Comment / STP governance arrangements – what and how?

There is broad consensus that the NHS needs to transform service models and patient pathways to provide sustainable services that are integrated around patient needs. Sustainability and transformation plans (STPs) should provide the route maps for this transformation. 

While STPs carry a big burden of expectation, they also represent a huge change in working practices. They mark a move away from a focus on individual organisations and market competition towards system working. Complex, with a large number of stakeholders, each STP also starts from a different point in terms of local relationships. 

The recent HFMA NHS financial temperature check sought an initial view of STPs from finance directors. There was broad acceptance of the validity and usefulness of the STP process, and agreement that the planning process had led to valuable strategic discussions to gain acceptance of essential change proposals. However, concerns were raised over governance, risk management arrangements and the perceived lack of aligned regulation from NHS England and NHS Improvement.

On the back of this, the HFMA has been exploring the emerging governance arrangements and how they support the delivery of financial sustainability and transformation in the NHS. The research has focused on what is working well so far, what the perceived barriers are and what each area should consider in developing their own governance arrangements.

Where STPs are beginning to work well, common factors include improved relationships, a focus on place, a clearly articulated story, commitment at all levels and transparency. In my view it is ultimately the drive of the people involved and quality of relationships that will make it work, or not.

The scale of the challenge is not to be underestimated and a number of barriers remain, some of which require a change in mindset and culture and some structural change.  These include the current financial position, historic competitive environment, complexity of structure, working with local government, capacity and engagement.  

Perhaps the most commonly cited barrier is the conflict between organisational and STP accountability. Nearly two-thirds of finance directors in the HFMA sample said they would prioritise their own organisation over the STP in meeting objectives and more than eight in 10 feel the regulatory system needs to change to support the delivery of STPs. If STPs lead to local dissatisfaction, it is unclear where the pressure and redress will fall.

STP governance arrangements are currently a work in progress and each footprint needs to determine at a local level how to co-ordinate effectively, both in the short and longer term. STPs need to be more than just plans and the supporting governance arrangements need to be streamlined enough to ensure progress, but at the same time allow for full engagement and consultation on issues.

On the whole, the published STPs are light on governance arrangements. Most include a delivery structure – typically a strategic board and delivery board overseeing workstream groups and supported by a programme management office. However, the level of detail provided on how the arrangements will be applied in practice, particularly as STPs move from planning to implementation, is mixed. 

Each area must agree what the governance structure will look like and how this will work in practice. The structure can be seen within a spectrum of approaches including planning forums, delegated decisions, devolved budgets and formalised partnerships. Each mechanism is appropriate to different situations and times. The HFMA will publish a briefing in February with further detail on what questions STPs should be asking themselves as they develop their governance arrangements. 

To navigate the many complexities and maintain momentum, governance models must be clear, robust and flexible. During 2017, visions will need to turn into practical reality as STPs take shape in a financial and care context that is already very demanding. This is likely to test governance arrangements – as will the involvement of the public as service and structural changes are subject to consultation. 

Some arrangements will stand up to this test better than others. However the prize – more integrated and sustainable services – is so important that the NHS will need to learn fast from these early forays into system-wide governance. If we identify governance models that work well, we will need to replicate this across the country. At the same time, we will need to be vigilant for any barriers in the way of system-level working becoming business as usual.