To implement STPs fully, the NHS will have to be transformed. From what we know about organisations that have transformed themselves, is the NHS capable of this?
Viewed from a systems perspective, the NHS is perfectly designed to achieve what it achieves: an (imperfect) reconciliation of competing goals. There is explicit and implicit conflict built into the design of the NHS system. For example, it is a national service yet encourages commissioning/postcode variation; it is publicly-funded and pursues PFI and privatisation; it manages a fixed budget unrelated to demand and yet runs deficits; and it offers a bottom-up vision but decision-making is highly centralised. Such dialectical contradictions lie at the heart of the NHS’s recurrent crises.
How will these paradoxical conflicts play out with the emergence of new Sustainability and Transformation Plans (STPs)? Setting aside the huge financial challenge, is the system in any way designed to deliver a new paradigm of care? Can it change?
Evidence (for example, Johnson and Scholes) shows that organisations that change successfully generally share three characteristics:
- They recognise their connection to the environment, the world outside. Unlike successful organisations which embrace outside forces, and recognise that only by anticipating and responding will they survive, the NHS is primarily a self- referential, closed system of interaction. The outside environment is the threat, hence the blame heaped on patients who don’t conform to the idealised pathway; the demonization of “health tourists” who consume our scarce resources; and the criticism of GPs who do not offer extended opening hours. Currently, the NHS mission appears to be to survive against the vagaries of the outside world, rather than to change to reflect its new environment.
- Secondly, organisations which change recognise fundamentally that they face a challenge which can end them, and terminate individuals’ careers. NHS leaders have been doing their best recently to emphasise the necessity change. Sir Robert Francis QC told the HSJ “the nhs was facing an existential crisis.“ The NHS is on a “burning platform of acute care,” according to Prof Mike Richards. It’s a war, says Lord Carter, and so on. In practice, though, there is little evidence that the NHS is responding with urgency, or a sense of strategy. Incoherent and inconsistent hospital and bed closures are the common theme of the 44 STPs. Meanwhile, in terms of developing new models of care, the “frugal innovations” described in the NHS Vanguards programme and the half-hearted Better Care Fund do not speak of a service recognising that it faces an existential crisis. With the exception of Greater Manchester’s investment in extended access, there are few initiatives designed to disrupt the existing models of care and thereby precipitate transformation.
- Organisations serious about transformation change the way they work. Where, though, within the NHS envisaged by STPs are the new behaviours, the new roles, the new incentives and processes? What are the new rites and rituals leaders will use to signify and communicate change? Where is the investment, the leadership, to move the NHS from an organisation focussed on execution, to one focussed on learning? How is the focus from managing targets to be changed to one where improvement and learning is facilitated? What is the plan for taking people with us? This not to downplay the impact of STPs. Certainly, STPs leads can close community hospitals, and reorganise some specialties. But, without an organisational development plan to address NHS culture, the wider purpose of STPs – transformation – can, and will be, marginalised, attenuated, and managed away.
What NHS leaders have offered as an implementation model is greater central control and structural streamlining. ”We are going to formally appoint leads to [all 44] STPs, going to give them a range of governance rights over the organisations in their areas; including the ability to marshal the forces of the local [clinical commissioning groups] and the local NHS England staff,” says Simon Stevens. Unfortunately for Stevens, the evidence is that highly centralised and organisational structures are not associated with high performance in rapidly-changing settings.
STPs have been developed by leaders who see the external environment as the problem, and view more central control as the answer. They lack an appreciation of systems thinking, central to which is the belief that transformational change requires a learning culture where experimentation, risk, and failure are permitted, and critical thinking which continually challenges existing organisational behaviours is encouraged. The approaches advocated in STPs have previously failed to deliver transformational change.