NHS reforms

STPs must ‘get real’ about time available for service transformation

Trying to impose a consistent and uniform statutory layer of STPs too quickly without thinking through their transition process will be a “recipe for chaos” and a “recipe for inadequate management of clinical risk” – instead, local systems need the time and space to move along at the required pace.

Those were the words of Chris Hopson, chief executive of NHS Providers, at a senior panel debate during this week’s STP summit organised by the King’s Fund. The think tank’s CEO, Prof Chris Ham, had asked panel members what they believed were the top priorities over the next couple of years in order to ensure STPs are as successful as possible, especially given the tight timescales and financial constraints affecting all plans from day one.

“For me, it’s the realism. Let’s get real,” Hopson declared. “If you look at what’s happening in the NHS today, if you talk to our frontline managers, they’ll tell you that they feel like at the moment, they’re almost in a life or death struggle to keep the existing service upright.

“And if you look at the pressure that’s coming on the service, and the gap between that and the funding that’s available and how much time it simply takes to get the service through day to day, we just have to be realistic about how much time we’ll be able to spend on doing transformation.”

The NHS Providers boss then cited two international delegates who spoke at the summit about their own journeys towards accountable care organisations in Spain and New York, explaining that these places actually had 15 to 20 years to build these services – and none of the day-to-day pressures the NHS has to deal with simultaneously.

His second priority would be to acknowledge the importance of creating new systems from the bottom up, not from the top down.

“Let me tell you a little secret: everybody in Number 10 Downing Street, the Cabinet Office and the Treasury would die for the idea of 44 STP leads who they can basically ring up on the phone and hold to account for NHS delivery,” argued Hopson. “Because at the moment, they’re trying to grasp the slippery eel of 209 CCGs and 235 trusts, each of whom is pointing at the other when there’s a problem.

“There’s nothing they would like more than basically creating a single statutory layer that has real power to effectively hold accountability and be responsible for performance in the 44 STP areas. That’s what they would like tomorrow morning.

“But the reality is that that completely cuts across the existing accountability and governance structures that are apparently in place, and we cannot make that transition overnight.”

Instead of forcing through this quick and uniform development of STPs enshrined in statute, the NHS Providers CEO said we need to be “very clear” that, particularly given how much pressure the system is under, any effort to do so will be a “recipe for chaos and a recipe for inadequate management of clinical risk”.

Hopson’s third and final priority for the year ahead was an amalgamation of the two former arguments: “give local systems the space and the support they need to develop STPs, and stop trying to do the top-down piece”.

“Help people and support them to do what’s needed rather than trying to force them all at a uniform pace, when to be frank, places like Manchester are five or six years ahead in terms of the work they’ve been doing,” he explained. “In other places, it was literally the first time the STP came together round the table, so the idea that they’d be able to go at the same pace seems to be just nonsensical. Let’s not try and pretend we can do this uniformly fast, or indeed with a consistent single model.”

Changing an outdated system

Also present at the panel debate, Niall Dickson, the new CEO of NHS Confederation, agreed that STPs don’t have 15-20 years to work details out and therefore need to find ways of speeding this up.

“I do think we have to recognise a reality, and it’s a reality politicians don’t recognise either: the current system is unsustainable. If we poured all the money in the world it would still be a bad system, a fragmented system – it’s still not doing what it has to do,” said Dickson.

“We have to try and sustain the system the best we can. It urgently needs more money in order to be able to do this transformation. But we cannot step off the gas either at a local or national level about saying: ‘this system has to be changed, because it wasn’t designed for the current pace of things that are going to happen’.”

The predicted doubling of over-85s in the next 20 years will also make today’s pressures look minimal as the system moves forward, he argued.

“What would I like to see? Relationships matter, clarity of vision; if we don’t have clinical engagement, this will not work,” stated Dickson. “Public engagement – real public engagement. And data is absolutely critical: we have to start re-stratifying the population, understanding what people are using the system for.”

As well as squaring up to the workforce challenge by creating “new kinds of work and new kinds of professionals to deliver it”, the NHS Confed boss underlined the need to start celebrating the new models of care emerging across the country.

“It’s a point Chris Wormald [permanent secretary at the Department of Health] made the other week: everywhere he looks around the health service, he sees innovation – but he never meets second adopters,” he explained.

“And actually, if you look at all other industries, the second adopters are actually usually the ones who do better, because they learn something from the first adopters. We need a lot more second adopters. Let’s stop saying it has to be invented here and let’s start learning from each other.”