I've visited eight adult social care departments this year, and talked with front line staff in all of them.
Thinking back to my time as a Special Advisor, first for Tony Blair then later for the Secretary of State for Health, the trickiest policies were those that were simultaneously complex and urgent. Making those policies have an impact in the real world (as I recall from my time in the Prime Minister’s Delivery Unit) is trickier still.
This week’s letter to the NHS and Local Authorities entitled ‘Developing Sustainability and Transformation Plans (STP) to 2020/21’ ticks all of those tricky boxes. Add in the requirement to nominate ‘a senior and credible leader who can command the trust and confidence of the system’ along with the condition that a good STP will become the gateway (or not) to substantial funding, then in the words of Sir Humphrey, this all begins to look ‘challenging,’
The letter (like the December guidance before it) makes clear that the STP is about the following:
- Better patient care and outcomes through transformation, especially prevention
- Unleashing energy to build and strengthen local relationships
- The means to drive a genuine and sustainable change
- Concrete actions rather than a ‘glossy brochure.’
It is of course important to frame the challenge clearly and root solutions in ‘strong analysis and insight’ as the letter confirms, but STPs are about changing the world, not just analysing it.
Many areas have done good work already and we know from all of the guidance that STPs are not the only game in town but they are the big overarching framework into which everything else fits. This need not challenge the autonomy of individual organisations, but equally the solution requires closer co-operation to deliver better outcomes, and at a lower cost through transformed care.
It is interesting to see how much the letter emphasises credibility, rigour, good governance and, above all else, shared and energetic leadership. Without all of these things areas will fall behind and over time will be subject to increasing scrutiny and, where necessary, direction from the centre. The incentives are carefully balanced with sanctions.
So where are the big risks and how can you avoid them?
Too much time planning and not enough relationship building: Individual organisations will still matter a lot but the STPs will require much closer working across organisational boundaries and at bigger geographical levels. A key test of credibility will be how partners are working together, leading the change and resolving challenges. This is partly about structures but in the words of Ken Kizer (who as Under-Secretary of State with responsibility for the Veteran’s Health Association engineered what is widely regarded as the largest and most successful health-care “turnaround” in U.S. history) described the change process as ‘more sociological than technological.’ Investing time early in building strong relationships and the guiding coalition will be crucial.
A polished strategy is no guarantee of delivery: Another key test of how credible the STP is will be the likelihood that it will deliver. If we focus on out-of-hospital integration as one of the core elements of transformation, then we know from international evidence that some programmes succeed but many fail. Understanding the critical success factors for delivery and best-practice will be key ingredients in creating a strong plan. It is possible: I led a joint project with Age UK (national) in Cornwall that has delivered a 32% reduction in all admissions and a 27% increase in well-being and we are supporting other organisations to develop world-class preventative models of care that have a similar impact.
A financial model that does not meet the gap: The balance between provider-led efficiencies and new models of care will shift over time but whatever the mix, the numbers will need to stack-up. This is not as easy as it seems because of the challenges in quantifying the value of reduced demand on the acute sector from a new model, not to mention the investment shifts required to deliver a new care model. iMPOWER is developing a model to support organisations with this thinking. Our recent iMPOWER survey of CCGs demonstrated that most Chief Officers understand the gap all too well but 70% did not think they had well-developed plans and scored and average of 4 out of 10 for the confidence they had in their plans.
Getting the incentives wrong: There are a range of helpful levers that can be deployed to support the re-shaping of services but these need to play out at two levels: Securing the change and then delivering better outcomes at lower cost. All of the international evidence about successful transformations in health shows that incentives matter. The collective impact on outcomes also means that whole-system incentives will be required to encourage collaboration and share rewards (and risks).
Not clearly demonstrating how performance will be managed and delivery secured: The NHS and Local Government are strong at performance management but the history of partnership working suggests that this can be a tougher ask when multiple organisations are involved. Getting this well-designed, agreed and built into contracts backed by incentives is an important early consideration. Governance can turn into administration rather than traction. At iMPOWER we ensure the latter not the former by drawing on world-class best-practice to ensure delivery.
On the 10th March we are hosting an evening event where Michael Macdonnell, the national lead on Sustainability and Transformation Planning for NHS England will be joining us to give the latest insights. This will be an opportunity to engage with Michael in a discussion about how best to take this agenda forward. This will be a small event for around 10-12 organisations and a number of the places have already been taken, so if you work for a CCG and would like to attend, please let us know as soon as possible (07976 297670 or at firstname.lastname@example.org)