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Lord Kerslake: STPs need better scrutiny to function effectively

Bob Kerslake
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Sustainability and transformation partnerships (STP) are the new vehicles to support the delivery of the NHS Five Year Forward View.

As a recognition that health and care should be place-based, locally driven and carried out in collaboration, they are the right vehicle. Can they ever achieve what is being asked of them? On the early evidence many would have their doubts but for me they are an essential part of changing local systems.

The Centre for Public Scrutiny has carried out research to learn from the experience of operating in an STP environment. Working with the University of Manchester, our report contributes to existing debates but specifically highlights the complexity of multi-level governance arrangements in STP footprints.

Almost our interviewees considered collaboration as fundamental to STPs. Most agreed time and resources were needed to support collaboration where relations were adversarial. Some areas are progressing well and in others there was a consensus that STPs are doing a sterling job getting people round the table.

A number of themes emerged: the perceived top-down structure of STPs; a lack of shared understanding; the complex landscape of stakeholders; a persistent culture of silo working; and the dominate-mode of working still located at the organisational level. The specific geographies of STP footprints were frequently referenced, as was the lack of change within the regulatory framework, meaning there are no incentives for system-wide working.

Financial transparency and clarity were concerns. The situation is currently seen as confusing and leading to unwarranted tensions between partners. Sharing funding positions honestly is vital if trust is to be developed in local areas and to fulfil the presumption that a system-wide approach will operate on pooled budgets.

There were concerns about the lack of clear pubic narrative and consultation. Participants felt neither local health scrutiny committees nor local politicians had been sufficiently represented in the process. All felt existing scrutiny and public participation mechanisms should be applied. This would add credibility to the process. Likewise, scrutiny could bring together a range of people to discuss the impact of the proposed changes to the health service.

However, there was also recognition that for scrutiny to play a bigger role, there would need to be adequate support dedicated to it. Local government scrutiny support has been significantly reduced over recent years. Some argued it might be necessary to increase health scrutiny’s powers so they can deal with the demands of new systems.

The report recommendations are aimed at leaders in health and local government. It would be easy and unhelpful to see health as the villain. We want to see resource dedicated to supporting: strong local leadership, having a shared goal, understanding individual organisations’ motivations, more transparency and using existing mechanisms such as scrutiny to involve others.

Lord Kerslake, chair, Centre for Public Scrutiny and King’s College Hospital Foundation Trust

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