Governance as a driver for STP implementation | Susanne Hasselman

Susanne Hasselman

Clinical commissioning group lay member Susanne Hassleman considers seven burning questions sustainability and transformation plan footprints must tackle to ensure governance is the driving force behind their plans.

Sustainability and transformation plans (STPs) are a crucial way forward for cementing place-based systems of care and changing the way the whole system works together to deliver high-quality and sustainable health and social care services. 

As a clinical commissioning group (CCG) lay member, I’ve been asking a number of questions about how governance will drive STP implementation and ensure the best possible decisions are made to support the needs of each population. 

Good governance is the cornerstone of effective and faster decision-making and transparency. It ensures that we have an efficient and effective organisation and are working in the interests of patients, the public, and taxpayers by making the right decision at the right time in the right place. 

The complexities inherent in achieving each STP vary considerably. In some areas, CCGs, providers and local authorities have been working on similar plans for a number of years, and therefore developing an STP has been a logical extension of their current strategies. 

This is in contrast to other local systems where STPs have been used as a means to bring different stakeholders to the table and start discussions about how local health and social care systems can work better together, and how to use resources more effectively across a wider geography. 

As each footprint works to finalise their STP operational plans, the following key considerations are ones we all need to keep in mind to ensure that governance is the driving force behind the plans and supports effective decision-making, throughout the NHS, that’s accountable to patients and the public. 

Accountability: Who will be accountable for the delivery of STPs?
Most STPs have been organised by consensus. This, I would argue, may be appropriate for developing plans, but will not be acceptable for their implementation. 

Accountability is key to the management of performance and delivery of the STP objectives. Although individual organisations will still remain accountable for their own plans, who will be accountable for the delivery of the STP? And how do the statutory duties for each CCG, trust, etc, relate to the broader roles and responsibilities within the STP arrangement? 

Having an understanding of how organisation-based accountability structures connect and intersect with the broader footprint will be crucial for the effective delivery of each plan. 

Patient and public engagement: How do we ensure the needs of patients and the public are at the heart of STPs? 
Governance arrangements must ensure that the best interest of our patients and the public are at the heart of decision-making, and that the perspectives of our local communities are considered at every phase of development and delivery. We can achieve this by involving clinicians, CCG lay members and trust non-execs, and by having wider engagement with local politicians and the public. 

When significant change is required, we must bring local populations with us and this means, in the first instance, their representatives. These are local politicians, clinicians and sector-specific voluntary organisations. Their early involvement in STP planning and delivery will bring long-term benefits. We disregard them at our peril. 

Local government: Are we building the right relationships within STPs? 
STPs are about integration – social care and health integration, closer collaboration of CCGs, and bringing together responsibility for the commissioning and provision of services within innovative arrangements. As such, building relationships across the NHS and local government within each footprint is paramount for STP delivery. 

Governance structures within STPs must support effective working across commissioners of both health and social care and help organisations make joined-up decisions for the patients and populations they commonly serve. 

Organisational structures and efficiencies: How can STP governance help organisations work most effectively together?
There is an inherent tension between making decisions quickly to speed up transformation and making the right decisions openly and transparently, with the support of our main stakeholders in the system. This means that we need a governance structure that is streamlined but that allows us to communicate well with individual trust boards, CCG governing bodies, and health and wellbeing boards. 

It is incumbent on those who represent these individual organisations to ensure the channels of communications are open both ways to enable feedback and comments to be gathered, and information to be disseminated. 

Good governance will help us form closer working relationships and identify areas where we can share resources to avoid duplication, and align incentives so that all arms of the systems are united under common goals. This will mean a cultural shift from maintaining individual power bases to a more collaborative way of working that supports joint decision-making. 

In the end, that is how we will serve our patients best and possibly even create a better working atmosphere – from kicking each other to learning to dance together.

The clinical voice: How can STPs preserve the clinical voice? 
The real – and hopefully lasting – success of CCGs is the impact clinicians have had on the development of health services and the running of CCGs. Let’s face it, without the clinical voice in everything we do, we will not succeed. 

It is therefore essential that we enshrine in all STPs clinical input and ensure that the clinical voice sits equally alongside the managerial voice to drive service transformation and improvement.

Independent scrutiny: What role will lay members and NEDs have in delivering STPs? 
The centre has left it open what STP operational structures will look like, leaving it to each footprint to determine the form their governance structures will take. No matter how governance structures develop, the non-executive community – whether provider NEDs, CCG lay members or elective local authority members – should be represented throughout the decision-making process to ensure that scrutiny, transparency and decision-making remains firmly in the interest of the public and our patients. 

Audit and assurance: How can we make assurance processes more effective within an STP?
What have we already learned about effective assurance systems that can be applied to STPs? I have chaired clinical governance committees for a primary care trust (PCT), a PCT cluster and now two CCGs in a joint committee. I have seen real benefits from gaining assurance across a wider PCT cluster area that enables benchmarking and learning. 

However, within CCG structures, we achieve closer links with our providers, primary care and independent nursing homes because we are more connected with local stakeholders. STPs should encourage us to review the benefits of these different systems and support new ways of working that deliver place-based quality assurance, wider footprint benchmarking, and sharing of learning, as well as forge a closer link with local authorities and their overview and scrutiny function. 

‘Shared control totals’ have also featured prominently in discussions on STP finances. If we are contemplating this, we have to have an STP audit function to monitor the financial integrity and probity of financial flows, the internal control mechanisms and risk management. 

To support this shift towards more integrated finances, there are a number of joint actions we can take across organisations to share best practice (such as cost improvement plans and quality, innovation, productivity and prevention) and align audit functions. For example, joint internal audit reports commissioned across organisations may be a cost-effective way of supporting governance. 
Governance is the conscience for every organisation, and as we move away from organisational strategy to new place-based ways of working, we need to make sure our ideas for governance follow and reflect the new realities of the NHS. 

Done well, governance will assure that STPs are accountable to the populations they serve and that the best possible decisions are made at the right time. If governance isn’t handled proactively, STPs will fail to live up to their potential and leaders will struggle to establish effective ways of working, which are needed to translate plans into action. 

With so much at stake, we must continue to ask ourselves these questions and make sure that governance does not become a box-ticking exercise for STPs but the driving force behind everything we do, and must set out to accomplish for patients and our local populations.

Susanne Hasselman is a lay member at NHS South Eastern Hampshire Clinical Commissioning Group and chair of NHS Clinical Commissioners’ Lay Member Network. Follow her and the network on Twitter @SusanneHas @NHSCCPress

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