Comment / All systems go

Perhaps the biggest challenge facing the NHS in England at the moment is the move to system-wide working. Sustainability and transformation partnerships (STPs) – the alliances of bodies leading the development and implementation of sustainability and transformation plans (which share the same STP acronym) – focus on place based working as a vehicle to deliver sustainable healthcare services.

The transformation required to deliver quality services that are cost effective can only be achieved by working across whole systems. This was clearly recognised at the HFMA Convergence conference at the start of the summer, bringing together the HFMA Provider Finance Faculty and Commissioning Finance Faculty.

So, eight months on from the publication of plans for each of the 44 STP footprints, what progress has been made to take these plans from the page to implementation?

The most recent HFMA NHS financial temperature check, our seventh such briefing setting out finance directors views on financial issues facing the NHS in England, asked a number of questions in relation to STPs. It found broad acceptance of the plans, with finance directors welcoming the focus they bring. It is positive to see a picture of improving relationships with over 50% believing that there are strong enough relationships with NHS providers and commissioners to deliver the required cross organisational change, compared to 20% in December 2016. 

However, this picture varies and in some cases relationships remain immature.  Further work is particularly required to strengthen relationships with local authorities, general practice, ambulance trusts and the voluntary sector.

Concerns over STP governance remain high with 68% of finance directors concerned, compared to 72% in December 2016.  Respondents emphasise that ‘STPs are still at the early stage of development, with difficult decisions yet to be made’ and arrangements are ‘large and unwieldy’. The need to develop a system-wide approach, while retaining the existing architecture of separate organisations – for many – has led to a lack of clear accountability for delivery and decision-making.

 The HFMA explored the governance challenges in its spring briefing, Emerging approaches: developing STP governance arrangements. Governance arrangements must be clear, robust and flexible and their development can be supported by understanding what is working well and what the obstacles may be. Experience is mixed, with footprints at differing stages of progress, reflecting that one size does not fit all. The briefing provides a series of questions that footprints can use - based on breaking down governance into 10 key themes – in developing their own tailored arrangements.

Speakers at the Convergence conference provided further reflections on developing accountable care systems, both in the UK and further afield. Although there is still much uncertainty, particularly around accountability and infrastructure, all examples point to a clear and agreed direction of travel towards system-wide working.

Capital funding was also a clear concern for those surveyed as part of the temperature check.  Only 1% of trust finance directors and 3% of clinical commissioning group chief finance officers believe there is enough capital to support their STP transformation programme.  Despite the recent £325m allocations announced for STPs, based on the Naylor review, there remains a large gap between what is needed and the funding available.

It is key that the NHS and local authorities work together to tackle the problem.  In June CIPFA and the HFMA published Capital collaborations between the NHS and local authorities setting out the problems that NHS bodies are currently facing in relation to capital funding and some opportunities for working together on capital projects.

The scale of transformation required and the complexities involved in making system level working a reality are not to be underestimated. Time and time again we hear that leadership and relationships are the differentiating factor between whether progress is made or not. This is recognised in NHS England’s STPs progress dashboard, with leadership being one of nine priority areas.  As at June 2017, 68% of STPs were assessed as either having established or advanced leadership. Being aware of the challenges and sharing experiences of what is working are also essential in driving change. 

As STPs continue on their journey, the HFMA will continue to provide opportunities to facilitate this sharing, starting with an STP governance survey this month; the Provider Finance Faculty’s technical forum (also in September), which explores how to make STP finance a reality; and the faculty’s director forum in October.