One and one doesn’t make STP

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Change is in the air…again. I’ve just got back to The Good Governance Institute after a week half term (a post Brexit/school half term/poor exchange rate/limited hols to Northumberland since you ask) to find that Mr Stevens has announced a radical re-shift in the way that health and social care will be delivered.

The purchaser/provider is dead in the water. Arise Sir ACO and Lady MCP to rescue the parlous financial state of the service and dramatically transform care.

Or so the story goes. Of course in reality it isn’t anything like this. Over the last few months we have been working with several of the new models of care and the emerging collaborative arrangements to help think through how these can be structured, organised, arranged and ultimately delivered. My biggest fear is that we fall into the age-old trap of seeing STPs and ACOs as the vehicles that drive out cost and create efficiencies; and this becomes the mantra that the Treasury and central government buy into. That is not to say that collaboration doesn’t bring big opportunities, and indeed many of our partner organisations have created hefty business cases that demonstrate this, but money alone will not be an incentive to make this work. In fact, in many areas, taking money out the system will need to come second to investing in more services closer to home, providing the opportunity for longer term reduction in acute spend.

What really concerns me is that policy does not appear to, yet, strongly recognise that any collaboration requires not just financial alignment but cultural and behavioural alignment. I have been going on for the last year now about the need for us to look at the ‘Dynamics’ of governance and as the STP/ACO areas start to get past the first business cases and position papers it is interesting to see how quickly the alignment of personal incentives becomes an issue – but should we be surprised by this?

It is an obvious and natural position for any person (or organisation) to take – we are asking Boards who have had organisational sovereignty drilled into them for the last 20 years to suddenly give this up, join into something bigger and more expansive. A key issue with this being that we are asking them to do that without clarity, without transparent plans, and to assert themselves into a world of trust, integrity and belief that this will work. We should not hide away from this fact, we should own it, shout it loud and make it ok not to be clear, not have all the answers, not to know every detail of the process. The learning comes in the journey too and this is a process we must strive to protect.

Which is why leading with financial sustainability is only part of the picture – sustainability also needs clear leadership, trust, ownership and above all, a real belief that at the end of all of this the NHS will actually be better for it.

Even as an ex PCT Director, I happen to believe that it will be better for it – but lets not kid ourselves that we are asking our leaders, our Board, our organisation to change behaviours and approaches they have been managed by for most of their careers.

David Cockayne is Managing Director of The Good Governance Institute; and occasionally misses his days as a PCT Director

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