Cornwall’s STP: Why we need to see what’s going on

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When we are told ‘Don’t worry: no decisions will be taken before the public are consulted’ we have every reason to worry!

Right now work is going ahead on preparing a Sustainability and Transformation Plan (STP) for health and social care in Cornwall and the Isles of Scilly. Under the brand name Shaping our Future (SoF), a team of people are beavering away to produce a ‘plan’ of some kind. It seems that this is due to be unveiled in a few months’ time, and is to take the form of a Pre-Consultation Business Case.

For anyone who is concerned about what the ‘plan’ will mean for them and their family and neighbourhood, the problem is this. During the planning process, as in all planning processes, things happen to narrow down the options that are available at the point when the public are eventually consulted. For example:

♦  Time and staff resources are used up. Once a deadline has been set, there is simply not the time and manpower to go back to square one and start again. If no alternatives have been investigated and considered, there is no time now to investigate them. Even if alternatives have been considered, these will have been reduced to a shortlist, and it won’t be possible to resurrect any that didn’t make it on to the shortlist.

♦  The staff working on the plan become psychologically committed. They take decisions about the kind of plan they want to see, and about working methods, i.e. how they are going to produce the plan: to go back on these decisions, and write off some of the work that has been done, will generate stress and involve loss of face. Similarly, people make assumptions and become wedded to these: even if evidence turns up that shows that their assumptions were unrealistic or – like budgetary limitations – could have harmful consequences, they may disbelieve and deny that evidence (the phenomenon of cognitive dissonance).

And the staff working on the plan will have their own motivations. They will have personal ambitions, such as advancing their careers, and typically will want to produce something distinctive and striking. Such ambitions too generate commitment.

♦  The planning team may have a budget for research, and agree a contract with an outside research outfit for it to do this work. This contract will set out ‘terms of reference’ for the work, e.g. to explore and evaluate the implications of possible plans X and Y. Then as the planning team forges ahead it may become apparent that there’s a third possibility, option Z. But it may be that the research budget has all been used up, and there is no money to explore and evaluate option Z. So option Z gets ruled out by default, long before a point of formal decision is reached.

♦  Some people, particularly members of powerful interest groups, will have easier – ‘preferential’ – access to the planning process than others. For example, in the NHS senior managers and consultants may get together privately to find and agree a course of action that suits both groups. Once that agreement has been reached, it will be very difficult for members of allied health professions, let alone the public, to get it reviewed and altered.

♦  The situation on the ground changes. A facility may be closed for repairs, and it happens that staff drift away, local people at first protest and then find ways of coping, the building gets starved of maintenance and begins to decay, so the option of restoring it to use becomes increasingly expensive and consequently difficult to justify (the ‘planning blight’ syndrome). Or a service that up to now has been provided at local level gets abruptly withdrawn, to be replaced on grounds of economy by centralized provision, transferring costs to patients who have more travelling to do and importantly making it difficult to restore the service at local level.

Never underestimate the effect of these dynamics. By closing off options they pre-empt formal decisions. As a former very senior civil servant has put it: ‘The experience of anyone who has worked in Whitehall is that there is an early stage in any project when things are fluid; when, if you are in touch with those concerned and get hold of the facts it is fairly easy to influence decisions. But after a scheme has been worked on for weeks and months, and has hardened into a particular shape, and come up for formal decisions, then it is often very difficult to do anything except either approve it or throw it overboard.’* He might have added that there is invariably a huge penalty attached to throwing it overboard at that stage.

It is true that the widespread criticism of the previous ‘engagement’ over the STP for Cornwall caused the process to be restarted. However, this appears to be very much the exception that proves (in the sense of ‘proofs’, or tests) the rule. Anyone who bets on this happening again would be virtually certain to lose their money.

We have to be alert to the fact that managers who are familiar with these phenomena can deliberately take advantage of them. Thus they can limit the number of staff working on the plan and impose unrealistic deadlines, they can impose stringent budget limitations, they can reach deals with the more powerful interest groups, and they can change the situation on the ground. Indeed, they may have reached their present positions in their organizations precisely because they are skilled in using strategies like these.

So while these managers may be absolutely correct when they say that no formal decisions will be taken before the public are consulted, they may have a host of strategies under way to guarantee that they get the result they want. We have every reason to worry!

What can we do about it?

Public money is being spent on producing plans for new health and social care arrangements. It is my contention that those spending it should be directly accountable to the public for their work, not via paymasters with their own personal and political agendas. Such accountability requires – and it is an essential and fundamental requirement – transparency.

Transparency needs to be good enough to enable us to follow every step in the planning process. So we need to see what terms of reference the planning team have been given. We need to see what they tell the Transformation Board or whoever it is that supervises them, and what instructions and ‘steers’ they get from that Board. We need to know what skills the members of the planning team have, so we can see whether there are gaps in their range of skills. We need to know what contracts they give to researchers and management consultants, so we can see for ourselves what limitations are built in to these contracts, and we need to see the reports that these people produce. We need to know about deadlines, so we can gauge the impact of these on the process. And we need to keep a close eye on the situation on the ground, so we can judge how day-to-day decisions are closing off options for the future.

In a nutshell, we need to see what’s going on!

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*Lord Bridges (Cabinet Secretary 1938-46, Permanent Secretary to the Treasury and Head of the Home Civil Service 1946-56), ‘Whitehall and Beyond’, The Listener, 25 June 1964. Cited in Peter Levin, ‘Opening up the Planning Process’, in Stephen Hatch (ed), Towards Participation in Local Services, Fabian Tract 419, 1973 and in Peter Levin, Making Social Policy, Open University Press 1997 (p.44).