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How will STPs transform care?

How will STPs transform care?
8 March 2017

As sustainability and transformation plans (STPs) began surfacing in the public domain late last year, leading figures in healthcare were criticising them as last-ditch efforts to keep the NHS alive. Simon Stevens, chief executive of NHS England, described STPs as ‘the only game in town’ and Chris Ham, chief executive of the King’s Fund, asserted that STPs must work because ‘there is no plan B’.

As sustainability and transformation plans (STPs) began surfacing in the public domain late last year, leading figures in healthcare were criticising them as last-ditch efforts to keep the NHS alive. Simon Stevens, chief executive of NHS England, described STPs as ‘the only game in town’ and Chris Ham, chief executive of the King’s Fund, asserted that STPs must work because ‘there is no plan B’.

The five-year regional plans were first announced in NHS England’s planning guidance in December 2015 and are designed to tackle three broad issues: improving care and quality; improving health and wellbeing; and making services more efficient. The process is also intended to improve integration between healthcare, social care and other services overseen by local authorities.

The plans were constructed by representatives from clinical commissioning groups, trusts, foundation trusts, and local government in 44 areas across England, each with an average population of 1.2 million.

However, as Plan A, they were looking increasingly bleak. Dr Maureen Baker, former chair of the Royal College of General Practitioners, called for a rejection of STPs that fail to invest enough in general practice.

Meanwhile, the British Medical Association asserted that 87% of GPs in London were not formally consulted about their STP.

The view from secondary care was equally wary over the plans’ contents. Chris Hopson, chief executive of NHS Providers, told the health select committee that the plans would be ‘vastly over-ambitious’
and that the process was at risk of ‘blowing up’.

Despite NHS England pushing back the STP final draft deadline from June to October, every plan was released to the public by mid December, with one, Devon, already beginning the consultation process.

The picture of a future NHS painted by the documents shows many areas are proposing similar schemes to help primary, secondary and community care get in the same game of improving patient care while saving money. But what are these common threads across STPs and will they help the NHS close the financial gap while improving quality of care and population health?

Extending and sustaining primary care

Guidelines written by NHS England to help local health and social care leaders laid out a list of minimum expectations, including a requirement to show ways of delivering primary care at scale. However, different sustainability and transformation plans (STPs) approached this requirement at different levels.

In north east London, footprint leaders are planning for GP practices to serve populations ‘no smaller than’ 10,000, in larger buildings with access to on-site diagnostic services like ultrasound and blood tests. In Bedfordshire, Luton and Milton Keynes, similar plans will involve merging practices or forming partnerships to practise at scale.

Dr Sam Everington, North East London STP’s clinical lead, said working at scale will sustain primary care by managing the bureaucratic workload at different levels. For example, healthcare leaders in the area are considering procuring indemnity at scale across three of the clinical commissioning groups (CCGs), while 36 practices in Tower Hamlets CCG alone are looking to purchase supplies at scale, he says. ‘HR functions, payroll, there’s a whole raft of things that you could do at scale.’ This would relieve pressure so that GPs can focus on patients.

However, other areas went a step further by planning ‘care hubs’, considered the ‘building blocks’ of a vanguard in the multispecialty community provider (MCP) contract framework released in July. This framework says each hub typically serves a population of between 30,000 and 50,000 people.

The Frimley Health plan proposes 14 care hubs across the footprint, where patients can access specialist and family doctors, physiotherapists, social workers, psychiatric nurses and pharmacists, among other healthcare providers. The model is expected to save more than £65m by 2020/21.

Moving care out of hospitals and closing beds

As one of NHS England’s minimum requirements for the plans, nearly every sustainability and transformation plan (STP) has proposed a new care model. Many have opted to set up either a primary and acute care system, a multispecialty community provider, enhanced health in care homes, acute care collaboration or an urgent and emergency care vanguard. But Wider Devon is expanding its integrated care organisation (ICO).

The Torbay area was announced as an ‘integrated care pioneer’ by NHS England in late 2013. In order to spread the care model, footprint leaders from North, East and West Devon clinical commissioning groups (CCGs) are planning to cut the number of hospital beds in half by closing 72 beds.

