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BLMK STP Questions & Answers

1. General matters

Q1.1. What’s the Sustainability and Transformation Plan (STP) all about?

A1.1. In March of this year, NHS England invited the leaders of health and social care across Bedfordshire, Luton and Milton Keynes (BLMK) to see how, by working together, we could improve the health and well-being of our resident population and increase the clinical and financial sustainability of our local health and social care services. A total of 16 partners have worked on the development of our STP.

Considerable progress has been made, from a standing start, since April. However, we certainly don’t yet have all the answers. We have though, developed some consensus around our priorities.

These priorities have been guided by our future vision for health and social care. This vision is grounded though, in a frank assessment of the disposition, fitness for purpose and affordability of current services and the health and well-being outcomes we’re achieving.

Whilst we have much to be proud of, and many good things to build on, we also have a strong appetite for improvement and a deep appreciation that we have a significant transformative journey ahead of us.

Q1.2. So, what are the STP’s main priorities?

A1.2. Just before answering this question, it’s important to recognise that the STP is not solely, or indeed, primarily, about hospitals. The STP’s focus is on health and well-being in all its manifestations.

We are interested first, in keeping people healthy for longer. Healthy lifestyles and illness prevention are therefore, key to the STP. We’re also keen to make it easier for individuals to take more control over their own health, and for us to enable greater independence for those living with long-term illnesses.

Second, we are keen to make sure that physical and mental health care delivered in primary and community settings (including the home), is strengthened. This is crucial because over 80% of all contacts between people and the NHS take place away from hospitals.

Equally, we have a huge and talented care workforce at our disposal, either directly employed by Councils or in the independent and voluntary sectors. This workforce is three or four times the size of our local NHS workforce. We need to get the very best out of this workforce, which means enabling and empowering them, because, if we don’t, then pressure will just build and build on our hospitals.

Third, we want to make sure our hospitals deliver clinically excellent care, year-in, year-out, to those that need acute and/or specialist hospital care. Ironically, this means reducing hospitalisation rates so that hospitals focus on what they are set up to do. However, this will only happen if we strengthen capacity outside hospitals, we get much better at co-ordinating people’s care as they transition between different care settings and we succeed in placing more care close to the home.

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We have identified five 1st order STP priorities that we think, in combination, will help us achieve this vision. Unsurprisingly, these priorities overlap, and the benefits expected will only be fully realised if all five proceed in parallel. No one priority is therefore, seen as more important than any other. The five priorities are:

Priority 1: improving health and well-being and prevetning illness

Priority 2: improving the quality, accessibility and resilience of primary, community and social care

Priority 3: creating modern, high quality, sustainable and affordable hospital services

Priority 4: creating an informaiton and communications digiital platform to support 21st century helath and social care

Priority 5: Creating the right system-level capabilties and levers to ensure organisations work alongside each other to achieve improvements in health

Q1.3. How well developed are the solutions identified in the October STP submission?

A1.3. Taken together, our five STP priorities signal an ambitious and far-reaching overhaul of, and investment in, health and social care across BLMK. A raft of work programmes are being overseen by the STP Steering Group. These programmes outline a range of activities and solutions designed to enable BLMK to achieve its priorities.

Progress in identifying, defining and developing these work programmes is summarised in our October submission. However, whilst some work programmes are more progressed than others, there is still much to do to test our ideas with a wide range of stakeholders and the general public. This is why we have planned a rich and diverse programme of engagement in the coming weeks and months.

Q1.4 How are decisions made in the STP?

A1.4 The STP itself has no formal decision-making power, other than that vested in the post-holders that sit on it. All decisions therefore, need to be made by the individual statutory bodies that the 16 STP leaders represent.

The STP can make recommendations, and the involvement of senior officers and staff from our 16 partners should ensure that these recommendations are well-informed, sensible and, hopefully, well-received. However, the Boards or Cabinets of our STP partners will ultimately need to make decisions on matters that fall within their statutory remit.

Q1.5 The STP identifies a funding gap that reaches £311m each year by 2020/21 – this equates to around one-fifth of the funding we receive each year. Doesn’t this signal very dramatic cuts in services are ahead of us?

A1.5 We need to set this “funding gap” in context.

