What is a Sustainability and Transformation Plan/STP?
Sustainability and Transformation Plan’, or ‘STP’ for short is the name given to a new initiative in the NHS that seeks to address a number of growing problems in the following areas: (1) Health and wellbeing; (2) Quality of care; and (3) NHS finances. In essence, everyone in Staffordshire and Stoke-on-Trent deserves good quality, safe health and social care services that make the best possible use of taxpayers’ money. These should be readily available to you regardless of your age, ethnicity, social and employment status, sexuality or where you live. The standard of care should be the same, whether you need physical, mental health or social care services, support with conditions associated with Learning Difficulties, or a combination of all of these. Most services should be as close to where you live as possible and for the vast majority of the time you should be able to go home to your own bed as soon as treatment is completed. These are just some of the things the STP seeks to achieve.
Is the STP about downsizing/cost cutting/closures?
The STP is about improving local health and social care services and making sure that they are affordable so that we can provide services now and in the years ahead. But the reality is that, to achieve this, some difficult decisions may have to be made about what we could do without, or what we could do more effectively, so that we can stabilise our financial situation. Once we have done this we can begin to think how we transform things to provide really positive change. We need to thoroughly review how we do things and ask ourselves honest and frank questions, and give honest and frank answers. Some of those answers may be unpopular because people are very protective of their services. But we as a local health and social care economy are faced with some significant challenges which need to be addressed if we are to not only survive the coming months and years, but also begin to thrive and improve as we move towards 2020.
What are the benefits of this plan? Can you give concrete examples of how it will benefit the local population?
We are at the start of the journey when it comes to how we will overcome some of the challenges facing us in health and social care. The most important thing is that we will do it together – in discussion and consultation with the public, with patients and with our staff. At a high level though, the main benefits we hope to see are: (1) You will stay healthier and more independent for longer; (2) The right care for you will be closer to you and easier to access; (3) Receiving treatment will be easier for you as we will join up services where appropriate; (4) The quality of the care you receive will be improved; (5) Treatment will be more efficient and effective, helping you feel better sooner; (6) Mental health issues and conditions associated with learning difficulties will be treated on an equal basis with physical conditions, and we will treat the whole person, not a series of symptoms.
How big is the financial problem in Staffordshire?
For the financial year 2015/16, there was a £129 million gap between the money we have available to spend and the services we need to fund. If we look ahead to 2019/20, that figure increases to £542 million across health and social care, which is a massive amount and highlights the need to make some changes and potentially make some difficult decisions.
Why can’t the government just give us more money?
All public services are under pressure and the Government argue that they have already allocated additional funding to the NHS. Whatever your views on this, overall levels of funding are determined by central Government and we cannot solve this locally and regionally within Staffordshire. We also have a duty to make the best use of taxpayers’ money; making sure services are efficient as possible and to reduce any duplication. Patients tell us their frustrations over the way services are delivered currently and we need to address these – not just to improve the patient experience but to also reduce any waste and unnecessary financial pressures.
Why has the NHS in Staffordshire overspent its budget?
It is important to recognise that the financial gap is not down to bad management – all NHS organisations have been expected to reduce costs for many years now. The reality is that our budget for the last six years has not kept up with the increase in the costs of the things we need to buy, such as medicines or new healthcare technology or the increase in demand for our services. Even if we wanted to, we are not in a position to simply stop providing services overnight unless they are clinically unsafe, so over time the financial gap has got bigger. Local government is not allowed to build up debts, so instead have already taken some difficult decisions to reduce some services, including aspects of care services. They certainly won’t be able to make the kind of investment needed to keep up with the growing care needs of their citizens over the next five years unless a very different approach is taken. Put together, these two things are storing up a range of problems which we need to solve together. What we must avoid is pushing the problem backwards and forwards among different NHS and local authority organisations which is what has happened for many years because of the way that the money works.
Will this plan solve the financial gap that Staffordshire is facing in health and social care? And if not, why not?
The current plan should enable us to deliver health and social care services that will improve care now, and in the years to come. However, it is unlikely to solve the entire financial gap, so we need to keep talking to people about different and innovative ways we can tackle some of our larger challenges, as well as consider the national context for health and social care funding.
