Intense financial pressures and an ageing population have challenged NHS England to rethink the ways in which health and social care can be delivered in future. Sustainability and Transformation Partnerships (STPs) are the key strategic place-based plans that outline a new approach to maintaining financial balance while achieving an improved and integrated health care model. Here Jolanta Shields reflects on the role of partnerships and collaboration in implementing these plans by sharing some key findings from a report published this week by The Centre for Public Scrutiny – Governance of Sustainability and Transformation Plans: the verdict so far.
- The added-value and shared purpose of these partnerships needs to be clearer
- Information about the level of money available to develop and implement the plans needs to be accessible, open and honest
- There needs to be a willingness to invest time to build new relationships and develop attitudes that transcend organisational and professional barriers.
- The balance of power between central and local government matters and clarity is needed to avoid conflicts and facilitate cross sector partnership working. There is a clear role for local scrutiny mechanisms (old and new) to oversee the process.
The National Health Service (NHS) in England is facing major change. This is neither the first nor probably the last time the NHS will be reorganised. Indeed as Nicholas Timmins from the Kings Fund remarked in his 2012 study, change might well be dubbed ‘the NHS disease’. There seems to be a general consensus that the NHS has to change, as the existing model of care is no longer able to meet the demands of a growing and ageing population.
Plans and place-based action
In responding to these challenges the Government produced a set of recommendations in 2014, outlined in The Five Year Forward View, to help achieve efficiency, drive improvements and more importantly ensure that the NHS in England is sustainable into the future.
The Sustainability and Transformation Plans (recently renamed Partnerships) – STPs, are the road map for how to achieve this vision. They take a novel, albeit at times contested form, consisting of 44 geographical footprints across England to deliver place-based action. Essentially, the STPs seek to establish a more integrated system by planning different aspects of health care together, e.g. the community, acute and social care that a person may need at some point in their life. This approach offers obvious benefits and yet as the recent report by the Centre for Public Scrutiny found, the experience of working in partnerships raises a series of challenges.
The Centre for Public Scrutiny (CfPS) is an independent charity and the leading national organisation that works to promote and develop transparent, inclusive and accountable policy and practice in public services. The report draws on a series of interviews with key stakeholders from the NHS, local authorities and the voluntary sector that took place in April and May 2017. Most of the findings presented in the CfPS report confirm what we already knew or anticipated given the long history of policy interventions around health integration. Examples of this would include case management in the 1980s, ‘The New NHS’ of the 1990s that promised to replace the internal market with integrated care, or the integrated care pathways championed in the 2000s. In this sense, STPs do not mark the beginning of something new, but rather a continuation of a process already begun. Sceptics, therefore, argue that STPs are nothing more than a new name to be added to an already long list of programmes; a new label on an old bottle of wine. Whilst STPs may not be perfect there is simply no alternative, no plan B to turn to.
The CfPS report offers deeper insights, exploring what it really means to work in a multi-level governance system of healthcare and how easy any such transition to new arrangements might be, given the earlier policy preoccupation with markets and competition. The report highlights some of the key areas that appear of particular relevance to such interactions and considers some potential strategies that could prove helpful in developing and maintaining system-wide health care.
- Collaboration. Collaboration needs commitment, resources and time to develop and to be sustained. It is a means to an end and not an end point. It is a long-term process that needs to be based on realistic expectations and clear understandings of what the added value of partnership working is. In other words, why couldn’t the same outcome be achieved working alone rather than collaborating with others?
- Understanding how funding models work is crucial to joint working. Information about the level of money available to develop and implement the plans needs to be accessible, open and honest. It should explain and communicate clearly how different systems work, how they fit together and the impact of flows of money between health care organisation and local authorities.
- Transparency. Transparency could be improved by ensuring accessibility and the reliability of information through public engagement and a solid evidence base. The information in STPs should be clear to understand so that someone with no expertise in health care can make sense of what is being communicated, why it matters, and what the consequences are.
- Organisational Culture. A system-wide focus requires a willingness to invest time to build new relationships, to learn about one another and develop attitudes that transcend existing organisational and professional barriers.
- Shared Values. The key challenge comes from not knowing what ‘success’ for STPs looks like, how to work towards that and what the reasons for collaboration are. There is a lack of clarity of a shared purpose and the mutual understanding of how to achieve it in a consistent and complimentary way.
- Consultation. There is still a lack of understanding of how significant the changes proposed by STPs are. There is also an absence of various stakeholder group engagement in some areas of STP development, for instance hard-to-reach communities and young people.
- Power. The balance of power between central and local government matters and clarity of responsibility is needed to avoid conflicts and facilitate cross sector partnership working. There is a clear role for local scrutiny mechanisms (old and new) to oversee the process.
- Leadership is not just about the position of structural power but an ability to bring together different groups to achieve shared goals. It relies on leaders being able to effectively engage, nurture and support complex networks within system wide STPs.
The list is neither exhaustive nor final and there is certainly plenty of potential for embedding principles of good governance. However, irrespective of which way forward is right, the question remains: why does integrating health and social care remain so difficult? What are the factors that stop a sensible idea becoming a reality? After all, who would not rather have a service that can attend to our physical, social and mental wellbeing, all in one place?
There are clearly many potential answers to these questions (see contributions from the Kings Fund 2017 and Anna Coleman 2016), and none of them simple or right.