Sustainability and Transformation Plans: are we taking people on the journey?

November 7, 2016

In my work I am lucky to regularly talk to people about the challenges facing health and social care. As part of a learning session I deliver we spend time looking at the context for change. Unsurprisingly when asked the question, ‘’why is the health and social care landscape changing?”, people respond with a range of replies, including; lack of money, politics (including but not the same as politicians and policies), demand and supply, and a response to failures such as Mid Staffordshire.


Within the debates that follow, we unpack what that means in reality from the perspective of real people living real lives. A sense of the discussion that emerges includes, is it a lack of money or are the existing funds deployed in the wrong places? People often consider their position as a tax payer, or in other words a co-owner of one of the most revered social welfare systems in the world. Would the society of today agree to a system that means one person can ‘pay in’ everyday and never need to use the service, whilst their neighbour may never ‘pay in’ but need to use the services everyday?


People are often taken aback when they realise that as the NHS was created by politicians it can be un-created by them as well. That a political ideology of a health and care system that is organised on commercial market based principles has led to an NHS that is now managed and provided by 1000’s of organisations delivering products and services via a contract under ‘brand NHS’. That the GPs who hold the power in terms of making decisions about how millions of pounds are spent are essentially private providers who as a profession have never been fully within the NHS family. They are usually taken aback when they realise those same GPs are also responsible, in many areas, for paying for and delivering their own services. Most commonly, given some time to reflect, people feel a little uneasy about this situation and are not sure how it came to be like this without them realising.


Over time, people are more and more familiar with the mantra of a growing older population with increasing levels of complex long terms conditions that are expensive and difficult to manage. People can see that as patients we have come to rely on a system that has favoured expensive medical intervention over more community based, social responses. They tend not to understand why less and less money is being made available in the community and generally don’t understand how to access options other than A&E when they can’t find another suitable alternative. They are less tolerant of why we are not prepared for the inevitable knock-on effect of better technology, drugs and access to information and treatment and they find it difficult to understand why the increase in demand has come as such a surprise.


Discussion about system failure and the impact of this is on people is another key driver for change and often a difficult one to talk about. People can understand the principles of competition and choice, such as supermarket wars, but what they find unpalatable is if these concepts are deployed when lives are at stake. When a hospital goes under you can’t just take your business elsewhere, there is more at stake than cheap beans. Talk often turns to the warning signs identified by the Mid Staffs inquiry. Including:

  • A focus on doing the system’s business – not that of the patients
  • an institutional culture which gave more weight to positive information about the service than to information capable of implying cause for concern
  • standards and methods of measuring compliance which did not focus on the effect of a service on patients
  • too much tolerance of poor standards and of risk to patients
  • a failure of communication between the many agencies to share their knowledge of concerns
  • assumptions that monitoring, performance management or intervention was the responsibility of someone else;
  • and a failure to tackle challenges to the building up of a positive culture.

The realisation that many make in considering these warning signs is how unremarkable, obvious and predictable they are when set against the other drivers for change[1].


New in post, Simon Stevens set out his Five Year Forward View in June 2014. It aimed to address the issues of reducing resources, rising demand and the potential for system failure. It describes a vision for increased efforts to prevent ill health, more integrated services bringing primary care, hospitals and social care together, putting patients more in control, creating local health communities, re-designing urgent and emergency care, investing in primary care and having a much greater focus on leadership. The political response for new models of care was adopted from an American approach and announced by Jeremy Hunt in August 2014 with a request for CCGs to become Accountable Care Organisations. This was followed in January 2015 by NHS England inviting 50 CCGs to take up the Vanguard initiative with the aim of creating blueprints and inspiration for the rest of the health and care system. In January 2016 the NHS shared planning guidance required health and care services to be organised around the needs of populations with a request for 44 Sustainability and Transformation Plans (STPs) to be developed.


In April 2016 NHS Improvement was created, bringing together a number of regulators under one umbrella it is tasked with being responsible for overseeing and providing support to Foundation Trusts, NHS Trusts and other independent providers that provide NHS funded care. This week there are further calls from Alan Milburn in his role as an advisor to Price Waterhouse Cooper to go one step further and merge the newly formed NHS Improvement with the 3 year old NHS England and look to create new local democratic structures.


In reality STPs are likely to be the start of the next phase of change, with new arrangements and organisational structures to follow. Just over 3 years in, could we be seeing the end of Clinical Commissioning Groups towards Regional Care Groups?


What is less clear is how each of these initiatives builds towards a cohesive strategic vision for change. Each seems to have been developed within a loose set of ideas but there appears to be no obvious narrative to link them.