Consultation and Engagement
Will patient and public feedback actually be used, or is this just a box ticking exercise?
We all need to think more carefully about how and when we use our local health and care services, and we need to start asking ourselves some difficult questions if we want to preserve the NHS and social care and community services for future generations. However, there is also a really exciting opportunity to design local healthcare so that it becomes an equal partnership between you and the health and care professionals who support you. We think there is also a great opportunity to start a conversation with you about how we can support you in living your healthiest life – this may be by offering you help and encouragement to stop smoking, by having an honest discussion with you about getting to a healthy weight, or by offering the tools to help you manage your emotional health. We see these conversations as key to offering you a local health and care service that is there for you when you need it most, and that delivers the right care, in the right place at the right time. The feedback provided to us by patients and the public is extremely valuable to us and we take it very seriously. We want to move forwards in partnership with our local patients so that local healthcare is transformed to reflect what is actually needed and wanted by the residents of Staffordshire and Stoke-on-Trent. We are eager to listen to not only your feedback, but also any ideas you may have. What have you seen that could be done better? Where do you think money could be better spent? What services mean the most to you and how can we improve them? If more of the care you need is available close to where you live, how far is it acceptable to travel to receive specialist care? What can we do without? Is it right to expect people to budget for their care needs as well as their overall living expenses in old age? However, it is important to understand that it is unlikely that we will be able to implement every idea or action every bit of feedback received. We will take on as much feedback and advice from you as possible, but unfortunately that doesn’t mean all of it can be used or implemented. It may contradict with feedback we’ve had from elsewhere; it might not be a financially viable solution; it may not be representative of the overall aims and objectives of the area. This doesn’t mean the feedback was not valuable, however, so it is important you provide it wherever possible.
Why has it taken so long to publish the Staffordshire STP?
NHS England requested that no STP was made public until such time as they have been reviewed by them to ensure the plans comply with the various standards in place. We wanted to make sure we could share our thoughts and plans having had those conversations. However, we have been talking with many of you over the past few weeks in public events, about the issues and challenges we face in Staffordshire, and discussing the themes of the STP, as we felt it really important to include the public and patient voice early on in the process. Now that our plan is published, we want to continue on this journey with you.
What are you doing to engage with the public?
Healthwatch Staffordshire and Healthwatch Stoke-on-Trent hosted ten events across the area throughout November and December. The purpose of these events was to allow patients and the public to come and ask questions and be involved in critical discussions about the future of health and social care provision in the area. Following these events and the publication of the plan, we will be in regular contact with the public and patients, as well as with clinicians, about the progress we want to make, involving them in discussions and asking for feedback. Regular conversations have also been held with existing patient participation groups and we have been working closely with the community and voluntary sector to take information out to existing community groups and forums. These will continue throughout the programme. To try and reach as many people as possible, and in particular those who may not be able or willing to engage through traditional methods, we are also working with Healthwatch to recruit volunteers to facilitate conversations with the wider public. These ‘Ambassadors’ are provided with information and resources to conduct their own conversations with groups they already attend and feedback any views, comments and suggestions to the programme. Should there be any major changes to service provisions, we will conduct formal consultation with the public.
When will consultations happen?
We anticipate that any consultation periods would start in 2019, although the timing will evolve as we work through the plans in more detail. We will work in partnership with our valued staff, including doctors, nurses and therapists, as well as with patients, the public and local councils to understand the priorities for change and the best way to go about meaningful engagement and consultation.
What will the consultation process be?
At this stage we haven’t got agreement about what we are consulting on. We would want to discuss the scope and timescale of any future consultation on major changes to services with a number of partners including local overview and scrutiny committees.
Prevention and Self-Management
Why do we need to look after ourselves?
You know your own health better than anyone and, if we are honest, we could all do more to look after our own health, and plan for our old age, which would take some of the burden away from the NHS and social care, allowing them to focus on the services that only they can provide. With the right support and advice we could make better lifestyle choices to help us stay well, and when we do develop long term conditions such as diabetes or heart disease we could do more to manage our own conditions, (self-care) particularly if we had access to the right technology. We could also do more to think about how we are going to look after ourselves and our loved ones when they get older, and how we are going to save the money we will need to pay for our non-medical care. We all need to think more carefully about how and when we use our local health and care services, and we need to start asking ourselves some difficult questions if we truly want to save the NHS and social care and community services for future generations. However, there is also a really exciting opportunity to design local healthcare so that it becomes an equal partnership between you and the health and care professionals who support you.
