STP0002

Written evidence from Mr John Popham

1                     Who the authors are and their reasons for making this submission

1.1              This written evidence is submitted by several Chairs and other members of Patient Participation Groups (PPGs) in North Somerset in their personal capacities.  Our names and addresses accompany this submission.

We belong to a PPG network facilitated by North Somerset Healthwatch.  We work to support our GP Practices, Healthwatch and the local CCG to help improve the quality of health and social-care services and to disseminate information to PPG members.  We responded to our local STP as part of the initial consultation process and have given considerable thought to the problems facing the NHS.

Having held positions of responsibility in our careers, including managing projects to deliver organisational change, quality improvement and better customer servicing processes, we believe our collective experience has given us a mix of skills that enables us to comment on the practicality of the STP proposals and to suggest where changes of approach are needed. Having no commercial relationship with the NHS or local authority care services, our views and concerns expressed to the committee are unconstrained.

1.2              It is a matter of concern to us that most citizens are still unaware of the changes proposed and how they might impact on them.  We strongly believe that the lack of open and effective communication with citizens and the failure to involve them and some groups of key players in the process thus far has been a huge mistake that needs to be put right. 

The support of all key players involved in providing the delivery of services and of the public (who fund services via charges, tax and National Insurance) is essential to ensure the proposed changes have their active support.   

We believe STPs to contain many worthy ideas.  Our main concerns are the muddled objectives, lack of supporting data and published plans for translating ideas into actions and the virtual non-existence of specific proposals for the enabling actions that our experience tells us will be needed for STPs to be implemented successfully.    It is our belief that, as they stand, the STPs we have seen are doomed to failure.

The names and addresses of the signatories to this submission in alphabetical order:

John Gowar, Batchworth, Long Lane, Redhill, Bristol, BS40 5SE

Geoff Mathews, Butts Cottage, Butts Batch, Wrington, North Somerset, BS40 5LN

John Popham, Apple Acre, Star, Winscombe, Somerset, BS25 1QF

Julian Simcox, 6 Southern Way, Clevedon, North Somerset, BS21 7UL

Pam Yabsley,  81 North Street, Nailsea,  BS48 4BS

2              Executive summary

For STPs to succeed the following are needed:

• An exercise to ‘take stock’ of the roles, responsibilities and relationships of the current bodies  involved in delivering health and care services to define and clarify these as the starting point for change.
• Actions to stabilise services so that staff are fully able to participate in making changes without having to ‘firefight’ at the same time.
• A clear and realistic statement of objectives distinguishing between short and longer term measures to deliver sustainable service improvements.  
• Transparent and effective communication with citizens and their involvement in all stages of the change programme.  
• Testing of all proposals for change to ensure the benefits claimed can be substantiated before implementation commences.
• Revision of future funding mechanisms for Health and Social Care services so service changes can be designed to be sustainable within this framework.
• Management of the pace of change at a rate that all concerned can cope with without being overwhelmed.
• Changing the overall emphasis of governance of the Sustainability and Transformation Programme away from centrally prescribing solutions in favour of defining issues to be addressed locally in ways that suit local needs.

3              Key points we wish to make

3.1              Defining the starting point for change

We were not able to find data in the public domain to provide clear guides to the roles and responsibilities of the various bodies that make up NHS England and the various bodies that provide the Local Authority and Voluntary sector care and support.  We would advocate an exercise to ‘take stock’ of the roles, responsibilities and relationships of the current bodies  involved in delivering health and care services to define and clarify the starting point for change.

In our experience this exercise will also highlight gaps, duplication, overlaps and other opportunities for improvement.

As work progresses such a guide would help those planning changes to take account of alterations to roles, responsibilities and relationships needed as part of the change process.

3.2              Actions to stabilise services

To date the focus on cost reduction has put short term budgetary issues before the need to rethink how Health and Care services are delivered.   

Until the mismatch between funding provided and costs incurred is bridged progress on longer term issues is likely to be inhibited and ‘crisis’ management rather than service redesign will continue to be the priority.

3.3              A clear statement of objectives

3.3.1              STPs would be better renamed ‘Sustainability and Transformation Programmes’ to reflect that as they cover a range of initiatives, some short term, some longer term, some still at the ideas stage and some ready for implementation.

3.3.2              Based on our experiences of managing organisational changes we believe STPs will fail to deliver unless they include:

• A vision of what health and care services will look like after the longer term changes (including revised roles and responsibilities) to act as guide for those making changes.
• Setting out clear and believable measures of success with information on why these were chosen and how they were derived.
• The training and equipping staff to look continuously for opportunities for further improvements.

3.3.3              The emphasis of the current NHS model is on treating illnesses rather than prevention. STPs do seek to encourage lifestyle changes with a view to prevention.   This longer term shift of emphasis needs to be kept at or near the top of the statement of objectives.

