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BLMK STP Questions & Answers

  1. Generalmatters

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

A1.1.In March of this year, NHS England invited the leaders of health and social care acrossBedfordshire, 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.

Thesepriorities 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 individualsto 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 theytransition between different care settings and we succeed in placingmore care close to the home.

We haveidentified 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 fiveSTP 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.

Q1.4How are decisions made in the STP?

A1.4The 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 thatfall within their statutory remit.

Q1.5The 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?

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

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 difficultieswe will need to overcometo 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.

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

A1.6Since the beginning of July, the work of the HCRhas beensubsumed 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.

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

A1.7In 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.
  • Non-clinical support services– to configure non-clinical support services so theyare 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

Q1.8Is the SCSTB authorised to make decisions?

A1.8The 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.

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

A1.9Although 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 whichthe CCG AOsare kept abreast of progress by the SCSTB chair and the programme support team.

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

A1.10Each of the four different workstreams flowing into the SCSTBare 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.

Where recommendationsare 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.

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

A1.11We 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 engageto add real value to them.

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

A1.12Clearly, 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 thepace, 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 usto 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 harbourabout 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 canconclude 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.

  1. Matters of specific interest to CCGs

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

A2.1CCGs 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.

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

A2.2This 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.

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

A2.3We’re not sure of the detail yet – but, if accountablecare 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 throughthe 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 servicessupply chain - in this way, the number of contracts that aCCG 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.