What does looking after ourselves mean in practice – what won’t we get in future?
There are different ways that people can look after themselves from both a prevention perspective such as trying to maintain a healthy diet and lifestyle or making sure you take up the screening programmes and vaccinations that are offered. For people living with a health condition, there are often things you can do to manage the condition yourself and to try and prevent it getting any worse. We do know, however, that in order for people to manage their condition effectively they need to be given the right information and, in some cases, the right level of support – which is something we are looking to improve. No final decisions have been taken yet, but prevention of illness is in everybody’s interests and should help us all lead more fulfilling lives.
Why have some services in Staffordshire been closed without public consultation and before the plan was published, such as the Children’s A&E at County Hospital?
There are specific reasons why organisations may review, change or suspend certain services. In Staffordshire specifically, the difficult decision was recently made to suspend services at the Children’s Emergency Centre at County Hospital, on the grounds of clinical safety, and in the best interests of the patients. Where this is the case, consultation does not apply. We promised we would bring services back to County as quickly as possible and a Minor Injuries Unit for under-16s was opened at County Hospital on 10 October 2016, with 16 and 17 year-olds able to be seen in the main A&E Department at County Hospital.The Royal College of Paediatrics and Child Health is carrying out review of the CEC and will report its findings in January 2017.
Why were community beds in North Staffordshire closed without speaking to the public?
Most hospitals open and close beds on a regular basis as part of their normal day to day work. For example in the past wards have been opened during winter to help cope with extra pressures and then closed again. This is a sensible, cost effective way of working. However, in Northern Staffordshire a number of community hospital beds have been temporarily closed to new admissions in recent months. This has not been part of the STP work, but reflected existing plans from the commissioners of health and social care in the region. From December 2014 and throughout 2015, the CCGs consulted on providing more care for people in their own homes, this model of care is known as ‘My Care, My Way – Home First’. The consequence of implementing the model, which was made clear during the consultation was that there would be fewer patients cared for in beds and the potential need for fewer beds. A second period of public involvement to inform the public about the options for change and seek their views took place during November 2016, with events and other opportunities for engagement having been planned across the health economy. Difficult decisions will have to be made, but the commissioner has a continuing commitment to involve patients and local people to help shape the future services, leading up to final decisions being made by the Governing Bodies. No decisions about the future of community hospitals will be taken without formal consultation.
What is happening regarding the community hospitals in Lichfield and Tamworth?
Community hospitals play an important role in delivering care closer to home and this is recognised by both the Trust and local commissioners. It is standard practice within the NHS to review services regularly. Health services must constantly evolve to meet the changing population’s needs and take advantage of the latest technologies and best practice. The Trust is working closely with commissioners to review the services delivered at the community hospitals, to ensure they are meeting patients’ needs now and are fit for the future.
What does it mean when we hear that commissioners have served notice on the community hospitals?
Commissioners are obliged under NHS contract rules to give a trust 12 months’ notice on the contract for any existing services if they want to change and/or improve services. Serving notice does not mean that the Commissioner will be stopping services; instead it gives them the flexibility to ensure services are meeting patients' needs. No decisions have been made. Commissioners must first engage with doctors, nurses and other healthcare professionals as well as local people to understand what is working well and what could be improved, before any plans are developed.
You are offering a number of things to the population, such as providing services closer to home – how will you do this when you have to save money?
We can only invest in community services if we reduce costs elsewhere, and if people accept that they have a responsibility to manage their own health in partnership with health professionals. We will talk with you about ways we can balance the provision of services in your area and ask for your feedback.
We’ve heard all this before, had lots of promises, and all we see are things being removed – particularly at County Hospital – what’s different this time?
