Agenda item

The draft Kent and Medway Health and Social Care Sustainability and Transformation Plan (STP) was publically published on 23 November 2016. This report brings the draft plan to the Committee for information. Work is ongoing regarding the STP programme and a more detailed case for change will be published for public consultation in 2017.

Discussion

The Programme Director for Kent and Medway Sustainability and Transformation Plan (STP) apologised that the Senior Responsible Officer for the STP, who was also the Chief Executive of Maidstone and Tunbridge Wells NHS Foundation Trust, had been unable to attend the meeting. The Programme Director then introduced the report.

Guidance that introduced the concept of Sustainability and Transformation Plans had been provided by NHS England on 22 December 2015. The guidance asked for the plans to do three key things. These were to look at health inequalities and how they could be reduced, to look at the quality and performance of local care organisations and to consider how the finances of health provision could be made sustainable. Partnership working would be key to the future effective delivery of services.

The Kent and Medway STP was proposing significant changes, including in relation to the quality agenda, especially given that a number of local health providers were currently in special measures.

Across Kent and Medway, there had been a £105million deficit in NHS funding at the end of 2015/16, with a deficit of around £125million across organisations providing health and social care. The STP was focused on four themes, which were care transformation, enablers of care, productivity and system leadership. Care transformation was about preventing ill health, intervening earlier and bringing care closer to home. Enablers of care included investing in estates, digital infrastructure and the workforce needed to underpin high-performing systems. Productivity included finding efficiencies in services, procurement and prescribing, while system leadership would see the development of the structures to deliver the other elements and would involve organisations coming together to deliver improvement. It was acknowledged that the reduction in costs for non-clinical areas, such as back office functions, were not as effective as they should be.

The Kent and Medway STP had been identified as one of four national pathfinders in relation to productivity. These were looking at how resources available for frontline care could be maximised.

There were four sub-themes within the Care Transformation theme. The most significant of these was local care. This was about the provision of appropriate care in the community, close to the patient’s home. There were a number of hospital patients in Kent and Medway who were not best served by being in an acute hospital bed. Work had been undertaken in relation to patients, particularly elderly patients, who did not have a clinical need to be in hospital and investigating alternatives to support patient need.

The ability for investment to be made in local care was limited. The aim was to be able to prioritise money being spent on local care by reducing the reliance on acute provision. Current acute provision was quite thinly spread in some areas. One example was stroke care, with all seven acute hospitals in Kent currently providing this. A more effective and efficient service could be delivered through the provision of specialist services at fewer sites.

The same was also true for vascular provision, with it having been identified that focusing service delivery on fewer sites led to reduced mortality. There needed to be a separation of planned and un-planned emergency care as planned care was put at risk by the need to prioritise emergency patients arriving at hospital.

Mental health was a key theme within the STP. The aim was to end the distinction between mental and physical health. The prevention agenda was also key. Refocusing efforts on reducing ill health and promoting prevention would realise benefits to health and social care and to wider society.

A robust programme approach was in place to deliver the STP. Engagement with Medway Council had been positive. The next key step on the critical path was to develop a case for change that would go into detail about why change was necessary. This document would be published at the end of January and it was suggested that this was presented to the Committee.

The Committee raised a number of points and questions as follows:

Appropriate Care: In response to a Member question that asked what was meant by appropriate care, the Programme Director advised that individuals with multiple underlying health problems, who were often elderly, were often admitted to acute hospital beds because of a lack of alternative. This could have a detrimental effect on them, resulting in loss of ability to maintain their independence. Appropriate care would be care that did not result in loss of independence. The STP was a high level document which would require the development of workstreams to identify what appropriate care would look like. What would be appropriate care varied from person to person. The Member said that there was little mention of care homes within the STP. She considered that more care homes and competition would result in prices falling and questioned whether the personal care provided in a home could be part of the package provided to people in their own home. The Programme Director said that there was a need to ensure that care standards were met regardless of the setting. Providers would be held to account to deliver these standards.

