NHE | King’s Fund: If STPs do not work ‘then there is no plan B’

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14 November 2016

King’s Fund: If STPs do not work ‘then there is no plan B’

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Despite being plagued by problems in their infancy, STPs offer the best chance of improving health and care services, a new report by the King’s Fund has revealed.

STPs have faced strong criticism by politicians, local authority leaders and patient groups. The think tank’s new report, based on interviews with senior leaders in four STP areas, echoes many of these criticisms, especially for the scant engagement with local government, clinical staff and patients and a lack of governance for STP leaders. 

However, it also recognised that the backdrop against which STPs have been introduced – in a time of tight NHS finances and the greater competition sought by the Health and Social Care Act 2012 – is a difficult one, and it has therefore urged the government and the NHS to continue to back STPs. 

“It is clear from our research that STPs have been developed at significant speed and without the meaningful involvement of frontline staff or the patients they serve,” the report concluded.

“But collective action through STPs still offers a preferable alternative to the ‘fortress mentality’ whereby NHS organisations act to secure their own future regardless of the impact on others.”

While supporting the principle of STPs, the King’s Fund’s report made clear suggestions for patients and all parts of the health and care system to be involved in the STP consultation process, along with improved governance supported by changes in NHS regulation.

In response to the report, an NHS England spokesperson said that by the end of this week, at least half of the STp reviews would be published. In recent weeks, a number of the draft STPs have been made available to the public, but serious reservations have been made about the process and the plans. The King’s Fund also noted that officials leading the development of STPs are “struggling with a confused process”, with changing or unclear deadlines and guidance from national NHS organisations.

“I am sure there are things that could be learnt about the process,” said Prof Sir Bruce Keogh, NHS England’s medical director. “But when you are trying to improve care across a whole system, things are never going to be straightforward.”

Recently, the Royal College of Emergency Medicine (RCEM) warned that STPS could have a “catastrophic” impact on emergency care, after a survey revealed that almost a third of CCG leaders are considering closing emergency departments. Shortly after this, the Health Select Committee recommended that the process must include an assessment of the infrastructure investment needed to ensure type 1 emergency departments – or major consultant-led A&E departments open 24 hours a day, seven days a week – are fit for purpose.

The latest King’s Fund report also advised that STPs be ‘stress-tested’ by NHS national bodies in order to ensure that the changes they propose are realistically achievable.

Chris Ham, chief executive of the King’s Fund, accepted that the introduction of STPs has been “frustrating” for many in the health service, but stressed that it is vital to stick to them.

“For all the difficulties over the last few months, their focus on organisations in each area working together is the right approach for improving care and meeting the needs of an ageing population,” Ham explained. “It is also clear that our health and care system is under unprecedented pressure, and if STPs do not work then there is no plan B.

“The progress made so far has only happened because of the hard work of local leaders who have been prepared to work around the difficulties. It is vital that NHS national bodies learn the lessons so far, so that we can see STPs fulfil their potential.”

The Health Foundation recently called for the NHS accountability framework to be revised to accommodate new models of care such as STPs.

Jeremy Taylor, chief executive of National Voices, the coalition of health and care charities, said: “The NHS’s own guidance to STP areas states that ‘involving people, communities and stakeholders meaningfully is essential to effective service improvement and system transformation’.

“While some areas are trying to put these principles into practice it is very variable. We agree with the King’s Fund’s analysis that lack of engagement creates risks. We recommend the Six principles for engaging people and communities, developed by the People and Communities Board, which offers  practical guidance on meaningful engagement.

My reply to We Own It’s “It’s our NHS: Don’t Slash, Trash and Privatise” e-mail

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Over the weekend I’ve received some e-mails from local residents linked to We Own It’s It’s our NHS: Don’t Slash, Trash and Privatise campaign

Dear Cllr Paul Bull.

You may be aware that the government is dividing the NHS in England into 44 areas or ‘footprints’, each of which has a ‘Sustainability and Transformation Plan’ (STP). I believe that these plans are intended to help the government to Slash, Trash and Privatise our NHS – leaving local areas to deal with the crisis that follows.

Jeremy Hunt wants to force councils to quietly sign up to an NHS that simply cannot meet people’s needs within the budget he has fixed.

Privatisation is already part of the waste problem causing this crisis – the market in the NHS costs at least £4.5 billion a year. But these cuts will also lead to more privatisation in turn as the NHS struggles to cope with the pressure.

This is all happening behind closed doors. Only 15 of the 44 plans have been published. The plans are due to be signed off completely by Christmas – yet the public still hasn’t seen most of them.