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First, the good news. We expect to see overall funding into BLMK go up over the coming years from £1.33bn in 2015/16 to £1.67bn in 2020/21, a rise of 26%. The not-so-good news is that, if we don’t change anything, this increase is likely to be soaked up by rising demand for services.

The £311m funding gap in 2020/21 represents the shortfall between projected funding and anticipated demand on the basis that we sit back and do nothing. It combines a funding gap that would sit nominally with local NHS bodies (of £203m) and a similar gap (of £108m) nominally sitting with Councils in respect of health and social care services they commission.

However, we’re not going to sit back and simply “do nothing”. First, the £311m funding gap takes no account of what we call “business as usual” savings. These are the year-in, year-out efficiency savings that all public bodies make.

After making some sensible assumptions about the level of “business as usual” savings that can be achieved in the coming years, the 2020/21 funding gap reduces from £311m to £63m. This is a fairer representation of the challenge we need to meet by transforming health and social care.

We shouldn’t underestimate the difficulties we will need to overcome to make this level of savings in the coming years. However, at just under 4% of the income we receive year-on-year, we believe we can, and we should, grab the opportunity to design and implement local solutions, in a sensible and measured way. We believe our STP priorities can be used to steer the way forward.

Q1.6 What’s happened to the Healthcare Review (HCR) and how does it fit with the STP?

A1.6 Since the beginning of July, the work of the HCR has been subsumed into the STP. It has been recognised that, locally, long-term, sustainable secondary care solutions need to centrally involve all three local hospitals.

Equally, and perhaps different to previous reviews, the STP is focusing just as much time and effort on strengthening care provided in community settings and in the home. The right solution for hospital care is wholly dependent on putting the right solutions in place for our out of hospital care.

Q1.7 So how is this work being taken forward within the STP?

A1.7 In July 2016, we set up a Secondary Care Services Transformation Board. Its remit covers four limbs of activity namely:

Speciality clinical services – to develop transformational integration plans for each major clinical service so as to inform the optimal configuration of secondary care services across BLMK in the future.

Clinical support services – to identify opportunities arising from integrating clinical support services across pathology, radiology, pharmacy and the therapies services delivered by the three hospitals.

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Non-clinical support services – to configure non-clinical support services so they are operationally and cost effective and they support the emergent BLMK-wide operating model for secondary care services.

Non-medical clinical workforce - to develop and agree standardised models to reduce variation and ensure most effective use of non-medical clinical workforce resource

The SCSTB is chaired by Pauline Philip, the STP SRO and the CEO of LDUH. Other core members are: The acute Trust CEOS The three acute Trust Directors of Nursing The three acute Trust Medical Directors The STP Programme Director for Secondary Care The STP Medical Lead for Secondary Care

Q1.8 Is the SCSTB authorised to make decisions?

A1.8 The SCSTB currently exercises authority only through the delegated authority attaching to post-holders sitting on it. It therefore, has no collective authority.

The three acute Trusts recognise that there is a strong argument for the SCSTB to be underpinned by some formal governance vehicle through which the three Trusts can exercise some joint decision-making powers. There are a variety of ways that this can be done.

One solution, a Committee-in-Common that operates across the three Trusts, has recently been introduced in South and Mid Essex. We expect our chosen governance vehicle to be up and running before the end of the 2016 calendar year. All three acute Trust Boards will, of course, need to agree to any recommendations emerging from the STP.

Q1.9 How are the CCGs involved in the workings of the SCSTB?

A1.9 Although it plays a crucial role, the CCGs interest in the work of the SCSTB is focused primarily on the review of speciality clinical services. They also have an indirect interest in overall progress with other work programmes that fall under the purview of the SCSTB, not least because these programmes are expected to make such a telling contribution to BLMK’s 2020/21 financial gap.

The CCGs and the SCSTB are currently debating the best way to structure the interface between them. This might manifest itself in one of the CCGs taking a lead role and joining the SCSTB. Alternatively, it may make sense to create a bespoke liaison mechanism by which the CCG AOs are kept abreast of progress by the SCSTB chair and the programme support team.

Q1.10 When are recommendations from the SCSTB likely to start emerging?

