Points of view: challenges for STPs

8 February 2017

We asked three members of the PCC governing body for their views on the challenges facing the 44 sustainability and transformation plan areas. Our panel were Dr Phil Yates, chairman of GP Care, a federation of 100 GP practices mainly in the south-west of England, Dr Jonathan Leach, a GP and clinical lead with Redditch and Bromsgrove CCG, and Lesley Goodburn, until recently head of communications and engagement at Midlands and Lancashire Commissioning Support Unit, now an independent patient experience specialist.   

Apart from funding, what’s the biggest challenge for STPs?

Phil Yates: Involvement of GPs as providers and finding a new and sustainable model for general practice that secures out-of-hospital provision capacity as per Five Year Forward View plans. I don’t think independent contractor status for GPs is sustainable – even though much will be lost when it goes.

Jonathan Leach: Where do you start? They are huge which range from acute trusts really struggling, mental health and then primary care re-configuration.  

I’ve read a number of STP plans, which have common themes that reflect both the real challenges they face and the tasks set for them by policymakers, which are not necessarily the same thing. They include streamlining back office functions and sorting out the buildings estate – both huge projects that should have been tackled years ago.

They need to reduce secondary care beds or at least not open any more to reduce costs. The concept of “my bed is better than a hospital bed” is correct but clearly patients need to be admitted when they require the expertise, technology or support of a hospital.

Likewise all STPs recognise the need to improve primary care.  Again this is a huge project and my sense is that current plans just don’t go far enough.

Lesley Goodburn: The first challenge you face before you have any hope of dealing with the others is communication and engagement of the public, patients and key stakeholders.

The perception is that the plans have been developed in secret and behind closed doors, but most STPs will contain historical work and plans that have already been substantially shaped by the opinions and feedback from local people. These are assets that could be used, avoiding the need to involve local people in a whole set of new conversations.

Having said that, there is also a big job to do in terms of working with local authority scrutiny committees to define and agree if the changes are substantial variation and if formal consultation is required.

Is it possible to solve problems in collaborative groups and local networks without further radical structural change?

JL: Yes, and actually we have to. Structural change would distract us as it has done before. It would also create a year of stagnation before and years of regrouping and lost momentum afterwards.

LG: Yes, but only if leaders truly support the approach with a combination of initiating and sustaining sponsorship.

PY: We’ll see. Although many areas have opted for unified control totals the rub will come when individual organisations have to give up part of their budgets for system objectives. There need to be very strong incentives – both positive and negative – for this to happen. I doubt it can while [payment by results] still sucks money into the acute sector. Different financial models between organisations will become necessary.

Most people agree that primary care (particularly general practice) is essential to wider transformation. If this is true, then why are STPs struggling to engage general practice?

JL: Primarily because they have not tried or not tried hard enough.  There have been lots of meetings in large buildings, but have any actually taken place in GP premises?  If so, they are the exception, not the norm.

General practice is a distributed model and with no hierarchy, you have to tell all and often. There is no chain of command whereby you tell the chief exec who then cascades to everyone.  Plans have not taken this into account, nor have they looked at the barriers that make GPs unwilling or unable to attend meetings or engage.  

PY: STP leaders think they have engaged GPs when they are talking to CCG commissioners – but GPs are essentially providers. Most have no one organisation which can be said to represent them. Some federations are trying to take this ground but have not yet been accepted by STP leaders to be the single voice of general practice. Also GPs generally are so lacking headroom for work outside the practice that they are difficult to release for this work.

LG: STPs generally are not engaging with GPs and where they are they are taking a stakeholder approach rather than a collaborative one. In other words they recognise that GPs need to be on side and are keen to get their endorsement, but that’s not the same as working with them as equals.

Are STPs doing enough to engage patients and the public?  What more could be done to overcome fear of ‘secret NHS plans’ and other negative perceptions?

LG: We just need to be honest with people. We also need to recognise that involvement and consultation does not mean agree or disagree. STPs should recognise that there are benefits of ongoing debate and discourse beyond fulfilling legal obligations. We need to use the insight, intelligence and critical friendship that patients and the public can provide.

PY: STPs were never told to consult the public as they started their work – just the opposite. They were told to get on getting their thoughts together with a view to public engagement later. Now the STPs have been published they are obliged to go to formal public consultation on the options for service change they are proposing. STPs couldn’t consult on the plans before they were formed and they were under such pressure to produce them that there was no prospect of other kinds of engagement. But it’s easy to see how negative perceptions of secret plans with the public left out in the cold have been whipped up.

The perception that most needs to change is that STPs are only about saving money. Of course this is an important component, but at their best they’re also about changing the service model to a better, more integrated one.

JL: STPs need to be open, transparent and engage, engage, engage, which will mean listening to concerns and addressing them.  The public are not fools and however difficult we need to answer the questions they pose.

We hear a lot about the importance of leadership in STPs, what qualities will the leaders need?

LG: System leadership means you need to embrace volatility, uncertainty, complexity and ambiguity and be adaptable in your approach.

PY: Leaders will need strategic vision, doggedness, resilience, excellent interpersonal communication and influencing skills and a lot of personal and professional peer support around them – this is very underdeveloped in primary care at present.

JL: There’s a long list, but my top attributes would be: be visible and approachable, know how to listen and act, be resilient but also recognise human frailties, build a team and then delegate, and finally know your limitations. 

What gives you most cause for optimism?

PY: As I’m a cup half full man, perhaps then the recognition of the importance of care outside the walls of an institution, the appreciation that hospitals are often bad for people, and that people can be better supported at home and more locally.

Also that people are beginning to recognise that the schism between primary and secondary care is deep and has been highly damaging. It remains to be seen if some of those in positions of power in the NHS will act on this insight. I hope so – the right noises are coming from the top.

JL:  Patients. They have not changed in terms of how they approach me as a doctor and in the main they just want the best for themselves and their family. We need to harness this and to be honest we need a much better debate about what the NHS can and what it cannot do.  

LG: People who work in the NHS who are the closest to patients, the commitment and dedication of staff and the growing recognition that staff and patient experience are inextricably linked to compassion in health care. We have to focus on what matters to people.

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