Engagement: The Healthwatch Medway representative advised that the organisation had recently been invited to be part of the Communications and Engagement Group and that Healthwatch Medway would be publishing the STP on its website. It was advised that a review of governance of the STP had been undertaken and that engagement would increase. A Partnership Board and a Patient and Participant Advisory Group would be established and a meeting was due to take place with Healthwatch the next week to discuss engagement further.

Financial Challenge: A Member highlighted that there was a £486 million financial challenge facing Kent and Medway if no action was taken and that the plan was to close this to £29 million by 2021, a saving of £427 million. She considered that the proposed changes were not driven wholly or partly by the idea that local care was a good thing. They were instead, due to the extremely challenging financial situation facing the NHS, due to underfunding and the failure to face this. The right to increase Council Tax to fund social care that had been announced by the Government was too little and would not address the funding shortfall. Another Member questioned why they should have confidence in the ability of those responsible for the STP being successful when there was already a funding shortfall of £106 million. He also queried apparent discrepancies in some of the figures within the STP documents.

The Programme Director recognised that nationally, resources were limited and there was a need to make the best use possible of what was available. The financial gap of £486 million was a projection of how the existing budget gap would escalate if no action was taken, based upon forecast demand. There was, therefore, no choice but to look at the model of care and to deliver a strategic plan that enabled provision of high quality care and for this to be sustainable. Plan delivery was not, however, all about financial considerations. In particular, ensuring the best care setting was important.

A Member requested that details of the current health and social care budget for Kent and Medway be provided, along with details of the expected 2020/21 budget. The health and care budget for the current financial year was noted to be approximately £3 billion. Adding in expected increases, it would be around £3.4 billion. It was requested that these figures be included in STP documents and that clarification of the budget figures be circulated to the Committee. It was noted that ability to manage demand was restricted by the fact that healthcare was an open access service where it was not possible to precisely predict patient numbers.

General Concerns in relation to the STP: A Member considered that the four key areas within the STP were adequate but that they would not be meaningful to the general public. The STP highlighted the importance of partnership working but the Member questioned what was actually changing in this area. She considered that the changes proposed by the STP would cause a significant clinical shock. One example of these changes included the aim to limit persons over 70 to a maximum of 10 days in hospital. There had previously been attempts to share patient records across Kent and Medway. These had been unsuccessful and costly, so the Member questioned how this would be delivered in the future. The idea of social prescribing was sound but the Member questioned whether services had the capacity for this to be provided. Overall, the Member was extremely concerned and wanted more reassurance and a look at the STP in more detail to give her confidence that changes being proposed could be delivered.

In response, the Programme Director advised that the document presented to the Committee was the summary that had been submitted to NHS England and that consultation would be undertaken. A more accessible summary document had also been published. The aim for there to be zero use of private beds was in relation to mental health patients. The latest available figure showed this had reduced to 23 in Kent and Medway, although another Member was concerned that this reduction could be partly due to people waiting in hospital and leaving again without receiving treatment or being admitted, due to waiting times. There had been a significant decrease in the number of mental health patients in out-of-area beds. The reduction in out-of-county mental health bed placements was a structured programme to bring individuals back on a case by case basis. The reductions experienced were planned reductions attributed to this programme.

The STP would consider how organisations could work collectively in the most effective way. It was recognised that existing infrastructure had not always supported this. The STP was about enshrining new ways of working. The Programme Director was impressed at how organisations were coming together to deal with the challenges that they faced.

Mental health and engagement: A Member was concerned that the aims stated in relation to mental health could not be achieved and considered that mental health provision was at crisis point in Medway. Unless there was intensive engagement with mental health providers, there would not be a clear picture of the challenges faced. There were seven layers of engagement within the STP oversight groups, which seemed rather a lot to the Member. On the other hand, there appeared to be a lack of voluntary sector representation and it was disappointing that engagement with Healthwatch Medway appeared to have only recently started. Engagement should also include the Police. The Member was also concerned about the complexity of the wording used in the STP documents, which would make it hard to engage people with the proposals. Several Members were concerned that there was not enough focus on mental health within the STP, especially given that one in four people would suffer some form of mental health issue in any year. A Member noted that the need for local mental health provision was based upon provision being provided within 15 miles of the patient’s home. However, there was no acute mental health inpatient provision within 15 miles of a significant number of the Medway population. The Member acknowledged that this situation was improving.