A1.10 Each of the four different workstreams flowing into the SCSTB are progressing at different paces. However, all four are expected to provide their settled findings to the SCSTB by the end of March 2017. If we can progress faster, we will.

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Where recommendations are made that require statutory consultation either with staff or the general public, then these processes will be conducted at the appropriate time. In the meantime, our engagement activities will ensure that key stakeholders remain informed.

Q1.11 Why has there been such secrecy around the development of the STP?

A1.11 We don’t believe there has. Sixteen local partners from across local government and the NHS have been involved in the development of the STP since its inception in April 2016. Three of our five key STP workstreams have either been led or co-led by Councils, two by CCGs and one by the acute Trusts. All 16 partners sit on our STP Steering Group.

It is true that we have been keen to ensure that, when we engage wider audiences, first, we have something sensible and evidence-based to discuss and second, we have received the benefit of feedback from national NHS bodies on our priorities and our plans. This has meant that our broader public engagement activities kick in following our October submission. Equally however, our plans are not set in stone and there is every opportunity for those involved with whom we engage to add real value to them.

Q1.12 What do you think the key risks are in achieving the STP’s vision?

A1.12 Clearly, a programme of this breadth and complexity will not be without its risks. Our October submission identified those risks at large across the programme and also those that might slow the pace, or worse, derail progress, of specific priorities.

Just picking out one or two, it would be naïve of us not to be concerned that recent history on potential changes to hospital services, particularly between Bedford Hospital and Milton Keynes Hospital, dampens enthusiasm for the improvements the STP is signalling. We hope that, by focusing on the inter-connectivity of all elements of health and social care, we can excite local people enough for them and us to move on and for them to add value and momentum to our whole-system planning work.

We need to make sure that, through engagement and involvement, we create an environment where people recognise that, whilst some change needs to happen, the change envisaged is manageable, it is not calamitous, and is more likely than not to address concerns they harbour about living healthier lives, living more independently and about getting timely access to health and social care professionals, in the most appropriate care setting.

A second risk that sits rather outside our control is access to capital. We know that capital is in short supply. As a result, we have tried to keep our estimates within realistic bounds. However, we still have work to do before we can conclude our thinking on secondary care, and some of options available to us may be constrained, depending on the capital expenditure required to implement them. We will have a much clearer picture on this by the end March 2017.

2. Matters of specific interest to CCGs

Q2.1 Given their pivotal role in commissioning health services, what role have CCGs played in developing the STP?

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A2.1 CCGs have been centrally involved. All three AOs and their clinical leads are members of the STP Steering Group. In addition, CCGs are providing the STP lead (or co-lead) for two of the five STP priorities.

It is crucial that CCGs both influence the work of the STP and are content with the transformation journey that it charts. Given the role they play in statutory consultation in respect of service change, CCGs will need to be a leading advocate of any recommendations in respect of service change and therefore, their support is crucial.

Q2.2 What does the future hold for CCGs in the new world of STPs?

A2.2 This is not something that we can answer locally. Neither are we are aware of any plans nationally to alter the statutory duties or status of CCGs.

Notwithstanding this, a number of CCGs in England are looking at the way they currently operate to see if they can improve the impact they make on the health and well-being of their local population in the most cost-effective way, but without altering their statutory form.

Some CCGs are working together to pool the commissioning support services they receive from third parties (such as CSUs) or which they provide internally. Others are pushing this further and looking at ways they can pool leadership resources and/or combine their decision-making capacity.

Finally, several CCGs are looking to exploit opportunities emerging from NHS England’s work on new care models, particularly those now being taken forward by the NHS Vanguard programme. These promote quite different ways of going about commissioning, contracting for and providing health and care services – through accountable care approaches. This involves fundamentally changing the relationship between commissioners and those that provide services to them, under contract.

As part of our STP priority 5 work, our local CCGs are continuing to examine these new ways of working and to see whether they can be used to advance and indeed, accelerate the transformative journey we need to press on with across BLMK.

Q2.3 What does a move to accountable care mean for CCGs?

A2.3 We’re not sure of the detail yet – but, if accountable care approaches are developed locally, we will need to adjust how we work. Quite a few places in England are looking at accountable care - some interesting and more advanced examples are Dudley, Northumberland and Stockport – and much of this interest has arisen through the work of the NHS Vanguards.