3.3.4              Currently the dominant theme is short term cost reduction.   Whilst budgetary issues are being resolved and ideas are tested and (if viable) action plans are prepared, tasks that can the undertaken in the interim include:

• Updating the ‘digital infrastructure’ of the NHS.
• Continuing to seek a cross party consensus to managing Health and Social Care services to minimise the risk of political differences hindering progress.
• Continuing to increase the numbers of Doctors, Nurses and other staff being trained to meet projected future needs.
• Ensuring sufficient ‘Marketing and Communication’ resource becomes available to inform and seek feedback from citizens and all those working in the Health and Social Care sector at each stage of transformation.
• Working to make careers in the Health and Social Care sector more attractive to counter recruitment and retention issues.
• Reviewing the funding mechanisms for Health and Social Care services, making these self-adjusting as demand varies and, whilst maintaining financial discipline, allowing the current gap between funding and day to day operating costs to be bridged in some way so attention can move away from crisis management and onto improving operational processes.
• Introducing/expanding the subject of ‘Managing your own Health’ into the school curriculum to teach future generations what they need to know in order to prevent ill health in later years and if/when/how Health and care services will support
• Setting up and/or expanding existing mechanisms for recording and sharing information on examples of good practice for use by those wishing to copy these where they could be applied.

3.4              Transparent and effective communication

3.4.1              The STP implies significant, long-term changes to the working practices of most health and social care professionals and to the life-styles of patients.  This will require a huge ongoing marketing and communications effort which must be appropriately resourced, locally and nationally. 

3.4.2              In its call before the 2017 election for feedback on STPs the committee asked what public engagement will be necessary to enable STPs to succeed, and how should that engagement be undertaken?

• The ‘marketing’ of STP proposals to date has failed to alert most citizens to the extensive changes likely to affect them and their families for decades to come.
• Despite a requirement for the NHS to ‘engage’ with citizens, this ‘engagement’ is, in practice, very limited.    After 70 years as a monopoly supplier of health care our perception is that resources for ‘marketing and communications’ to ‘sell’ the NHS and its plans to its users are not a priority for the NHS, nor Public Health.
• We are not sure if Local Government Care agencies have greater marketing and communication resources.  We doubt that they do.
• Involving citizens in the process of planning and overseeing changes ensures there are opportunities for the ‘customer viewpoint’ to be taken into account and for changes to have an ‘outward’ rather than an ‘inward’ focus.
• If citizens are to be convinced of the merit of changes, support them and meet the extra costs involved personally or via the tax system, communicating the facts will be the key.  

3.5              Substantiating the benefits from proposed changes before implementation.

3.5.1              Prior to contemplating roll-out or implementation, every STP proposal should be thoroughly tested for evidence of its ability to deliver the benefits claimed, and these evaluations should be put into the public domain.

3.5.2              STPs must avoid proposing ‘magic bullet’ solutions that, on past experience, have rarely succeeded.  Examples are:

• Attempting to reduce staff quickly by implementing complex computer systems.
• Attempting to go paperless
• An over-zealous quest for big economies of scale in diverse non-production-line services.

3.5.3              Prior to the 2017 election the committee asked: Are there major areas where plan content needs testing for credibility and realism?

We see the STP approach of breaking down barriers to co-operation between NHS and Local Authority Care component organisations as a sensible approach.   However, forming 44 STP areas (following electoral boundaries) creates a set of new barriers not covered in plans we have seen.  

Differing approaches may lead significant to differences in services in neighbouring STP areas.  Where GPs have patients living in two or more STP areas their patients will tend to look to their GP for guidance regarding the services they need and how to access them.  Attention therefore needs to be given to managing the following:

• Enabling GPs to know about any differences in service delivery arrangements affecting people registered with them.
• Patients with needs for ‘joined up’ Health and Social care support require the agencies involved to work together.   Health care currently tends to be arranged via the citizen’s GP and Social Care via the relevant council.   Thought needs to be given as to who would advise on and arrange the delivery of any joined up care required?   

3.5.4              The committee also asked: Are the NHS efficiency estimates in STPs robust?

As members of Patient Groups we have (so far) been unable to find out what evidence exists to support any of the estimated savings and activity level reductions quoted in our local STP.   Being brutally frank, in the absence of supporting evidence we suspect these are numbers which, if achieved, would just happen to ‘balance the books’.

3.6              Publishing future funding mechanisms for Health and Social Care services

3.6.1              It is necessary to review the funding mechanisms for Health and Social Care services to make these self-adjusting as demand varies and to publish the formulae for future funding so service improvements can be designed to be sustainable within this framework.

3.6.2              As part of stabilising services prior to tackling service redesign and improvements, some way needs to be found to bridge the current funding gap so that attention can move on from crisis management.

