The King's Fund examine STP planning process

policy digest

29 / 11 / 2016

Sustainability and transformation plans in the NHS: How are they being developed in practice?
Then King’s Fund, November 2016

This report from the King’s Fund explores experiences of the STP planning process from four different STP footprints. The authors found leaders were invested in and enthusiastic about the concept of STPs, but had found the planning process tricky and were concerned about the realities of implementing their plans. The report recommends that the process can be improved through strengthening involvement in the process for key stakeholders, strengthening STP governance and leadership and providing more coordinated national leadership.

The report begins by summarising the development process for STPs so far. The plans, introduced in the NHS planning guidance in December 2015, encourage local organisations to come together to develop ‘place-based’ plans for services in their area. They were asked to address three key concerns: improving quality and developing new models of care; improving health and wellbeing; and improving efficiency of services. This qualitative report is based on interviews with NHS and local government leaders involved in developing STPs in four different, representative, localities.

Looking at the initial set-up of the STP process, the report notes that STP footprints were originally intended to be locally defined, with STP leads nominated by the STP area. In reality, the report finds that the level of local determination varied. In several areas locally agreed footprints were rejected by national bodies, who then created larger footprints that made less sense to those involved at a local level. In some cases these footprints cut across existing plans and priorities. NHS England and NHS Improvement also “played a significant role in selecting STP leaders”, in some cases overruling local leaders’ choices.

Governance and leadership is identified as a significant issue for STPs, both during the planning process and for future implementation. One of the most fundamental issues has been the mismatch between existing NHS accountability arrangements and the aspiration to collaborate. NHS providers “face strong incentives to improve their organisations’ own performance and only weak incentives to collaborate”, with no clarity on how organisations will be held to account as part of a wider STP. This governance issue can only become more challenging as the process progresses. 

The report goes on to look at levels of involvement in STPs. Beginning with NHS organisations, it notes that the most actively involved NHS organisations have been CCGs and NHS providers, but this engagement is described as “shallow”, often reaching only those directly involved in planning groups. GP involvement had been difficult to secure in the four study areas, with CCG involvement often seen as a proxy for CCG involvement. Clinical engagement has been described as weak, with tight timescales blamed for making proper clinical engagement unfeasible. Local authority engagement is shown to be very variable, with local authority leaders in some areas feeling that they may have been informed but not actively involved in development, or that their involvement had been limited to certain elements of the plan rather than the full picture. The biggest lack of involvement noted is that of patients and the public. It is noted that doing this properly within the timescales would have been “impossible”. National NHS bodies also hold responsibility for this, after asking for draft STP details to be kept out of the public domain.

Discussing the management of the process at a local level, the report notes that STP areas had not received any additional money to fund development of their plans. Substantial investment had however been needed, to create new teams, fund new roles and in many cases hire management consultants. One area described their STP programme as “nowhere near sufficiently resourced”. Management of the process had also been confused by national planning, with very tight deadlines a particular concern. Difficulties were also created by delays in providing planning guidance and templates and changing expectations for plans. It is also noted in the report that STPs were being developed alongside a number of other transformation programmes, including vanguards and devolution plans. The relative priority of these initiatives was often unclear and leaders in some areas were “concerned that future funding for their local transformation work would now be reliant on STPs”.

Different areas have worked in different ways to define the priorities for their STP. The authors found that acute hospital reconfigurations were often “high up the agenda”, with many leaders concerned that primary and community services and the wider determinants of health were not being given enough attention. This chimed with concerns that “broader priorities were often getting lost in a drive to achieve financial balance”. The financial templates submitted to national bodies set out how local areas would achieve financial balance for NHS finances, however the authors found a lack of confidence at a local level in the accuracy of these assumptions and the analysis underpinning them.

The study areas were overall critical of the management of the STP process at a national level. Common factors included guidance arriving late, lack of clarity on the number and importance of priorities, and a lack of knowledge of the future stages of the process. One leader is quoted as saying that they were “trying to do a good job in spite of the centre’s approach rather than because of it”. The lack of alignment between NHS England’s national and local teams was another challenge, as was tension between the approaches of NHS England and NHS Improvement. There was a feeling that national bodies increasingly valued closing financial gains above all else, with changes to acute services seen as central.

The key concern for many STPs going forward is how they will actually implement their STP. There are questions raised around skills and resources, particularly the need for upfront investment (both capital investment and funding to double-run services). The report conveys the sense from many leaders that “the real challenges were yet to come”.

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