In very broad terms, accountable care involves three things:

A long-ish term contract – 10 to 15 years is being contemplated by NHS England as norm

Service scope embraces a broad range of health and social care services under a contract awarded to a single (prime) contractor, who then has the responsibility for assembling and managing a wider clinical services supply

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chain - in this way, the number of contracts that a CCG must manage can markedly reduce

The transfer of capitation risk from the CCG to the contractor – this means that if demand increases, then the contractor must manage that demand without going back to the CCG for more money

If BLMK does choose to pursue something like this, it would unavoidably change what the CCG does (although all statutory functions would need to remain with the CCG) and how it goes about doing it. The STP will be looking at this in more detail over the coming weeks.

Q2.4 If the CCGs do adopt an accountable care approach, are we likely to need a smaller workforce in commissioning and in commissioning support provided by, amongst others, CSUs?

A2.4 We’re not sure of the detail yet and this will be worked through, involving staff and their representatives, in the coming weeks and months. It’s also fair to say that intelligent and effective commissioning becomes even more important in an accountable care environment.

Two consequences are reasonably foreseeable if an accountable care approach is adopted:

i. We would expect it to make the health system easier, and cheaper, to administer, with less bureaucracy. This is likely to manifest itself in fewer contracts, fewer procurements and less burdensome contract management and administration.

ii. We may see certain functions that sit currently with CCGs move across to an ACO. Whilst therefore, this may not reduce the number of posts doing commissioning jobs, these posts could, in the future, sit elsewhere. TUPE protections would be available to those individuals in posts where the post (substantively) transfers from the CCG to an ACO and any ACO will more than likely be an NHS body. Similar protections would apply to post-holders sitting in CSUs where such posts are mainly dedicated to supporting CCGs in BLMK.

Q2.5 Do CCGs need to pay back deficits accumulated over recent years?

A2.5 Our STP currently assumes that CCGs will not need to repay deficits accumulated in recent years, notably by NHS Bedfordshire CCG and NHS Luton CCG. We are currently in discussion with NHS England about financial control targets in the next two years following which we will be able to make a fully-informed view of this any additional pressures this might introduce in the period up to 2020/21.

3. Matters of specific interest to Acute Trusts

Q3.1 What does the STP work on secondary care mean for the future of the three acute Trusts?

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A3.1 We’re not sure just yet. We do know that if each of the three Trusts continues to operate in the isolated fashion of recent years, then more stresses and strains will surface.

The STP has made collaborative working between the three acute Trusts the organising principle by which any opportunities, be they clinical, operational or administrative, are being examined.

The executive teams of the three Trusts believe that many of their individual activities are on a convergent path, but talk of merger, takeover and other forms of institutional re-structuring is both premature and it distracts from the main task in hand – to make all three hospitals clinically and financially sustainable, as quickly as possible.

Q3.2 Will the convergence of the three Trusts make it easier to make major changes in hospital services without public consultation?

A3.2 The size of an NHS body has no bearing whatsoever on whether a particular service change being considered requires statutory public consultation. In broad terms, it is the size and nature of the service where change is under consideration that determines whether public consultation is required and Health & Well-being Boards play a central role in this decision.

Q3.3 Will the three Trusts merge?

A3.3 There are no plans currently being developed on an institutional merger of the three acute Trusts in BLMK. We are clear that many of the things we are seeking to do to strengthen the clinical and financial sustainability of our acute Trusts can be achieved without institutional merger.

Collaboration is the watch-word and we expect this to inform and help determine many of the operational and strategic decisions that need to be made by the three independent Trusts. Some examples where benefits can arise without restructuring institutions include:

Taking the best clinical practice, wherever it manifests itself in our three hospitals, learning from it and applying it, where relevant, to help reduce unwarranted variations in resource inputs or clinical outcomes.

