NHS transformation plans are beset by infighting

Behind the vision documents and targets, what is really going on inside the sustainability and transformation plan (STP) process?

A clinical commissioner outside one meeting was overheard asking: “How are we going to shaft the acute?” But elsewhere there is a growing recognition that old-style NHS infighting is a big part of the problem. For there to be any chance of ensuring services have a viable future, local leaders are increasingly trying to understand what skills they need to run health and care as a system.

To fathom how the people immersed in these tough negotiations are behaving, and what they need to do to think and act as leaders of the whole system, I interviewed 10 senior health and local government managers for the Institute of Healthcare Management.

The resulting report, Swimming Together or Sinking Alone, reveals frank assessments of the difficulties they are encountering, alongside their insights about what needs to happen.

The impulse to work together is strongest in areas where they know they face a crisis, while some of the most fraught discussions are where everyone is just about managing – inspection results are acceptable and financial targets are largely being hit. Like a drunk struggling to stay upright, there are worried that the slightest move will tip them over.

As leaders from different organisations edge closer, the thought processes can resemble the “prisoner’s dilemma” – the optimum outcome requires everyone to work together, but an individual might benefit from breaking ranks. As one manager put it:

They are thinking, ‘What if we behave as doves and they behave as hawks?’ They are worried they might … be taken advantage of

The big message is that systems leadership depends on trust. Without it there is no system, just individual institutions manoeuvring and negotiating. Trust means shared ownership of problems and solutions, an appreciation of the value of all the players involved, and authentic leaders behaving the same in public and private – a lesson our “shafting” clinical commissioner would do well to appreciate.

A few STP groups have recognised that they need to invest time and effort in their own organisational development, because simply sitting in a room together and expecting understanding and trust to develop won’t work: “Those who learn together, work together.”

Health managers often find working with local government baffling and frustrating. Difficulties included rivalries between councils and nervousness around this May’s local elections.

But NHS leaders are coming to understand that building political support can be critical in shaping and driving through change. In the current financial climate, local government politicians and managers are constantly making tough calls on local services, so they know what it takes to win public acceptance or ride out controversy.

Building a relationship with local government means listening, not asking them to rubber-stamp your plan. Good local politicians see the wider picture – what really is driving demand, why people really turn up to A&E – because they spend their lives talking to local people and have insights into how those issues might be tackled.

Worryingly, STPs have given little thought to engaging with staff and patients. Since the whole process is ultimately about getting clinicians to work differently, STPs are risking serious resistance to their plans unless clinicians shape and lead it.

Perhaps the biggest threat to STPs is management overstretch. Virtually every part of the country has serious concerns about whether they have the skills and capacity to deliver these plans. As well as doing their day jobs, managers and senior clinicians will have to spend many hours winning support and working through the details of delivery. Project management skills are in short supply.

Difficulties will inevitably be exacerbated by pressure from the central bodies to deliver change more quickly the local teams can manage.

STPs are exposing the shortcomings of decades of silo working. If local managers can work as system leaders focused on the needs of communities rather than organisations, they have a chance of escaping the relentless cycle of crisis management and short-term fixes that fails patients and demoralises staff.

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NHS transformation plans are beset by infighting