In the NHS now we have to focus on the system, not the organisation, and places, not institutions. Our draft plan creates a platform for doing that.
The West Yorkshire and Harrogate STP is a place-based plan, developed by organisations working together. We tackle the three gaps in terms of health, care and finance. In doing that we’ve got to work in a very different way. We have to be clear about what we’re trying to achieve, which is making the biggest difference we can to the outcomes for local people, and delivering the Five-Year Forward View.
Also, we’ve set out some principles, because we’re working in different sectors and places, and we’re in different financial positions. So we have five principles:
• We are ambitious for people receiving care and staff.
• That this STP belongs to commissioners and providers, the NHS and local government.
• We avoid duplication, so we’ve used the governance where it exists already.
• We have a shared analysis of the problem, even if we can’t agree on a solution.
• Subsidiarity – you tackle a problem as close to the issue as possible, so most things get done locally, rather than at a West Yorkshire and Harrogate level.
In West Yorkshire and Harrogate we’ve got six local authorities; we already have a place-based plan, so we’ve built our STP on that and added things that we could only do at West Yorkshire and Harrogate level. There are three tests for those:
• If it’s something rare or expensive, we do it at West Yorkshire and Harrogate level.
• If we discover people are doing something good, we all copy it.
• If there is something we don’t know how to do, we work it out together.
Our plan is built from those six local plans plus the West Yorkshire and Harrogate work, and it’s ambitious and will make a big difference. I would also reiterate that the STP is a plan, not an organisation. You can’t visit the headquarters. It’s a different way of working. It’s not hierarchical, it’s a network of leaders trying to make change happen, and that’s one of the biggest challenges for the NHS – because we have a system built over recent periods on hierarchy and central control.
A clear vision for the future
There are three gaps in the NHS. We’re trying to address the health improvement, health inequalities, the care gap and the financial gap. Most are focusing on the money, but we’re focusing on these things too. So our ambition is to completely change the way care is delivered. At the moment we look at health and care at the end of the telescope – we start at the institution, usually the hospital. And the pressures in A&E are a symptom of things that are going on in the system.
We’ve got a clear vision for the future. You’ll get a good start in life, be supported to live well, so you’ll age well. Supported self-care will be the norm for people with a chronic condition, backed by peer support and technology. Joined-up services in communities will work on the outcomes that are important to people. Hospitals will be networked to be sustainable and centres of excellence will deliver world-class care. All of that will be commissioned by councils and the NHS together, and will involve significant change in engagement with the public. If we’re going to look at the person and their life, there are a number of things we should improve.
We want to increase cancer survival rates to 75% by 2021
To do that, we focus on lifestyle choices that drive cancer, so smoking, obesity and alcohol, in every local authority and health and wellbeing board. We then have to make sure cancers are detected early, so we’re increasing primary care diagnostics. We then need to make sure people can access specialist care quickly, and that the best and most cost-effective treatments are available.
So at each level we build up evidence of the plan, to deliver the outcomes we want. The draft proposals are very high level at this point. The next challenge is to turn them into delivery. So we’re looking at capacity, leadership and what the change means for organisations.
There are 226,000 people at risk of diabetes in West Yorkshire and Harrogate. Some 50% of the population are overweight, which increases their likelihood of getting diabetes and cancer and so on. Each place will have to work differently because they have a unique age and diversity mix.
So we say to the directors of public health, ‘How do we work on this at scale?’ We start by looking at our 113,000 staff and making sure it’s easy for them to be a healthy weight, and do what we can as an employer. Then they can be role models and advocates for other programmes. But we’ve set ourselves a significant challenge, because every developed nation is dealing with obesity and I don’t think anybody’s got it right yet. So, I think we’ll have to be flexible – some plans will work, some won’t and we’ll have to change.
We know that not everybody has access to good alcohol liaison services
We know that people who drink too much aren’t well supported, particularly those who are vulnerably housed or homeless. So we’re looking at the good practice in places like Leeds, where there’s a good service for vulnerably housed people, and aiming to implement it systematically. That’s one of the advantages of an STP – you can take a mechanism that’s good in one place and apply it elsewhere.
Our plan has got to be realistic and achievable
And we’re not starting from scratch. Since 2012, every place that has a wellbeing board has had a health and wellbeing strategy based on the needs of local people. So we’re already ahead if make those the bedrock of what we’re trying to achieve. Every trust has had to produce a three to five-year strategy, every foundation trust has business plans for five years, so there’s a lot of work to build on.
Now, delivering a plan includes doing things that are tricky. For example, we’ve got plans to ensure we have consistent commissioning policies across our 11 clinical commissioning groups (CCGs), which allows us to end the postcode lottery, but might mean some things are no longer available if we don’t have the resources. So we tried to put together something that is achievable if we have access to transformation funding.
We’ve got nine work streams and six place-based plans. Also we’ve got enabling strategies, and workforce is one of them. There are a lot of local workforce advisory boards, and one of the chief executives is leading that with Health Education England. We want to look at primary community and public health staffing, the registered workforce and advanced roles, the non-registered workforce and associate roles and apprenticeships. We want to look at prevention at scale. And if we keep the workforce healthy, it’s more productive and you get better outcomes.
We also want to be a good, flexible employer and make our area a place people want to come
At the moment we’re in an arms race with each other about staffing. So organisations in West Yorkshire and Harrogate will have been trying to create incentives for people to work in their organisation, robbing Peter to pay Paul. We need to say it’s the same system.
So we want to make it easier for people to move around for us to work together, so we retain the workforce, allowing people to develop, which will drive up productivity. We’re trying to show that local government, NHS commissioners and care providers, the third sector, the police, the fire service and a whole host of other people can work together to make our area healthier, with consistent care and sustainable services. But all the regulatory and financial pressures are about individual organisations and more activity being done in hospitals. We also need governance and agents that allow us to make decisions. And we have to address the public debate, which confuses what STPs are for.
The political noise is about underfunding – so the public think the STP is there to deliver cuts
There isn’t an alternative to a place-based approach to transforming care. I think STPs offer power to support leaders to transform care. But we must have the headroom to make changes happen. Also, we need to take the public with us. We must make sure that continues to be the case by engaging with people and asking is this right.
The NHS will always be an important political issue. If you ask the public what defines being British the NHS is in the top two features.
We must understand that political choices have consequences, though. I’ve come back to West Yorkshire after a couple of years away from being a CEO in the region. I’ve now seen a degree of collaboration that never existed before. The hospitals, community providers, councils, charities and CCGs are working together to create new forms, new commissioning arrangements and accountable systems that will help transform care. There is much to give us hope.
Don’t misunderstand me when I say the plan is deliverable – it will not be easy and will require tough choices. It is also the biggest challenge we’ve ever faced in the NHS’s history, so if we achieve it, we should all be incredibly proud.
Rob Webster is lead for the West Yorkshire and Harrogate STP