These plans are dangerous. I don’t want to see an NHS that says ‘sorry, this hospital is closing, you need to travel further to have your baby or deal with your emergency’. I don’t want to see more privatisation.

I am writing to ask you to do two things

1. Demand that the ‘Sustainability and Transformation Plan’ for our ‘footprint’ area is immediately released for public consultation. (The following plans have already been released but need scrutiny: Newcastle, Tyne & Wear • Durham, Darlington, Teesside, Hambleton, Richmondshire & Whitby (Footprint 3) • W Yorkshire • Birmingham & Solihull • Bedfordshire, Luton & Milton Keynes • N Central London • NW London • SE London • SW London • Gloucestershire • Somerset • Dorset • Devon • South Yorks and Bassetlaw • Lancashire and South Cumbria)

2. Oppose the local plan to Slash, Trash and Privatise and refuse to sign up to it. It is part of a bigger plan by government to undermine our NHS as a public service through cuts and privatisation. Some brave councils are already taking a stand for our NHS. Hammersmith and Fulham, Ealing and Sutton councils have refused to sign up to the plans. This is the right thing to do.

Steve Cowan, leader of Hammersmith & Fulham council said: “This is about closing hospitals and getting capital receipts. It’s a cynical rehash of earlier plans and is about the breaking up and selling off of the NHS. It will lead to a loss of vital services and will put lives at risk. Our job is to protect the NHS and this plan is about dismantling it.”

The plans will mean reducing the number of A&E hospitals from 140 to less than 70 across England and cutting hospital beds – while hoping that care in the community (also being cut) will pick up the slack. The plans also include selling off land and assets that belong to the NHS. They include huge shortfalls of millions of pounds – patients just can’t be cared for properly without more funding. The plans may include some good ideas, but overall they are unrealistic about funding and include untested assumptions.

The former head of NHS commissioning Julia Simon has denounced the STP process as ‘shameful’, ‘mad’, ‘ridiculous’ and the plans as full of lies. Only 16% of NHS finance directors believe they can deliver on STP plans.

NHS England health plans assume partnership with local authorities and they imply shared responsibility for the (potentially very serious) consequences. That means you can play a crucial role by refusing to sign up to these plans. This is about local democracy – councils should not allow themselves to be forced into signing these plans.

For more information see the We Own It website: https://weownit.org.uk/blog/its-our-nhs-dont-slash-trash-and-privatise

Health Campaigns Together has a guidance document for councillors here: http://www.healthcampaignstogether.com/pdf/Resource%20pack.pdf

Please don’t sign up to Slashing, Trashing and Privatising our local NHS.

Thank you for your time.

My reply to them is here:

Thank you for contacting me about the Government’s plans for our National Health Service, and your fears that they are using their Sustainability and Transformation Plans to Slash, Trash and Privatise the NHS.

It is e-mails such as yours that give me hope that Nye Bevan was right: “The NHS will last as long as there are folk left with the faith to fight for it.”

You say you are writing to me to ask me to do two things:
1) Demand that the STP for our footprint area is immediately released for public consultation.
The Wider Devon STP was originally leaked in the summer, and the latest draft was published on Friday 04 November 2016.

2) Oppose the local plans to Slash, Trash and Privatie, and refuse to sign up to the STP.
The local authority responsible for public health and well-being for Exeter is Devon County Council, and so I – and my co-councillors on Exeter City Council – will not be asked to sign-up to the STP.

However, with that said I will continue to lobby my County colleagues to oppose STP unless it works for the residents of Exeter and Devon.

And I hope that you have contacted your local County Councillor – Cllr Roy Hill [for Alphington and Cowick] or Cllr Rob Hannaford [for Exwick and St Thomas].

The DCC Health and Wellbeing Scrutiny Committee met on Tuesday 08 November 2016 and considered a report by Jenny McNeill, Associate, NEW Devon CCG.

The Scutiny Committee were concerned that they had no time to read the full STP document before considering the report, so It was MOVED by Labour’s Chair of the Committee, Cllr  Westlake, SECONDED by Councillor Sellis and
RESOLVED that a special meeting of the Committee be arranged (for early December) to consider in detail the recently published Sustainability and Transformation Plan for wider Devon.

I believe this special meeting has so been arranged be held on Thursday 15 December.

And just today the King’s Fund has publishedpublished a report on STP:
Sustainability and transformation plans in the NHS: How are they being developed in practice?

The report suggests that the STPs offer the best chance for health and social care leaders to work together to improve care and manage limited resources. But will the report also questions whether the plans will  succeed where other initiatives have failed?