3.6.3              We advocate spelling out the future ‘contract’ between the NHS and the Citizen so there is clarity about:

• What services the NHS is and is not intended to provide.
• If and when any ‘terms, conditions and charges’ apply for citizens using NHS and Local Authority care services.
• The obligation of citizens to do more to help themselves. There are suggestions about more “Social Prescribing” and “Self-care” but are these to be included or supported as part of the ‘contract’?
• The funding of elderly care, which is already a political ‘hot potato’, in particular, where ‘free care’ ceases, where self-funded care begins and the objective tests which determine the ‘dividing line’.   Whatever the arrangements are, they need to be explained clearly as part of ‘the contract’ so that what is free and what is chargeable is clear

3.7              Controlling the pace of change

3.7.1              In all walks of life people tend to be wary of and resistant to change.  Rapid and massive change (of the scale envisaged in STPs) is likely to generate resistance.  The pace of change needs to become more evolution than the ‘revolution’ implied by the pace of change in initial STP high level timetables.  It takes time for people to adapt and too much change in one go can be overwhelming.

We feel there is a need to:

• Present the components of STP plans in digestible ‘slices’, along with the work done to establish their viability and how likely benefits were assessed.
• Avoid a ‘big bang’ approach to bringing together the work of all Health, Local Authority and Voluntary Sector care services.   One ‘big bang’ change does not, in our view, seem a sensible approach for such a major merger of disparate service delivery organisations.

3.7.2              As indicated above we believe the current proposed timetable is hopelessly short.   Some progress can be made in the life of a parliament but some changes (e.g. changing lifestyles) will take much longer.

3.7.3              The STP themes of changing patient behaviours in the quest for healthier lifestyles and encouraging ‘self-care’ will be a long term project, taking a generation or more.     Whilst a good idea worthy of further action, hopes that this will significantly cut costs in the short term are unrealistic.  Bear in mind it took decades to cut the proportion of the population who are smokers.

3.8              Overall governance of the Sustainability and Transformation Programme

3.8.1              In its call pre-election for feedback the committee asked: What governance, management and leadership arrangements need to be created to enable STP planning and implementation to be carried out effectively?

• The whole structure of the NHS and its governance at national and local level makes proper debate and resolution of the current problems extremely difficult.
• There are too many parties involved and too much top-down instruction to make any significant change manageable.  Hence the need to review and clarify roles and responsibilities as a precursor to change.
• The NHS has a ‘command and control’ culture where there are ‘must do’ tasks to satisfy the next layer up the chain of command. Failure to comply is seen as being career-limiting.  Everyone tries to keep the next person up the line happy in the quest for good reports and career progression.  Actively trying to find ways to change things for the better may be seen as taking career risks.   We mention this because the current perceived management culture could constrain staff from contributing to change beyond simply ‘obeying orders’.
• This ‘command and control’ culture has persisted in STPs, with centrally planned ‘one size fits all’ prescriptive approaches.   An example is the pressure being applied to GP practices to merge to form larger centralised surgeries.   This model might fit the needs of some built up areas but would deprive dispersed rural communities of easy access to their local surgery.
• Over the years, a series of top down ‘reforms’ (not all of which were successful) will have left staff tired of change.   A new approach is needed.  An overall vision for the future is needed but wherever possible this time we would urge considering going for a more ‘bottom up’ incremental approach to change – making local service delivery the focus for improvement, with ‘front line’ staff playing a leading role in these changes.    That way staff are more likely to ‘own’ the changes and work harder to make them succeed.

3.8.2              There is a case for a 45th ‘STP’ to separate out the programme for all of the actions needed at a national rather than a local level.  This would include such things as:

• Any enabling legislation needed to allow Health and Social care services to be brought together.
• Providing standards, security arrangements and the infrastructure for storing and providing national access to patient records.
• Changes in Treasury and Local Government financing arrangements to redirect funding to combined health and care organisations.
• Where to locate centres of Excellence and facilities for treating rare conditions.
• National co-ordination of the phasing of Health and Social Care service integration to avoid ending up with many widely differing ‘regimes’ running in parallel, all needing to work with National bodies.

3.8.3              The committee also asked if the workforce is available (and ready) to enable the implementation of STPs?

• We do not have direct evidence but would draw your attention to the report by Professor Wachter (commissioned by Jeremy Hunt) into the 'Digital' agenda within STPs which drew attention to skills gaps needing to be addressed in many locations before implementation commenced.
• We have already highlighted issues in relation to ‘Marketing and Communications’ skills.
• We believe there is a need to prepare ‘front line’ staff to develop new ways of working and to continuously improve working practices.  The well documented approach of W. Edwards Deming in post WW2 Japan offers one framework for doing this.   These principles are echoed in the Francis Report into the Mid Staffordshire Foundation Trust and remain as valid today as they did over 50 years ago.

4              Concluding remarks

STPs provide an opportunity to have a national ‘conversation’ on the longer term delivery of health and social care services. This would include how they should be funded and the first steps to be taken towards this new vision.  It should be underpinned by cross party working, as was suggested prior to the June 2017 General Election, in order to minimise the risk of political considerations rather than citizens’ needs dominating the design of health and social care services.

Despite the complexity of the task, we have seen nothing that, given enough time, adequate resources and a willingness to change, need prevent NHS England and other service providers from moving to a more efficient, integrated arrangement for Health and Care services.  Keeping the public involved and well informed is equally essential.

Feedback to Health Select Committee on STPs, 7 Dec 2017 from John Popham and others              Page 8