STPs - The Mystery of 'What, Why and How'. A marking guide for STP assessors

Over the next few weeks 44 Strategic Transformation Plans (STPs) will be pored over and 'marked' by NHS England and NHS Improvement.

The NHS has been here many times before. There is a lot of expensively drafted history gathering real and virtual dust on many bookshelves of organisations, many of which exist only in the memory of the consultants who were paid a lot to write such things. So what needs to be different this time? What will give us any more confidence that we have this time solved the mystery of implementation - making the linkages between 'Why', 'What' and 'How'. I suggest both STPs and their assessors will need to discard some well entrenched orthodoxies.


What we might expect to find: An elegant and convincing exposition of the 'Why' replete with socio-demographic projections, public health prognostications, activity analysis and expenditure trends models linked, workforce analysis, funding gaps explored and obeisances made to the Five Year Forward View all packaged as an irrefutable case for change.

But how many STPs will acknowledge that the analysis is only as current as the date of writing (not even of printing) - that 'events' may yet fundamentally change the emphasis and priorities? What is said about how the 'Why' is continually reviewed and refreshed, how existing scenarios are continually updated and new scenarios developed, how changes in direction and priority are decided and how people understand that anticipating potential futures is not about being indecisive but being prepared?
How many STPs have modelled Brexit as a possibility? How many on submitting the plans last week will have included the caveat that the plan is now out of date and they will now have to revise it to include the Brexit scenario? Or are they just waiting to be given a new set of assumptions?


What we might expect to find: A detailed prescription of the 'What' without doubt including one of those delightful concentric ring diagrams with patients and carers comfortingly at the centre. There will be detailed integrated care models, proposals for service reconfiguration, matrices, flow diagrams, heroic savings projections and trajectories,  and lots to say about patient safety, quality and engagement. Vanguards will be quoted and there will be lots to be said about 'New Models of Care' - which in truth are not new but it is just that we have failed to find a way of implementing them so far.

How many STPs will be honest enough to acknowledge that 'no plan survives first contact with reality' and that what the system eventually ends up looking like might be very different from what was originally described. That the journey needs to be one of constant learning from a mixture of success and failure and adjusting accordingly. That change is a process of relentless exploration, making and taking opportunities and being brave enough to acknowledge failure and dead-ends and rapidly looking for alternatives. How many acknowledge that the biggest risk is not failure but the need to succeed at any cost?
The risks of the need to succeed at any cost

The risks of the need to succeed at any cost


And then we come to 'How' all of this will be achieved? And this is where history has a lot to teach us - not least that we would probably not be in this position now if we had managed to systematically sort out the 'how' in any of our previous NHS incarnations.

What we might expect to find: An elegant but busy governance structure diagram with Programme Boards, Committees, Locality Groups, Enabling Workstream Groups, Programme Offices and all the other bureaucratic paraphernalia. These structures are often a dense scaffolding confection that contains little more than thin air or platitudes - and moreover miraculously appear in mid-air built downwards. These structures will usually have a costed 'Programme Office' but will largely ignore the input costs of the time of those required to prepare for and attend the myriad of meetings and make no mention of the opportunity costs imposed because they are not running their own organisations and keeping today's business on the road. There will probably be little or no mention of the modern digital infrastructure that will support the process.

How many of these STPs will have a single coherent model of change at the core of the 'How'? How many of the platitudes of co-design, co-production, leadership, shared purpose, team building  and workforce development will be given backbone by a simple clear description of how front-line teams will tackle the challenges they are being set? Is there a clearly described, core system-wide change methodology that will be used consistently by every team and organisation (there is a place for a nice process diagram here - and here is an introduction to one I did earlier!)? What are the core capabilities and capacities that front-line teams - the 'Poor Bloody Infantry' of change - require to deliver this Standard Operating Procedure (SOP) for change and how will this be developed? 
Is the governance structure built from the ground-up as an enabling scaffolding for front-line teams - one that aligns with the single coherent model of change and that actually embodies in the way it conducts business the flexibility, agility and rapid learning that characterises successful and energetic change? Is the cost of the governance structure worth it and indeed why would anybody want to bother turning up after the first two interminable meetings?
Is there a modern digital collaboration infrastructure in place to support the front-line teams and the programme as a whole - or is it email and attachments as usual? Was it even used to develop the STP in the first place?

So the challenge for both STPs and those assessing them:

If you always start from where you have always started, do not be surprised if you end up where you have always ended up, feeling much as you have always felt.