Alumni story / Clearing the STP obstacles

Final sustainability and transformation plans (STPs) were published in the middle of December and now we can clearly see the gap between the ambition and reality.

My assessment is that some of these plans ignore long standing issues. In some cases there is a lack of detailed quantitative analysis and all important failure to close completely the financial gap they are in part looking to address. Given that these plans were produced prior to the announcement of the non-recurrent adjustments to clinical commissioning group allocations for the next two years, the gaps could even be larger.

The NHS is facing an unprecedented challenge to its financial sustainability and its ability to cope with ever increasing demands at the established service quality levels. These pressure are set to increase over the coming years as growth slows and inflation climbs.

The NHS is clearly facing what some academics and commentators term a set of ‘wicked problems’. Establishing multi-organisational and professional frameworks is, according to current academic consensus, the best way to manage these issues, so STPs should be the answer. But turning the theory into reality is a major challenge.

I think there are two major obstacles to success. The first is the legislative and regulatory framework. NHS Improvement, NHS England and the Care Quality Commission all focus on organisational performance. All the executive directors I have spoken to frankly admit that they feel they are measured on their organisation’s bottom line first and foremost. So this is where they concentrate their efforts rather than the aggregate STP patch performance.

NHS organisations are being asked to work counter to the recent legislative framework. Until recently in many STP patches, organisations have been in direct competition and are finding it difficult to build trusting relationships in the short time allowed.

The second major issue is process. Successful change requires managing and research has shown that there are a number of key steps that must be performed in sequence – from setting out clear, shared objectives through to agreeing resources. There is clearly a case for change. But in many patches the guiding coalition isn’t sufficiently powerful and effective as organisations’ boards protect their autonomy and are reluctant to delegate decision powers.

The key issue though is the lack of a compelling vision. I believe this is due to a lack of analysis. The NHS is faced with a massive financial turnaround problem with no additional resource to implement the change or undertake double running and a diminishing capital fund. In this context it must find those changes with the best return on investment.

Most STP plans seem to pick from a menu of ideas with no incisive analysis as to whether these represent the best value.  Instead, I think they should focus first of all on the patient streams that consume the greatest resource. In most cases these will be frail patients (three or more long term conditions), with the greatest spend being multiple non-elective admissions following a fall or collapse.

In my experience, most of these patients never have a definitive diagnosis as we have only limited understanding of how their multiple conditions and dozens of medications interact and impact their physiology. Most though recover in a few days and could be discharged with modest community support.

My research suggests that many of these patients will be admitted whatever community services exist because they need access to hospital diagnostics to rule out something serious. So, for these patients, rather than concentrating on admission avoidance, the focus should be on getting them out of hospital quicker.

To make positive steps in the right direction, there needs to be a far more rigorous analysis and understanding of patient demand and flows. This understanding then needs to be coupled with complete engagement of clinical staff in redesigning pathways.