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Governing for transformation:
STPs and governanceProfessor Paul Stanton
Necessity is the mother of
transformation
• System already creaking: coincident austerity:demand pressures
• Historic failure to invest in prevention > growth in lifestyle associated illness
• The compounding impact of deprivation on physical and mental health
• Short termism of former NHS leadership > inadequate preparation for
profound, inexorable & accelerative demography led demand escalation
• Failure to invest wisely in mutually supportive health and social care provision
> ‘structural iatrogenesis’ (Stanton, Strategic Leadership, 2006)
• “England has an inappropriate model of health and social care to cope with
the changed pattern of ill health from an ageing population” Ready for Ageing 2014
• “People are living longer … strong association between increasing incidence &
increasing age for most diseases (cancer, heart disease, dementia etc), population
change will be the biggest driver of H&SC need over the next decades” NESHA,2008
21st Century demography led
demand escalation
• Impact on age profile of inpatient population – complex co-morbidities - not
acutely ill but with no viable discharge options
• Back loaded escalation – 1930s to ‘twilight of the post war baby boomers’
• Increase 75+ by 2032 = 57%: 2039 85%: 85+by = 2032 82%: 2039 127%
• Increase 90+ by 2032 90%: by 2039198% - more people 90+than now 85+
• Extreme local variation: 85+ by 2032: Lichfield 139%: Barking 23%
• Local population need, not central diktat > ‘fit for the future provision’
• Minimise avoidable admissions – proactive frailty management
• Optimise Ambulance contribution: & assertive outreach to care homes
• Reversing EOL in hospital deaths - “should this trend continue, fewer
than 1 in 10 people will die at home by 2030” Health Select Committee 2014
The Five Year Forward View
• “England is too diverse for one size fits all … Doing more of the same is
not an option … local choice between radical alternatives”
• “Action is needed on three fronts: Managing Demand; Delivering Care
more efficiently; Securing additional funding.
• Less impact on any one of them will require compensating action on the
other two” FYFV 2014
• “It would not be prudent to assume any additional NHS funding over the
next several years” Stephens, July 16
• Rising demand, escalating deficits, lack of ‘system wide urgency and
focus’ > STP process
• Laudable intention – profound centrally driven process shortcomings
• Support the intention – refine and strengthen the process
Sustainability and Transformation
- from planning to implementation
• “The impact of ‘place’ is complex and multidimensional … How overall
policies are translated at area & community level requires local knowledge,
history & experience that no high-level analysis can provide”. (KF 2015)
• Many STPs by passed provider Boards (and ? ‘Governing Bodies’ ?)
• Clear sighted principle based Board appraisal of STP process adequacy
and outcome relevance - an essential aspect of local ‘governance’
• “Ownership one level down – not management one level up” Carver -
Expression of your statutory ‘duty of care’ to your local population
• The calibre and independence of local STP leadership?
• Robustness of modelling and evidence base that underpinned conclusions?
• Cost saving/postponement or need led/transformative – capital costs
Sustainability and Transformation
- from planning to implementation
• Statutory public and patient involvement – ‘a problem postponed …”
• Retro fitting due process ‘The Judge Over Your Shoulder’ - ‘Real
Involvement’ – in collaboration with H&SC partners
• Promote inclusion of all NHS and wider provider and commissioning
stakeholders – the law of unintended consequence
• Local government/ H&WB Boards involvement patchy
• Primary care: Ambulance Services; mental health and learning
disabilities
• Voluntary sector – Leeds 150+ focused on frail elderly + BME sensitive
+ carer sensitive
• Fostering ‘real involvement’ of front line staff and strong clinical voices -
harnessing the creativity and the energy of those who deliver care
Sustainability and Transformation
- from planning to implementation
• Predicated on ‘fit for transformational purpose’ central regulation
• Mixed picture: Default direction – support and guidance, forgiveness
• Radical rhetoric … “We are entirely open to the prospect that you choose to
abandon [payment by results] as the currency for deciding where funds should
go…. We’re not buying emergency clicks of the turnstile anymore, this is the way
we’re going to allocate funding on a programme basis across our population with
the agreement of all the organisations involved’, that’s absolutely fine with Jim and
me” Stevens, Oct 2016
• …jumping through the same old hoops
• “We want to back leadership momentum where we find it. For the
foreseeable future – by which I mean probably the rest of this parliament –
this supplements rather than replaces the pre-existing statutory
accountabilities.” Stevens, October 2016
The priorities for provider Boards
• Pragmatism – STP key in a funding lock
• Political adroitness – understand concerns of the blockers and the allies
• Measured altruism –
• “My organisation, right or wrong, is not what’s required from a new generation of leaders”’
Stevens, February 2015 – building ‘informed trust’
• “Salus populi suprema lex esto” [Let the good of the people be the highest law] Cicero
• “The startup of a new form of governance needs careful consideration and will take time”
Dalton, August 2016 - building ‘informed trust’
• Maintain unflinching grip on intra-organisational safety, quality & cost effectiveness
• Address Type A* problems and push forward with aligned improvement
• Type A = A problem whose resolution lies in the hands of the organisation itself: Type B = A problem
whose resolution lies in the hands of those who may be subject to influence; Type C = An insoluble
problem i.e. an unpalatable but inescapable fact of life.
Prioritise Type A; keep energy spent on Type B under review and if others prove
beyond influence, re-categorise problem as Type C. Don’t waste time on Type C!
The priorities for provider Boards
• “The application of collective wisdom to complex uncertainty” Stanton 2008
• A ‘risk sensitive’ Board culture – neither ‘risk reckless’ nor ‘risk averse’
• “In times of major turbulence in external environments, a Board’s collective risk
oversight must be strengthened. Different & potentially much more difficult
issues arise in the identification and measurement of risks. Past experience is
an uncertain or potentially misleading guide” Walker, 2009
• Competence, creativity, courage, currency and CLARITY
• “Excellence, is never an accident.
• It is the result of high intention, sincere effort, and intelligent execution;
• it represents the wise choice between many alternatives …
• choice, not chance, determines your destiny” Aristotle
