STP – Now for Implementation – Frontline July 2016 1

STPs – Now for Implementation

These reflections on implementation of STPs focus on ‘what now’ and ‘how to’. Plans have been

submitted, and feedback is awaited. That was the easy bit. Now to make it real.

The world has changed since STPs were set up. The post-Brexit prospects of rising costs – such as imported

drugs – potential workforce shortages from immigration caps, and uncertainty in resources, not to

mention the inevitable planning hiatus and reluctance to take risks, means that many STP assumptions

will need to be revisited. However, STPs represent an opportunity for major upheaval – upheaval in

systems, services, responsibility, people, accountability, costs, outcomes. This could be a paradigm shift

to shape demand. However, in a few years’ time, looking back, it could also be a lost opportunity.

Outlined below are some key issues that will help shape the work and emerging role of system leaders as

they implement STPs.

Come back SHAs, all is forgiven

There has been a clear void in system leadership in the NHS since SHAs were abolished. Gone is the

strategic view across the system, the ability to orchestrate change (including leaders), the sharp focus

on achieving targets. The subsequent free for all has resembled just that – resulting in lack of direction,

minimal co-ordination, and a loss of control, especially financial. NHS England offices and staff have

tried their best in many cases to fill the void, but lack leverage and influence.

Enter STPs – not to be confused with the American STP, which is a fuel additive,

(though there are indeed some analogies here). STPs started out as a thing,

namely a plan (sustainability and transformation plan) and have now become

an entity, a geographically bounded space with a designated leader. They are

a step along the path to what will become more formalised structures – which

will need an accountable leader who can make things happen. As a planning entity, some are more

logical in their design than others – given boundaries and patient flows – but as old hands know, these

regionalised structures keep changing anyway. Current STP design therefore places the onus on leaders

across STPs to speak to and work with each other – but the informal nature of these relationships means

that many will continue to fight their own corner.

What is important here is that there are now, as a first step, regionalised planning (and potentially

delivery) structures in place, and with great opportunities to reach beyond the NHS to get integrated

places. The STP leader will be the conductor of this orchestra, and the aim will be to get all the parts

playing the same tune. As any good maestro will tell you, this is no easy task.

The empire strikes back

The NHS is more akin to a conglomerate than a unified corporate entity. Across

England there is very little evidence of ‘National’ in NHS. It is more a brand with a

unifying Constitution than a single entity. The NHS today is like the US pre-Civil War,

where States were all powerful and the Federal government was powerless to end

slavery. Just over 150 years ago the Civil War ended and, after 620,000 dead, grammar

changed. As the preeminent historian Shelby Foote observed, “Before the Civil War it

was said ‘the United States are’. Grammatically, it was spoken that way and thought

of as a collection of independent states. And after the war, it was always ‘the United

States is’… and that sums up what the war accomplished. It made ‘us’ an ‘is’.”

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We are seeing the early moves in the exercise of central control over the NHS, if for no other reason than

to stop the race to the bottom – ‘my deficit is bigger than your deficit’. If there has been a void in

direction and control at regional level, there has been a similar void at national level. Though there has

been the merger of TDA and Monitor, there are still too many players on the pitch. National policies are

signed by multi-parties. Roy Griffiths asked who is in charge in 1983. Plus ça change.

The STP process is beginning to give an indication of who is in charge. The Treasury puts pressure on DH

which puts pressure on NHS England which puts pressure on NHS Improvement, which puts pressure on

providers. The buck has to stop somewhere, and many trust chief executives – and CCG chief officers –

are beginning to find out what accountability really means. This is a collective financial mess with

individual causes, and the buck is beginning to land. STPs mean it lands on the system, but individual

leaders will still be in the spotlight.

Bang for the bucks

While provider chief executives and their boards are not fully culpable for the financial mess, they can

be criticised for an insular perspective. To paraphrase X-Files, the answer to their problems is out there –

in their local system. The challenge is two-fold. First is to recognise that the balance between the

organisation and the system is now strongly tilted towards the system. Public finances are limited and,

with the reality of Brexit, times will get tougher still. Combining public sector resources is a no brainer –

more bang for the bucks.

Second, the performance management of organisations is changing. It was telling that in the provider

roadmap published by NHS Improvement earlier this year – Implementing the Forward View: Supporting

providers to deliver – there was no mention of foundation trusts. The FT model is past its sell-by date,

designed for a time when resources were aplenty. Resources are

scarce across the public sector, due both to cutbacks and

increasing demand. The tide of resources has gone out and will not

return – the only way of coping is to change patterns of demand.