In particular, the Kings Fund is concerned that little is known about the process of developing the plans and how the initiative has worked in practice.

Key findings:
– Despite the focus on local ownership, key elements of the process have been ‘top-down’;
– National requirements and deadlines for the plans have changed over time, and guidance for STP leaders has sometimes been inconsistent and often arrived late;
– The approaches of national NHS bodies and their regional teams have not always been aligned;
– Tight deadlines have made it difficult to secure meaningful involvement in the plans from key stakeholders, including patients and the public, local authorities, clinicians and other frontline staff; and
– Organisations face fundamental policy barriers to working together on STPs; existing accountability arrangements focus on individual rather than collective performance.

Policy implications
Based on these findings, the report makes a number of recommendations for the future of the STP process. There is a need to:
– secure the meaningful involvement of patients and the public in the plans, alongside clinicians, other frontline staff and local authorities;
– develop governance arrangements that allow organisations to make collective decisions and share accountability
– improve national co-ordination and leadership of the STP process;
– ‘stress-test’ STPs to ensure that the assumptions underpinning them are credible and the changes they describe can be delivered; and
– focus on the skills and resources needed to implement STPs, as well as the cultural aspects of making change happen.

If you need more information on the local situation, this guide – published by Save Our Hospital Services in North Devon – provides a good grounding in what the STP means for Devon.

And on the national scene, the National Health Action Party has published 5 Things You Should Know About STP.

However, that’s not the end of it – the plans for the NHS here in Devon go deeper that the Wider Devon STP.

It must be stated that what’s currently happening to the NHS nationally is a political decision, not an economic necessity – and the changes we’re seeing are a result of Tory dogma.
During Labour Governments up to 2009-10, UK NHS spending rose to near the average of comparable economies – but since 2010 it has fallen sharply.
UK spending on healthcare is significantly below the average of major European economies. If the UK were to increase its spend to 10.7% of GDP, this would equate to an extra £15bn of funding.
The table below shows the current status after 5 years of Tory Government:
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 NHS Funding was the subject of an Opposition Day debate in the House of Commons recently, when Ben Bradshaw challenged  the Secretary of State for Health, Jeremy Hunt:

Ben Bradshaw  [Labour] [Exeter]
The Government have been well and truly found out on this issue. Rather than quote selectively from Simon Stevens, the head of the NHS, will the Secretary of Stateconfirm that among the conditions that Mr Stevens put down to the Government as part of the five-year review was an increase in public health spending, not a 20% cut, and a policy of maintaining spending on social care? Will he also confirm—he was there in Simon Stevens’ presence before the Select Committee—that Mr Stevens made it quite clear that those conditions and others had not been met?

Jeremy Hunt The Secretary of State for Health
Mr Stevens said—I was there—was that social care and, indeed, public health provision needed to be maintained. We are increasing the social care budget by £3.5 billion over this Parliament. Although I accept that difficult cuts are being made to the public health budget, we are doing other things that do not cost money to make sure that we continue to improve this country’s excellent record on public health.

The full debate can be found in Hansard v616 31 October 2016
https://hansard.parliament.uk/commons/2016-10-31/debates/ED226001-FBBB-4E28-9675-5ECF5840931E/NHSFunding

So, although its Tory dogma, it wasn’t what they promised, was it?  I remember well, those Tory promises.
Before the 2010 general election David Cameron repeatedly promised that there would be no more top down reorganisations of the NHS.
So I make this commitment to the NHS and all who work in it.
No more pointless reorganisations.”
David Cameron, speech to Conservative Party conference, 4 October 2006
The NHS needs no more pointless organisational upheaval. It needs no more top-down reorganisations.”

Andrew Lansley, Conservative Party press release, 11 July 2007

In their 2010 manifesto , the Conservatives promised that they would cut bureaucracy in the NHS.
We will decentralise power, so that patients have a real choice. We will make doctors and nurses accountable to patients, not to endless layers of bureaucracy and management.
Conservative Party manifesto, April 2010, p. 45

These promises were repeated in was repeated in the Coalition Agreement.

We will stop the top-down reorganisations of the NHS that have got in the way of patient care.
Coalition Agreement, 20 May 2010, p. 24

Despite these promises, what we did see was that the Tory-led Coalition Government  – with the support of their Liberal Democrat allies –  imposed the biggest top-down reorganisation in NHS history.

Yet under Andrew Lansley, all those promises were broken.