Ensuring that, when new ICT platforms and/or new clinical diagnostic systems are commissioned or renewed, there is both inter-operability across the three Trusts and the opportunities for operational standardisation are fully examined and exploited

Where buying at scale across the three Trusts brings economies, to make sure we plan and co-ordinate our activities to leverage our collective buying strength

Where opportunities arise to enrich the clinical or personal experience of our hospital staff, to seize them by offering rotational opportunities across the three hospitals

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Q3.4 If the three Trusts are on a convergent path, are we likely to need a smaller workforce?

A3.4 We’re not sure of the detail yet and indeed, the answer may be different for different activities.

In terms of our clinical specialties, we need to find ways of doing more activity through our existing permanent workforce. This should mean that we reduce our reliance on expensive agency staff. We also need to ensure that activity is moderated by investment in resources outside the hospital, so that clinical staff in our hospitals can focus their time and effort on the acutely ill.

Our early work on clinical support services, such as pathology, radiology and pharmacy, and indeed, non-clinical support services, indicates that some efficiencies could be secured through scale and through greater automation. However, we are not yet at the stage of understanding whether this has consequences for our workforce, either in terms of new skills or headcount.

Q3.5 What does a move to accountable care mean for the three acute Trusts??

A3.5 We’re not sure of the detail yet – and it rather depends on the nature of the accountable care system we choose locally. There are two main forms of accountable care under discussion in England – MCPs and PACs.

PACS brings acute care front and centre into accountable care arrangements. In its most integrated (and radical) form, a PACs solution could see traditional institutional boundaries between hospital, community and primary care services erased.

Conversely, MCPs focus accountable care arrangements on out-of-hospital services, and therefore, may have a less dramatic impact on the acute Trusts.

Equally, it would be possible to pursue different accountable care arrangements in different geographic patches across BLMK. For example, Luton CCG might choose to work with Luton Borough Council, Luton & Dunstable University Hospital NHS Foundation Trust, its incumbent community services provider and local GPs to design and implement an accountable care system for health and social care in Luton. Stakeholders in Milton Keynes might choose a different solution that works for them.

The STP expects to examine potential options for accountable care in the coming weeks, with a view to identifying and proposing the preferred solution early in 2017.

Q3.6 What investment is planned in digitisation?

A3.6 Digitisation is a key enabler to achieve our vision of health and social care across BLMK. The impact of a shared (real-time) care record, which is digitally communicable to health and social care practitioners wherever they practice, is expected to be game-changing, especially in ensuring that individuals receive advice, diagnosis and treatment in the most appropriate, and least intensive, care setting.

Investment in digitisation across BLMK is therefore a central plank of our STP.

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In total, our financial assumptions are based on there being a total of £52m investment in BLMK’s digital infrastructure, systems and communications capability between 2017/18 and 2020/21.

4. Matters of specific interest to Community Trusts

Q4.1 What’s does the STP have in store for community health services?

A4.1 A total of £80m (or 6% of the total health and social care spend) pays for adult and children’s community health services in BLMK. Three Trusts currently supply the lion’s share of community health services across BLMK, albeit each serves a separate CCG.

It is a clearly stated ambition for the STP to reduce hospitalisation, to strengthen care delivered in primary and community settings and to enrich social capital. Strengthened community health mental and physical health services, for both adutls and children, are crucial if we are to achieve this ambition.

This “once in a generation” improvement in the strength, resilience and modernity of primary, community and social care requires significant planning and investment (both recurrent and non-recurrent) and the development of more innovative and integrated modes of delivery.

From a somewhat under-developed base, the STP is seeking to design, create and mobilise a sound organisational, contractual, digital, workforce and estates platform to enable primary care, community health services and social care to operate at scale and to maximise the benefits that can arise from co-ordinated and/or integrated working in the community and in homes. The STP’s Priority 2 will focus exclusively on strengthening care delivered in community settings.

STP partners are keen to capture benefits from increased service integration and co-working that could arise through the development of a multi-specialty delivery model. This will need to be underpinned by contractual arrangements that incentivise organisations, teams and individuals to work collaboratively and to simplify and improve services delivered in setting outside hospital.

There is also a strong appetite to explore broader opportunities for co-working outside of the health and social care sector with, for example, housing, education and welfare, to provide holistic care supporting the health and well-being of the population. Further benefits could be derived from greater connectivity, potentially by increased co-location and/or systems inter-operability, between the NHS and local Councils. This should enable NHS bodies to become more familiar with activities, initiatives or agencies working to address wider challenges that have a major bearing on the health and well-being of our population (for example, housing, education and skills attainment, employment air quality).