Yes, celebrate the impetus for change and innovation that some FTs

brought to the NHS, but the demise of the stand-alone FT will enable

the performance management of systems rather than organisations

– and the emergence of new models of service delivery. Tapping

into FT members will provide leverage to this process.

Focusing on the public sector pound should also give leverage to the Carter proposals – to reduce

variation, duplication and waste, and increase standardisation. The prize is across the public sector in

STP places, not just the NHS. The £500m provider deficit this year is a system issue, not just a hospital one.

With STPs, money follows innovation rather than patients.

Democracy and the deficiency

As if the challenge of getting NHS organisations to sing from the same hymn sheet is not enough, add to

this complex equation the challenge of getting democracy and the deficiency working together –

referring to the democratic legitimacy that elected members give to their organisations, in contrast to

the ‘democratic deficiency’ as they characterise the NHS.

This contrast in authorising environments cannot be underestimated – the sun is a

different colour on the two planets. NHS leaders do not know local government, and

vice versa. Local government operates a social model of care, means tested for

access, governed by elected members with supportive officials. The NHS operates a

medical model of care, free at the point of delivery, governed by appointed officials

with preeminent executives – not to mention a cadre of hospital and primary care

doctors who use and allocate resources, still with a high modicum of freedom and lack of accountability.

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It will be in this wider system space where the benefits of STPs will truly be realised. NHS organisations –

providers and CCGs – can tinker with their closed system, but it is only by engaging with the open system

of local government, the volunteer sector, police, academia, economic development, communities and

citizens that the demand curve on the NHS will truly change. Demand on A&E and delayed discharges

can be addressed, if not solved, by this wider system work – not by technical solutions, but by adaptive

leadership approaches embracing the complexity of their system. STPs are therefore merely a step

towards real local devolution – of which we are now beginning to see the early signs.

The customer is always right

This is the mantra in the service industry – ‘the customer is always right’. We all abide by it when we use

services, except the NHS. The NHS was designed as a producer-driven service, lacking in responsiveness

to customers. It still largely is. Professionals in the NHS illness service are preeminent, and are placed on

a pedestal by patients. This is partly a factor of the psychology of illness, but is reinforced by the free

good nature of the service.

But we also know that the NHS customer is not always right. If they were, we would not

have the problems we have treating diabetes, coronary heart disease, cancer. With

an aging population and increased co-morbidity, the STP process opens up

opportunities to change the character of engagement with citizens and communities

before they become patients – to change both the short and long term demand curve

on the NHS. Atul Gawande in his book Being Mortal has written poignantly about this

as he challenges the medical profession to end the medicalisation of dying, and for

patients and relatives to take greater control of their choices and services. This is but

one aspect of patients taking on greater responsibility for their health and wellbeing,

aided and abetted by clinicians and the technology that is now increasingly available, though sadly

much underutilised. Many of us have personal experience of caring for relatives and finding that the

specialisation of professions and services gets in the way of treating the frail elderly. Innovative plans for

change presented in STPs can be a further move towards reshaping care for this pivotal group.

Public health can play a significant role in this process of building responsibility for good health in citizens,

and they are well placed to carry out this role in local government. However, their funding is going to be

squeezed more than if they had stayed in the NHS (not that they had a choice), so the challenge for

public health professionals is to demonstrate the impact of preventative health measures, and so protect,

and indeed expand, investment in wellness services.

Oiling the machine

The temptation is to think of the NHS as a machine – replace some parts,

redesign processes, oil and grease the components, put in more fuel.

This is machine leadership, which still predominates many sections of

NHS leadership. It hasn’t worked, and won’t work. This perspective is

aligned to the approach of seeking technical solutions to what are

adaptive problems – of service providers offering solutions from Henry

Ford’s playbook for the Model T, “Any colour as long as it’s black”.

Instead, system leadership recognises that any system comprises voids, and relationships fill these voids.

It is conversation that underpins these relationships. This conversation provides the means for leaders to

build up trust among themselves, and to convey a change narrative that attracts supporters – in both

the communities they serve and their organisations. A major challenge for STP implementation will be to

build up trust among the system leaders. This will enable open and honest conversations to take place

about demand – for leaders to shape public expectations, and for professionals to be honest about what

can be treated, where care can best be provided, and where responsibility lies.

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Flogging will continue until morale improves

The temptation now is to play hardball to bring about the necessary change. There

is no doubt that the tough environment needs tough action, but the solution is not

to keep flogging until morale improves. It won’t. This is for short term turnaround

stuff, maybe necessary for short term fixes, but only for just that. Long term,

sustainable change has to come from within – within the system, its organisations,

their people, their hearts. Frankly, most staff know what needs to be done. Ask them,

engage them, give them responsibility.