It’s not true to say that services have simply been removed. There has been significant investment in services across Staffordshire in recent years. University Hospitals of North Midlands NHS Trust (UHNM) is currently over half-way through an unprecedented £47 million investment programme at County Hospital, with work due to be completed in November 2017. The £47 million programme is part of a record £250 million investment aimed at improving healthcare services for people across Staffordshire at Royal Stoke University Hospital and County Hospital in Stafford. There have also been on-going improvements to the Royal Stoke University Hospital including refurbished wards, as well as similar ward improvement programmes at Queen’s Hospital in Burton.
The document talks about simplifying urgent care – what does that mean?
Urgent and emergency care is an important part of healthcare in Staffordshire. We want to support people to get the right urgent health advice, first time, and we want to make it as easy as possible to know where to go. For example, if you need help with a condition that isn’t serious, but needs looking at quickly, such as a badly sprained ankle, an insect bite, a bad tooth infection, or a minor burn, then you need to know your options, local to you, that don’t require having to go and queue in A&E. We want to talk with you about what these options could look like and get your feedback.
You’re saying we shouldn’t go to A&E unless it’s absolutely necessary, so where else can we go?
Depending on your symptoms, it may well be faster and more appropriate for you to be seen somewhere else and we want to talk with you about what these alternatives are now and what they could be in the future. By calling the number 111, that is usually the best place to start when you have a condition that you know doesn’t need A&E, but that just can’t wait and you want looking at right away. The trained callers can take your details and often, you can then get phone advice from a clinician, who will also let you know how else the NHS can help and who you should see. Options could then include going to a pharmacy that can prescribe medicines for you, or getting an out of hours appointment with a GP, or in the future, by going to a walk in centre that would help assess you and recommend treatment. These potential options are things we are looking at in Staffordshire at the moment, and that we want to discuss with you, as part of a plan to simplify the way people get treated for urgent care in the future. When people do have serious or life-threatening situations that are a real clinical emergency, they should expect to receive treatment in centres that have the specialist facilities and expertise they really need, including A&E or specialist trauma centres. In the future, we may offer different types of urgent care services in Staffordshire. This may end up looking a bit different to what you’re used to, but our aim is to make it easier to know where to go for urgent health advice and to ensure we get it right for you and your needs.
Does all of this mean you are going to close my local A&E?
A&E departments are an important part of our local healthcare service and our aim is to make sure they are kept for serious and life-threatening emergencies and accidents, where the specialist staff can treat people quickly and efficiently. One of the things we want to look at in the future is how we can improve and clarify the range of urgent care options available to you locally – where you live – so you don’t feel that queuing in a busy A&E is your only choice when you need help fast for something that’s not serious. Some of these options may include looking at different types of urgent care centres and walk-in centres, or may include linking in more closely with our local GPs and pharmacies. We may want to look at what our A&E departments currently offer, where they are based and how many people they treat, as part of that broader picture of starting to think about.
Are you cutting funding and/or services; e.g. minor injuries units? How will that affect the quality of care being delivered?
We are at the start of the journey and our commitment is to make sure that people in Staffordshire have access to a local health service that is there for you when you need it most, and that delivers the right care, in the right place, at the right time. Quality of care is our “north star” – the guiding force for all our activities and plans – although we are of course mindful that all our services need to make the most and the best use of taxpayer’s money and deliver real value. Over the coming months, we will be exploring different options for our urgent care services and will be talking with you about our ideas.
Isn’t this document too late – council are already cutting services; i.e. drug and alcohol?
It’s never too late to make positive changes but we do need to act quickly to tackle the challenges facing us – both Stoke-on-Trent City and Staffordshire County Councils are very important partners in our STP. The whole point of the STP is to ensure that strategies and budgets are aligned to make the very best use of taxpayer’s money.
The beds in north staffs are already closing, clearly this decision has already been made and contradicts what you are saying about no decisions being made without public input – why is this?
Some community hospital beds are temporarily closed to new admissions, however, no final decision has been made by the Boards of the CCGs about their future. There are a series of separate engagement events at which the CCGs are seeking the views of patients and the public about the implementation of the ‘My Care, My Way – Home First’ model of care. No decisions about the future of the community hospitals will be taken without formal consultation.
You mention care should be closer to home but also mentioned we might have to travel further for specialist treatment – what does this actually mean?