5. Matters of specific interest to Mental health NHS Trusts

Q5.1 How is the STP making sure that mental health continues to feature prominently in the STP?

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A5.1 Without seeking to underplay BLMK’s challenges in improving the mental health of our community, our “As-Is” analysis highlighted that:

Well in advance of the STP being created, BLMK CCGs have recognised the need for a step-increase in investment in mental health services for both children and adults, and this features prominently in commissioning intentions

Albeit from a challenging base level, the quality of BLMK’s mental health services is seeing a rapid improvement, due in large part to the contribution that ELFT and CNWLT have made as BLMK’s “cornerstone” providers of mental health

All BLMK CCGs have expressed considerable confidence that they will achieve NHS England’s nationally defined mental health diagnosis, access and referral standards

Notwithstanding the above, we will be looking to integrate mental health within all STP workstreams. Both mental health Trusts have nominated their (BLMK) prevention Board champion, and this will provide a strong platform for their involvement in Priority 1. The Trusts are also part of certain Priority 2 work packages and will be represented on the Priority 4 Digitisation Programme Board and this is an omission I have asked be remedied.

Mental health colleagues have been embroidered into BLMK’s urgent and emergency care work package and the composition of those clinical groups looking at secondary care services is being reviewed to ensure that the contribution of mental health colleagues is being harnessed. Finally, BLMK’s Priority 5 our October STP submission signalled that mental health Trusts will be represented on the overarching Accountable Care System Activation Board.

6. Matters of specific interest to GPs

Q6.1 How have GPs been involved in developing the STP?

A6.1 We know that GPs are crucial to us achieving our aim of clinically and financially sustainable health and social care services. We also know that, alongside our hospital emergency departments, they find themselves in the front-line in trying to cope with growing demand.

Our STP analysis shows that, at 2,349 people, the average list size per GP in BLMK compares unfavourably with England as a whole. Luton is a particular outlier at 2,699 patients per GP.

We also know that, with 24% of our GPs over 55 years of age (compared to 20% for England as a whole), we have an older GP workforce than is the norm, and local recruitment challenges for new GPs are considerable. Our primary care infrastructure is fragmented, is, in some cases, somewhat isolated from other services that could ideally be offering support and is some way from being fit for its future purpose.

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We have sought to engage GPs in two ways. First, by involving the CCG Clinical Chairs as members of our STP Steering Group. All three are inspirational, practicing GPs and have helped steer our thoughts and recommendations so far.

Second, we have tried to get out and about and to meet with practicing GPs so that we understand their concerns and we hear about their ideas and recommendations about what some of the solutions are. We have also taken the opportunity to test our thinking, especially in terms of system-level solutions that might lighten their load, but which also enable them to focus their attention on patients with complex and/or specialist needs

We have worked with one large practice in Luton to analyse the demographics of their practice list and the associated referral patterns of people presenting to GP clinics, so that we get a clear and detailed picture of demand, and how that demand is currently being dealt with.

In addition, we have held two multi-stakeholder events which were attended by over 400 local clinicians, many of whom were GPs, to describe and then discuss our plans and priorities.

Q6.2 What sort of help might GPs look forward to in the future.

A6.2 Quite a lot of the STP’s focus has been on ways to strengthen primary care. The goal is to free up GP time to focus on those with complex, chronic or specialist needs but who, with a bit of help, do not need to go into hospital, and indeed, can maintain very independent lifestyles.