‘We’ve got a very bed-dependent model of service,’ says Dr Angela Pedder, STP lead for Wider Devon. She notes that a 60-bedded community hospital in North Devon, which costs £75,000 to run, treats only 21 people on average each month. ‘That same resource can support around 82 people with appropriate packages of care and domiciliary support,’ she says. In total the plan is expected to save around £4m each year after reinvestment.

According to Pedder, Wider Devon has 600 people in hospital beds that don’t need to be there, including a large elderly population who deteriorate quickly when confined to a hospital bed. She said: ‘We’ve got a system that’s predicated on beds and we know for some people it causes harm. So if people want to be at home and we’ve got a system that isn’t delivering what needs to be delivered, the task is to enable people to get the care in the appropriate place.’

The new integrated service would see GPs able to refer patients, not just to A&E, but also to care at home, with patients only being assessed once.

Easing the pressure on A&E to meet care standards

This winter, A&E services have felt the brunt of the strain on NHS resources. The British Red Cross went as far as declaring a ‘humanitarian crisis’ as understaffed hospitals across England struggled to cope without enough beds. Yet some of the regional plans have suggested downgrading their A&E services, including Staffordshire and Stoke-on-Trent, which proposed turning one of their three emergency departments into an urgent care centre. The STP said this would lead to a 20% decrease in admissions and a 30% decrease in attendances at A&E, which will not only improve the area’s financial position but also allow their hospitals ‘to meet the national standards for care’.

Saffron Cordery, director of policy and strategy at NHS Providers, says improving the quality of care available at A&E is one of the benefits of concentrating expertise in centres of excellence. ‘If you downgrade an emergency department, you will usually see more effective treatment in a trauma centre,’ she said, acknowledging that some patients will be forced to trade quality for proximity.

‘It’s about concentrating people in the right places,’ she explains. ‘If you have a number of trauma specialists working together you’re much more likely to get better, more comprehensive care then if you’ve got trauma specialists dotted around because we don’t need them in every single place in the country. We need them to use their expertise together.’

This is especially pertinent in places like south-west London, where the workforce is spread thinly. The area has 117 clinician vacancies across five acute sites, which healthcare leaders say will make them unable to meet clinical quality standards. This has lead to proposals in the transformation plan outlining the closure of one acute site to maintain safe staffing levels. ‘We need to use what we’ve got more effectively,’ says Cordery.

Building long-term integration

Another way healthcare leaders are planning to use resources more productively is by setting up accountable care organisations (ACO) – a concept imported from the US, in which one provider takes over the budget for acute hospital care, general practice, mental health, social care, ambulance services and pharmacies. Many places, including Northumberland, Lancashire and South Cumbria and Somerset, are using ACOs to look after the budget for integrated care systems (ICOs).

‘There’s an underlying belief in ACO models that if you hand a large budget to providers and give them more flexibility about how to use that budget, they’ll be able to identify substantial efficiencies,’ says Ben Collins, project director at The King’s Fund. He adds that the flexibility to change how resources, including the workforce, are used is one of the ways that these plans could be a ‘substantial benefit’.

The other way, he says, is in the length of the contract between commissioners and ACO providers. In setting up these organisations, commissioners will be handing over long-term contracts to a single provider or a group of providers, which could last between 10 and 15 years. Not only does this take away any leverage commissioners have by removing competitive bids from other providers, it will also mean transparency about provider performance will be critical. ‘Once they’ve created this very integrated system they will have to work in a co-operative way with the provider system,’ Collins says. ‘They’re tied at the hip really.’

Whether the sustainability and transformation plans (STPs) will be implemented in the next four years, as NHS England plans, or 10 years, as Saffron Cordery from NHS Providers predicts, strong partnerships between commissioners and providers will need to be forged in the process.

‘There are compelling arguments that this type of transformation is the right thing to do,’ says Collins. But, he adds, how dramatic these changes will be, is still anyone’s guess.

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