At the moment most people default to going to their local A&E regardless of how severe their condition may be and acute care is centred on hospitals, when in reality this isn’t always the best use of those facilities. We hope to make it easier to be treated for smaller or routine issues closer to where you live by broadening the availability of treatments in community based care, such as pharmacists, walk in centres or your GP. However, when it comes to certain speciality treatments such as those for cancer, and to ensure you get the best possible care, we may need to group them all together under one roof. This means you won’t have to switch hospitals or change care givers, but may also mean you have to travel a little bit further to get to these centres of excellence. The reassurance is that once you are there, everyone involved in your care will be specialists in the types of treatment and care you need.
What is the ‘Five Year Forward View’?
The ‘Five Year Forward View’ is a document which sets out a clear direction for the NHS until 2021 – showing why change is needed and what it will look like. Some of what is needed can be brought about by the NHS itself. Other actions require new partnerships with local communities, local authorities and employers. Some critical decisions – for example on investment, on various public health measures, and on local service changes – will need explicit support from the next government.
Why have Sustainable Transformation Programmes (STPs) been set up to deliver the Five Year Forward View?
Local health and social care services across Staffordshire and Stoke-on-Trent have improved significantly in recent years, thanks to the hard work of staff. But there are still challenges facing those working in the NHS. The NHS Five Year Forward View (FYFV) (published by NHS England in October 2014), outlined three key areas for improvement across the country: health and wellbeing; quality of care and NHS finance and efficiencies. The FYFV also called for an NHS that gave patients more control of the care they received with less variance. This isn’t a new approach; many staff across Staffordshire and Stoke-on-Trent have already embraced more collaborative and efficient ways of working. Programmes like ‘Together We’re Better’ and ‘My Care, My Way’ have been working towards these aims for some time. STPs are a just a mechanism for capturing and accelerating some of this work and driving it forward to create a future-fit NHS by 2021.
Will STPs override existing plans and working processes across Staffordshireand Stoke-on-Trent?
The Sustainability and Transformation Programme isn’t a body in its own right. It is an over-arching framework, which is designed to help drive forward existing plans, partnerships and initiatives across the region (many of which have been in existence since before the publication of the NHS Five Year Forward View in 2014). The STP is not designed to replace existing plans and it isn’t there to over-ride existing governance structures. It is hoped however that the programme will enable staff, departments and organisations to find ways of working more efficiently, ambitiously and collaboratively together across their footprint area. The STP isn’t designed to erode organisational identity and recognises existing relationships and partnerships with local communities and organisations. The local, statutory architecture for health and care remains, as do the existing accountabilities for chief executives and accountable officers. This is about ensuring that organisations are able to work together at scale and across communities to plan for the needs of their population, and ultimately deliver the Five Year Forward View – closing the gaps in quality, health and NHS finances by 2020/21. Organisations are still accountable for their individual organisational plans, which should form part of the first year of their footprint’s STP.
Do we really need six CCGs in Staffordshire and Stoke-on-Trent? Are there any plans to merge CCGs?
One of the ways to reduce costs is to have fewer organisations with shared infrastructures. A number of CCGs have already shared management teams and other support functions and a number of CCGs have merged recently. We need much more discussion on this issue.
How will you engage with staff if you have already written the STP?
The STP document is in on-going development and has pulled on themes arising from previous engagement across Staffordshire and Stoke-on-Trent. A version of the document, along with the STPs for the other 43 areas, was sent to NHS England for review on 21 October 2016. NHS England are now reviewing these documents and providing feedback in waves. Even after this point, the plans for the future of services and working patterns will still develop and change as necessary. None of the ideas discussed in the current version of the document are set in stone yet. The exploratory conversations in the document have been developed with, and based upon, the needs of local patients and communities, along with the support of clinicians, staff and wider partners such as local government and informed by ongoing local engagement across the region. Any changes to services or working practices that are explored in the STP document will be fully engaged upon (by both staff and the public) when the document is at a more completed stage and signed off by NHS England. As mentioned above, some of the initiatives to improve efficiency, patient experience and working practices have already been extensively consulted upon (with public and staff involved in engagement) and further engagement when there are fully formed plans to engage upon. At this point, each organisation’s chief executive, staff representatives and managers will have a fuller brief to present to staff and your feedback and viewpoints will be sought.
How will we know if our jobs will change or if jobs will be lost?
