance that they might deliver the holy grail of better quality health and care services, at a lower cost.

Sarah Brooke, partner, Hill Dickinson