The Health and Social Care Act introduce new layers of bureaucracy into the NHS. New quangos created by the Tories include: Public Health England, Health Education England, Clinical Commissioning Groups, National Commissioning Board, SHA Clusters, PCT Clusters, Healthwatch England, NHS Property Services and Commissioning Support Services. According to the Royal College of GPs,the reorganisation moves the NHS from having 163 statutory organisations to 521.

For more, see Open Democracy’s Cameron’s betrayal on the NHS.

The cynic in me was always sceptical when the Government set up the CCGs – especially here in Devon. I believe they were set up to fail.NEW Devon CCG, which covers Exeter, is the biggest CCG in the country. Yet when it was set up by Lansley’s  Health and Social Care Act, was NEW DevonCCG funded to cope with the demands of local patients? I maintain not.

And now, according the BBC [12 February 2016], it faces an anticipated deficit of £430m by 2019 – and despite cost-saving measures of £239m, under current plans the CCG would still be short by £191m in five years.

So what has happened it that central Government has been able to absolve itself for the responsibililty of any cuts – with the added bonus being that hey can claim it was made by local people – including local clinicians and GPs!

As a result, NEW Devon CCG has been put into “special measures”, the Success Regime.

The reasons given for why NEW Devon was selected include:
–– Increasing health community deficit forecasts;
–– A lack of working together to develop a system wide service and financial strategy.

In September 2015 , Judith Dean, a former nurse who more recently has worked in transformation at Wiltshire CCG, was appointed as programme director. Carnall Farrar, a healthcare and public services management consultancy, were selected to provide consultancy support following a competitive tender. Dame Ruth Carnall, former chief executive of NHS London (and co-founder of Carnall Farrar), will take on the role of chair.

In February 2016, Devon success regime published the Case for Change, which outlines the financial and quality challenges to delivering care locally.

But even now, the Success Regime has been redefined with the publication of the STP.

It appears to me that the STP can only succeed if costs are reduced. And there is only one way to do that – refine need.

One of the proposed ways of doing that seems to be to close hospital services in North Devon. Not only will this be disasterous for the people of North Devon, this will place additional burdens on out own RD&E Hospital.

In addition, NEW Devon CCG is proposing a series of reductions to community beds across Devon – these proposals are outlined in the Your Future Care consultation document

Apparently, it is all about deciding the location of community hospital inpatient beds in the Eastern locality while giving people reassurance as to the improved care they can expect instead, in their own homes.

The proposals have been expressed as four options, outlined in full below. In addition to the consistent and enhanced provision of community health and social care delivered in people’s homes, the services will be supported by consolidated community in-patient beds in the following possible configurations:
Option A Beds at Tiverton (32), Seaton (24) and Exmouth (16)
Option B Beds at Tiverton (32), Sidmouth (24) and Exmouth (16)
Option C Beds at Tiverton (32), Seaton (24) and Exeter (16)
Option D Beds at Tiverton (32), Sidmouth (24) and Exeter (16)

Option A is the preferred option of the CCG – it thinks this combination results in the smallest impact in travel time and has the greatest benefit to the whole pathways of care

Members of the public are invited to respond  to the Your Future Care public  consultation by Friday 6 January 2017.

In addition to the on-line consultation , NEW Devon CCG has organised a series of public events

Your Future Care consultation events
Your Future Care consultation events

The Exeter-based events are:
Friday 18 November14:30 – 17:00 – Whipton Community Hal, Pinhoe Road, EXETER EX4 8AD
Monday 21 November18:00 – 20:00 – St Luke’s Sports and Science College, Harts Lane EXETER EX1 3RD

And the CCG have promised additional events if the demand is there.

There is no doubt that the NHS is under threat from the Tories – both locally and nationally.

To that end, I am planning to support the Labour’s Day of Action on the NHS, taking place across Exeter on Saturday 26 November.

The Save Our Hospital Services held a successful Devon Sees Red event in Barnstaple on 22 October 2016

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SOHS Devon Sees Red event in Barnstaple

And now SOHS plan a Save Devon’s NHS Rally for Exeter on Saturday 03 December. The theme is easy – turn up and wear RED

In conclusion I would like to echo some of the themes being promoted by the People’s Red Line campaign, which calls on the Government to implement 3 simple reforms:

1. Fix NHS funding as a proportion of GDP, equal to the average for developed nations;
2. Remove parasitic privatisations; and
3. End the internal market that has more than doubled management costs in the NHS
The People’s Red Line Campaign aim to do this by calling for:
1. The building of a movement to bring back a state funded, a
state provided and democratically accountable NHS; and
2. Taking part in collective action for lasting change.
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I hope the above clarifies my position on STP

Best wishes

Paul

Cllr Paul Bull

Labour and Cooperative Councillor for St Thomas