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Behind the scenes at an STP

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A commentary on LGC’s recent attendance at an STP system leaders meeting 

Much of the media has recently whipped itself into a frenzy over “secret plans” to close cherished health services as part of NHS England’s sustainability and transformation plan process.

However, the senior NHS and local government figures in one area should be applauded for last week welcoming a journalist into a meeting usually held behind closed doors. LGC was given special permission to attend the system leaders’ forum meeting of the Pennine Lancashire Transformation Programme, a sub-group of the Lancashire and South Cumbria STP footprint.

Readers anticipating a juicy tale of plotting and scheming will be disappointed; the reality was a rather more mundane, procedure heavy and detail light discussion.

At the forum’s previous meeting, leaders had agreed in principle to develop an accountable care system and the big ticket item on last week’s agenda was how to take this forward. However, so acute is the concern about the potential for a judicial review of any future service changes that the bulk of the meeting centred on the process for developing this system. This ‘planning to plan’ involved a lengthy discussion on the principles and model for change, which the forum was informed had been “tried and tested” through the courts.

The dictionary definition of a conspiracy is a “secret plan by a group to do something harmful or unlawful”. But to conspire in this way requires a high level of trust between individuals with a shared interest in the same outcome.

Neither of these factors were in evidence (nor, for the record, was any suggestion of any harmful or unlawful actions).

For a start there were 22 people on the forum representing four NHS organisations, two upper tier councils, all the GPs and the five district councils in the Lancashire Pennine area. It is hard to see where their shared interest lies with the disruption to existing services inevitably likely to result in winners and losers across the patch. And while relationships appeared cordial and mature – some people had clearly known each other for years – participants were clearly there to represent their organisations, not do the dirty on the staff back at the ranch.

At one point participants were asked to state their organisation’s current position with regards to a future accountable care system. The GPs made it clear any attempt to move away from list based primary care, which sees practices paid according to the number of patients they have, would be unacceptable.

Lancashire Care Foundation Trust, which provides mental health and community services across the county, warned it would be a problem if Pennine Lancashire wanted to work in a different way from other parts of its patch.

It is obviously useful to have any potential conflicts brought to the fore as soon as possible but this kind of softly, softly approach to teasing out differences exposes the limits of the collaborative nature of STPs: any one of the players could derail the process at any time.

What LGC actually witnessed was more akin to a negotiation, a delicate process inching forward tentatively in a bid to make sure any plans do not come unstuck at the end of the day.

But while the courts may need process and principles to determine whether a proposed service change is lawful or not, the public need a convincing narrative with a beginning, a middle and a vision for what the end will look like.

Pendle BC’s head of paid service Dean Langton, who was attending on behalf of all the local districts, put it well when he said conversation so far had been “stilted” because of the lack of options on the table.

In common with most STPs, Lancashire and South Cumbria is also planning to centralise a number of acute and specialist services on to fewer sites. However, details of what these will be have yet to emerge, a point about which NHS England was apparently critical. One participant defended the lack of specifics noting that “other STPs that have been more detailed have run into political problems earlier”.

There is an element of ’damned if you do, damned if you don’t’. Yet without detail the narrative of secrecy and suspicion gains ground. The public routinely underestimate the complexity involved in delivering services and find it hard to believe those at the top are not in complete control. When public services fail to meet expectations this bolsters a belief that this was, if not the deliberate intention of those at the top, then at least a result of their indifference. This hostility has been evident in abundance across the public realm in 2016.

In the distant pre-EU referendum days of spring it was rumoured David Cameron was preparing to lead the debate on STPs with a co-ordinated media strategy. Instead he is long gone and the NHS has lost the initiative in communicating the case for change.


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