We are still at a very early stage in discussions and there will be opportunities for staff to get involved and receive regular briefings in the coming months on what the next steps will be. The STPs have been developed in a very collaborative way across provider and partner organisations. CCG, Trust and provider chief executives have been steering this process and have been involved in developing the programme and the plans from the offset. They will be the first people to know about any changes to services and jobs and will be keen to communicate with you as soon as any proposals are firmed up. Your managers and staff representatives will alert you to any communications about changes and there will be many opportunities to join the conversation, either online, in face-to-face events or meetings, in response to briefings and through staff surveys. This is all part of the vision for a future NHS is to improve services and experiences for patients, creating an NHS with less variance of care and more financial and clinical sustainability. At the core this process is a desire to retain the wealth of skills and experience that we have within the NHS. The value of NHS staff and their experience will be a consideration throughout any process of change.
Is this a corporate document that won’t be very accessible to many people working in the NHS?
We are developing a public facing version of the plan that will be available to staff and the public after the STP has been published. This document will outline, at a high level, the aims of the STP, a vision for the future and some of the things we need to consider in order to achieve them.
How did you agree the footprints?
The NHS Shared Planning Guidance asked each area to develop a proposed STP footprint by January 2016, engaging with local authorities and other partners on what this should look like. The footprints were reviewed by the national bodies with regard to geography (including patient flow), scale and fit with footprints of existing change programmes, financial sustainability, and leadership capacity.
How do STP footprints fit with other health and care footprints?
The boundaries used for STPs will not cover all planning eventualities. As with the current arrangements for planning and delivery, there are layers of plans which sit above and below STPs, with shared links and dependencies. For example, neighbouring STP areas will need to work together when planning specialised or ambulance services or working with multiple local government authorities and, for areas within a proposed devolution footprint that cross STP boundaries, further discussion will be required in working through the implications. Other issues will be best planned at CCG level.
How will other partners be involved?
STPs will need to be developed with and based upon the needs of local patients and communities and command the support of clinicians, staff and wider partners such as local authorities. We simply cannot transform health and health care without the active engagement of the clinicians and staff who actually deliver it, nor can we develop care integrated around the needs of patients and users without understanding what our communities want and without our partners in local government. That is why we are asking for robust local plans for genuine engagement as part of the STP process. Where relevant, areas should build on existing engagement through health and wellbeing boards and other existing local arrangements. Nationally, we have established an Oversight Group to provide advice and challenge to the NHS CEO Five Year Forward View Board to help us develop this process.
What does success look like?
If we get this right, together we will better engage patients, staff and communities, allowing us to develop services that reflect the needs of patients and improve outcomes by 2020/21, closing all three gaps. We will mobilise energy and enthusiasm around place-based systems of health and care, develop the ownership, relationships and governance necessary to deliver, providing a coherent platform for future investment from the Sustainability and Transformation Fund. This will require a different type of planning process – one that releases energy and ambition and builds greater trust ownership. It will require the NHS at both local and national level to work in partnership across organisational boundaries and sectors, and will require changes not just in process, but in culture and behaviour. This will not happen overnight, but we will work with local and national partners to provide challenge and support.
How are you engaging with local authorities?
Regional directors are working closely with local government throughout the development of STP footprints and guidance as they are vital in helping to set the strategic direction of health and care service development locally. Staffordshire County Council and Stoke-on-Trent City Council are both partners of the STP.
How were footprint leads agreed?
The way that footprints have chosen their lead has varied from place to place. Some areas have chosen existing system leaders, and others have carried out ballots following nominations. Each STP has a senior leader who can command the trust and confidence of the local and national health and care systems. In Staffordshire and Stoke-on-Trent the STP lead is Simon Whitehouse who is the Programme Director.
What is the role of the STP footprint lead?
Footprint leads are responsible for convening and chairing system-wide meetings, facilitating the open and honest conversations that will be necessary to secure signup to a shared vision and plan. They are part of an emerging national cadre of system leaders who will drive health and care transformation. This is a new kind of leadership role, working across organisational boundaries. Footprint leaders will help to build consensus and ownership in their communities for their local plans, while providing the leadership to drive the transformation needed to improve the quality of care, health and wellbeing, and finance and efficiency.