STP implementation, especially if it embraces staff outside the NHS, means that there will be winners and

losers. Leaders need to think system rather than organisation, though their staff will find that harder. Staff

identify with their own manageable place rather than the unrecognisable system of which they are being

invited to be a part. Even the most attractive change narrative will come up against reluctance to

change. As Ron Heifetz has observed, “People do not resist change. They resist loss”.

The challenge for system leaders will be to help staff cope with this loss. Roughly 70% of NHS costs are

staff – there will be changes in location from institutions to the community, greater flexibility in working

across professional and organisation boundaries, and changes in approach to build responsibility in

citizens and patients. Investment in staff will underpin these changes, though this significant workforce

challenge will not be made any easier with Brexit.

It’s easy to make money on paper

All the STP plans will balance over the five years. That’s what they’re

supposed to do. Box ticked. The assumptions will then come home to roost.

Transition money will not be available, targets will be missed, partners will

fall out and not deliver for the system. The NHS cannot bank on the £350m

promised by some during the referendum debate. It’s best therefore to be

both realistic and gutsy from the outset. Gloria Steinem has a good

approach for this: “Without leaps of imagination and dreaming we lose the

excitement of possibilities. Dreaming, after all, is a form of planning”.

It is GPs who seek to make real money. They are small business entrepreneurs, and are already poised

through co-commissioning to make an entrepreneurial impact. They are also a further factor in the

authorising environment for STPs and system work. The last set of structural changes put GPs at the centre

of clinical influence on decision making and resource allocation. Let’s not lose this opportunity of a

counter-balance to the hegemony of acute hospitals. If GPs can be suitably incentivised for changing

the demand curve on hospitals, then let them make more money out of it. Factor this into the system

finances, but make sure the change is delivered.

What next…

Five key factors will shape the effectiveness of STP implementation – namely how these issues can be

addressed:

Leadership – This is the soft leadership of the conductor of the orchestra, the maestro using the baton to

guide and encourage partners to align their activities towards a common end. It is soft influence,

recognising that, though buttons will be pushed and levers pulled, there is a high probability that nothing

will happen. Relationship building and conversation to maintain trust will therefore be pivotal, while

continually paying heed to Field Marshal Montgomery’s observation that “The most difficult thing to

manage is the subtle withdrawal of enthusiasm”. Future formalised accountability structures will put

leaders in a position to exercise real influence.

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Engagement – There are three facets of engagement: getting hospital doctors and GPs to engage with

each other, getting elected members on board, and managing the expectation of the public. Elected

members are often the most ignored, yet they have the power of the electorate behind them, and can

mobilise support for the substantive change needed to fill the STP gap. Equally, if doctors get behind the

change rather than protect their vested interests, then the public will more likely be swayed – doctors

remain one of the few professional groups still held in high esteem.

Governance – This is about the authorising environment needed to legitimise change, the infrastructure

to make it happen, and the accountability for delivery. The authorising environment is like a big tent filled

with the top people in the system who will enable and support change. To paraphrase Lyndon Johnson’s

famous expression, it’s better to have their egos inside the tent instead of outside. Then there is the

governance infrastructure to make it happen. It is easy to make this top heavy. If there is trust in the

system, not all players will feel the need to be at the top table to manage the risk that comes from the

gutsy demand control and innovation trade-offs.

Delivery – There are many examples of successful structures for plans, planning and implementation –

Overlord, Crossrail – and those that are less than successful, such as the subject of John Chilcot’s recent

Inquiry. Suffice to say, keep the PMO structure light but impactful; follow the advice of the blogger Jason

Fried, “Meetings aren’t work. They’re about discussing things you have to do later”. If the STP was written

by outsiders, namely consultants, the challenge will be to get the fingerprints of all stakeholders on it, with

their commitment to the tricky decisions of implementation.

Resilience – This is both about individuals and the system. Both need worked on. Individuals will find the

going tough. Some will have to make decisions not in the interests of their constituencies. They will need

support when the fallout happens. System resilience comes from building the system’s capacity to

change, not focusing on the change itself. A compelling narrative, passionately communicated by key

influencers, reinforced by tangible results, will help build system resilience. Don’t rely on more resources.

The future is about not doing more for less, but rather less for less.

For a discussion…

In Frontline we support leaders both to lead system change and to deliver the tangible changes on the

ground. To explore these issues and find out more about how we can help you do things better to

implement your STP, please contact:

john.deffenbaugh@frontlinemc.com

07788 746550

Frontline July 2016