Ironically, our analysis indicates that the solution is not more GPs – which is useful given the pipeline is a little weak. Our solutions seek to wrap additional clinical and analytic support around GPs and their practices, equating to an additional 531 WTEs by 2020/21, in the following ways:

Enhanced primary care (EPC) – building on the registered list and GP practice through the addition of 299 WTEs by 2020/21, EPC will support population health management and prevention by directing the efforts of an enhanced EPC team focused on proactive and anticipatory care. Through new roles and capacity, EPC seeks to enable existing clinical professionals to work “to the top of their license”

Complex care management – focused on non-ambulatory patients, with complex care needs and advanced illnesses, enhanced community based care (at home, in care homes and in community hospitals), an addiotnal 83 WTEs by 2020/21 will be supported by specialist GPs or community-based specialists. It is linked to, but distinct from, EPC teams

Single point of access – a single inbound call center (dealing with urgent and non-urgent enquiries), bringing together, in a single clinical hub 111, 999 and NurseLine capabilities, and that offers informed triage to direct physical and mental health care and to guide service users requiring further support form statutory or non-statutory agencies. This will be supported by investment in additional 94 WTEs by 2020/21

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Acute-based care management – acute hospital based care (covering admission, discharge and transition to other care settings) focusing on improving throughput, so that use of secondary care capacity for specialist care is maximized

Referral management – managing and directing GP to specialist referrals, with clear standards and processes to ensure shared decision making, choice and access against national standards with the twin goals of reducing variation and maximising effective and efficient use of capacity across the continuum of care. This will be supported by investment in additional 55 WTEs by 2020/21.

Q6.4 When money is hard to come by, how can we afford the level of investment that is planned for primary care?

A6.4 NHS England has established something called the Sustainability and Transformation Fund (STF). This is recurrent money, and has been established by NHS England to support just the sort of initiatives that we would like to introduce to strengthen our own primary care platform. If a strengthened primary care platform can play a role in re-directing activity that would otherwise needlessly end up at the front door of our hospitals, this sort of investment can pay for itself very quickly and many times over.

Q6.5 When will the investment start?

A6.5 Our STP assumes that the investment would be made, and the support start to come on stream, during 2018/19. However, we are keen to see if we can accelerate this so we start to reap the benefits during 2017/18.

7. Matters of specific interest to Councils

Q7.1 How have Councils been involved in the developing the STP?

A7.1 From the outset, it’s been our aim to make sure our Council colleagues have sat shoulder-to-shoulder with the NHS as we go about developing and implementing the STP. This has manifested itself in several ways.

First, in April 2016 we established an STP Steering Group to oversee the STP work. The CEOs of all four of our local Councils sit on, and have assiduously attended, our STP Steering Group meetings. One of the Council CEOs is the deputy Chair of this Steering Group.

Second, the detailed workstreams that have been set up by the STP have included officer colleagues from Councils. Indeed, of the five STP priorities now identified, two are being led by senior officers from the Councils and one is co-led by another senior officer.

Q7.2 The Mayor of Bedford has complained that the STP has been produced in the absence of real engagement – is this the case?

A7.2 It’s true that the elected leader of one of our four Councils has complained publicly about a lack of engagement in the development of our STP. In a world looking for

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instant answers, it’s perhaps easy to forget that the STP was only created in April 2016, and indeed, was only asked to begin developing solutions for secondary care services in July 2016. We’ve chosen not to draw hasty conclusions but to try and assemble clear evidence to support any recommendations that we might make.

Equally, the STP is not just about hospitals. Indeed, the answer to sustainable secondary care does not lie in moving secondary care services from one hospital to another – rather it is to be found is strengthening our out-of-hospital services – our GP practices, our community pharmacists, our community nursing services, our social care services, our care home staff and in empowering individuals and family carers to do more.

To date, there has been wide-ranging involvement and engagement in the development of our STP. Such engagement has taken many different forms:

All the workstreams that form part of the STP have been led by and called upon senior clinicians, social care practitioners and senior administrators.

Working events, that have drawn in a wider group of stakeholders, have been held throughout the summer and autumn. These working events have been used to inform our priorities and the implementation plans that are needed to achieve them.

We have been out and about with our local GPs, finding out what the pressures on the ground look like and getting them to help us where we need to focus our effort to make the local health and social care system clinically and financially sustainable.

We have held two multi-stakeholder events, both in Bedford, which were attended by over 400 local clinicians, to discuss and describe our plans and priorities

Our October STP plan, which remains work-in-progress, is the third time we’ve drawn together our thinking into a formal submission for regulators. Each of the three submissions was authorised by all 16 STP Partners, including our four local Councils

Notwithstanding the above, the Mayor of Bedford may be reflecting some concerns about a lack of engagement, not with Council officers, but with elected representatives and the general public. It’s true to say that we have been keen to ensure that, when we do engage the public first, we have something fairly concrete and sensible to say to them, and second, we have received the benefit of feedback from national NHS bodies on our priorities and our associated implementation plans.