Even more difficult to determine is the role that people as users, tax-payers and co-owners of the NHS are playing in helping to address the shared issues that lie ahead. At present most STP’s are under embargo before publication. The short timescales have not really allowed for people and professionals to work as equals in the consideration of new models of care, despite increasing rhetoric about the importance of the voice of patients and the public and the value of ‘co-production’. In reality most residents within defined ‘footprints’ have no idea what an STP is, haven’t been asked to provide a view and are unaware what is in it or what is being proposed for the future of their health and care services.


It is useful to reflect on some basic change management theory to explore the case for engagement of real people in the leadership of effective change across health and care systems from the very beginning. The Beckhard-Harris Change Model says that resistance comes from people within the changing environment, not the organisation itself and that one of the most important reasons for reluctance for change is a failure to engage the participants in shaping the vision and the development of a strategy, instead forcing the change upon them leading to resistance. The model proposes that organisations do not resist change, people do. And although they resist change for highly personal reasons, there are some general principles to consider in the face of the context for change in health and care.


According to Beckhard and Harris, people resist change when they:


  • believe they will lose something of value in the change; in my experience people often talk of being attached to the buildings and people associated with their care, they value their familiarity, consistency and the ability to understand where and who they are, they worry that they will lose the services and people they value through change.


What can be done to have this discussion, to hear their fears, provide reassurance and agree a way forward?


  • lack trust in those promoting or driving the change; the media, political campaigns and previous experience of being kept in the dark and seeing changes that have a negative impact rather than a positive one mean that people often speak with suspicion and distrust about changes that are being implemented.


What can be done to open up an honest dialogue, to develop a relationship based on trust, where commitments are followed through and where difficulties are shared and options and solutions developed together engendering a spirit of trust and truth?


  • feel they have insufficient knowledge about the proposed change and its implications; a lack of investment, time and energy to engage populations in information sharing and debate about change leads to people not understanding why decisions are being made, people talk about ‘being done to’ rather than ‘done with’.


What can be done to ensure people are informed and knowledgeable about the issues faced, how can they be involved in the debate, able to understand the implications and options and given the opportunity to share in the responsibility of designing a better future?


  • fear they will not be able to adapt to the change and will not have a place in the organization; Beckhard and Harris talk about a place in the organisation, with the NHS it is important to consider who is in the ‘organisation’? As tax payers, funders and co-owners, the public are part of the wider eco-system of the organisational ‘team’ and therefore this principle applies equally to them as it does to staff. As users and receivers of services patients are also arguably part of the fabric of the NHS organisation. This creates an interesting dual role for patients and the public, for we are all both, and in both cases have a vested interest in whether we can adapt to the change and whether there will be a place for us in the organisation in future.


How can we help people to feel open to a different future, how can we shape the future with people and ensure that people continue to feel they know and understand the value of their place within the organisation of the NHS?


  • believe the change is not in the best interests of the organization; if we identify the NHS as an organisation that is a system for health and care, funded by taxation and free at the point of use, then we naturally assume that any change will be taken in the best interests of its funders and users. The NHS as an organisation is part of the fabric of our national culture and when people believe it is under threat or that change is not in the best interests of its future they can become defensive, active and resistant.


How can we better understand the interests that people have in the NHS as an institution? How can we recognise the attachment people have and the value they place on it as a part of a national culture and heritage.


  • believe they have been provided insufficient time to understand and commit to the change; there is never enough time, deadlines are short, budgets are tight, decisions need to be made and its difficult, but not half as difficult as it will be if people are rushed towards a future that they don’t understand. The scale and type of change required to meet the evolving health needs of the future won’t be achieved purely by policies, plans and timelines. It will require people to develop a different relationship with their health and the systems of health and care. There is a huge resource and capability available amongst the 64 million residents of the UK.


How can we open up a different conversation with people about the future, how can we define time in the context of what needs to be achieved, how can we stop being busy and make better use of the time we have available?


Beckhard and Harris, Kotter, and Yukl all come to similar conclusions, that by far the most effective method of leading successful change is to engage stakeholders in shaping the future, in assessing the need for change, in creating a vision of a better future, and working out how to achieve the vision. I wonder then, why we are still looking at plans and proposals developed without establishing a partnership with people, patients and the public that means that we can really travel the journey together.

“I may not have gone where I intended to go, but I think I’ve ended up where I needed to be”. Douglas Adams


Jessie Cunnett, Director Patient and Public Involvement Solutions

November 4th 2016

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