This is why we planned for our public engagement activities to start from November 2016. These are not one-off events. Equally, we hope that they don’t descend into a singular, constraining narrative about what our local hospitals might look like in the future.

Q7.3 What does the STP say about health and social care integration?

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A7.3 It’s a big priority and a big prize if we can achieve it. The STP is hugely encouraging about health and social care integration.

The design and composition of the STP itself is an acknowledgement of the need for local leaders with responsibility health and social care to work together. Equally, the STP has sought to examine and to address future funding pressures across BLMK, irrespective of whether such pressures manifest themselves with one of our Councils or with one of our NHS organisations.

Three of the STP’s five priorities aim at making it easier for health and social care practitioners to work together.

i. Priority 2 focuses on integrated service delivery by NHS and Council staff. It also seeks to strengthen the contribution that our non-statutory workforce can make to health and well-being, notably community pharmacists, care home staff and family carers.

Priority 2 is recommending two service development programmes, one of which, “Better Care, Closer”, involves, amongst other things, integrating the workforces providing primary care, community health and social care, for both adult and children’s services, to deliver linked/integrated care at/close to home.

Priority 2 will also see substantial Investments in new care models which will offer better support to care homes by local primary and community clinicians.

Our estates planning work at the STP level is seeking to lever work already being undertaken by Councils under the government's One Public Estate initiative. BLMK’s STP investment plans signal a strong appetite to develop and co-fund, with some local Councils, locality centres, accommodating multi-disciplinary health and social care staff, alongside other local public services, such as housing.

ii. BLMK’s Priority 4 workstream is led by one of its local Councils. BLMK Councils have invested funding in the STP to develop a co-ordinated approach to a cross-footprint Digital Roadmap. We are recommending both investment and convergence in information and communication systems and technology across both NHS bodies and the four local Councils

Priority 4 is also expected to enable jointly accessible care records and links to associated care plans. This should benefit real-time decision making by both health and social care practitioners, accelerate the pace at which integrated services can be operationalised and reduce duplication of effort and resource across health and social care

iii. Priority 5 is looking at how we can change the way the system operates so that it is much easier for NHS and Council services to be planned, funded and delivered in a more co-ordinated way. Accountable care approaches provide an opportunity for the NHS and Councils to pool budgets more comprehensively than is currently the case.

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We also want to make sure that we ease the administrative burden placed on local bodies when commissioning or delivering health and social care services. This should mean that, for example, we can reduce the number and complexity of contracts that exist and need managing, that we start to measure the right things, such as outcomes, rather than inputs and processes, and that we place incentives in the right place to improve the outcomes we now measure.

Q7.4 What does the STP say about prevention?

A7.4 Prevention has long been the Cinderella of health and social care services. The STP is seeking to change this, and prevention has been elevated so that it is now one of our five STP priorities. This workstream is led by the four local Councils in the STP.

Their work has already pushed prevention up the agenda of all NHS bodies by brokering the appointment of Board level prevention champions for all STP partners. These champions are responsible for ensuring their organisation commits to keeping people healthy. They can do this, in part, by working with our STP Prevention Team to develop and implement an organisation-wide Prevention Plan and enabling and advocating for successful implementation of the Prevention Plan inside their organisation.

The main mechanism through which the STP’s “Prevention Goals” will be achieved is through the development and implementation of organisation-specific Prevention Plans. These plans will set out the agreed actions that each STP partner will take to will ensure that a culture of prevention becomes embedded within their organisation and to deliver a radical upgrade in prevention. It is expected that the Prevention Plans will be finalised and signed off by March 2017.

The Prevention workstream is also progressing “evidence-based service developments”, the outputs of which are business cases, and, from there, preventative service developments. Two of these are expected to be delivered by March 2017, namely

Fracture Liaison Services Business Case

Social Prescribing Hub Business Case

stp q and a… · web viewcollaboration is the watch-word and we expect this to inform and help...

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