The Programme Director said that there would be support from communications and engagement colleagues. Engagement with the Police would take place via the Partnership Board that was due to be established. Engagement also took place via the Kent Chief’s meeting, which the Police were members of. There would be a focus on how to engage with the voluntary sector. He acknowledged the concerns around mental health in Medway. There had been a debate about whether mental health should be included within the STP as a separate section, as this could be seen as mental health being something independent of physical conditions. However, the danger of this was that there would not be enough emphasis on mental health. It had, therefore, been included as a separate workstream within the STP. With regards to prevention, individuals would be supported to manage their mental health needs. The definition of what amounted to local provision would need to be considered further. The key to addressing mental health difficulties was in individuals being able to access high quality local provision. Mental health provision needed to be embedded with physical health. A Communications and Engagement Plan was under development. 

Social Prescribing: Social prescribing was nothing new and a Member welcomed it. However, its success would require GPs to be properly engaged with it. The Programme Director acknowledged that arrangements would need to be put into place that would facilitate social prescribing.

Demographic Challenges: The significant forecast increases in the number of over 65’s and over 85’s during the next five years in Kent and Medway were highlighted by a Member. This would lead to a large increase in demand for health and social care provision. He considered that it was not clear from STP proposals how this increase would be accommodated, especially given the challenges already facing health provision. The increase in the total population would also need to be factored into plans. It was questioned what the current ratio of frontline to back office staff was and how this would need to change to cope with service demand. Another Member asked what use of population data was made in health planning.

The Programme Director advised that a key reason for the focus on local care was the demographic challenge. There were limited resources available so the challenge could not be met simply by spending more. Even if more funding was available, workforce challenges would remain as there were not enough GPs and other health professionals available to be recruited. There also was not the capital available to build new hospitals. System redesign was required to make the best use of the available workforce. The best way of doing this was to focus on the local care model and to create multi-disciplinary care delivery to make provision more robust. In relation to population projections, Office of National Statistics forecasts were utilised. In order to provide a greater degree of accuracy, other sources were utilised, such as public health and local authority figures.

Successful Delivery of STP: A Member said that healthcare was arguably the most important service in the country and felt that the comments previously made by another Member in relation to underfunding of the NHS was somewhat of a political point. Overall, he considered the STP to be a good plan with a lot points contained within it. The Member asked how confident, on a scale of 1 to 10, the Programme Director was that the STP would be successfully delivered. The Director said that there was no option but to change and was confident that the changes would be delivered.

STP Priorities: A Member asked whether there should be emphasis on the Stroke Services and Vascular Services review within the STP as these had already been taking place prior to the commencement of the STP process. The Member also noted that falling GP numbers had been a concern for many years and that this should be made a priority within the STP. The Programme Director said that there would be a need for a joint strategic health plan to be developed even if the STP had not been mandated by national guidance. It was for this reason that the STP included plans and focus areas that had already been under development. GP numbers were an ongoing challenge, with there not being enough new GPs. This would take time to address. The Programme Director suggested that Kent and Medway needed to be made more attractive as a place for doctors to work. The establishment of a medical school in Kent and Medway could help to address these challenges.

Long Term Planning: A Member asked how STP planning was being linked to longer term plans for the area. The Committee was informed that although the national STP guidance specified that the Plan should cover a five year period, longer term planning considerations were factored into the STP locally. This had included close working with colleagues at Medway Council.

Comments by Interim Director of Children and Adult Services: It was considered that industrialisation of preventative measures was required. While there would be growth in demand due to an increasing number of older adults, there were also growing pressures due to preventable conditions in younger adults, such as the misuse of alcohol. Improvements to integrated working with healthcare were already been made before the start of the STP process. There would be a need to map health and care resources around integrated hubs to enable primary care to utilise the resources more effectively. In relation to mental health, there were growing concerns. A successful workshop had taken place in relation to an Integrated Mental Health Strategy. It was suggested that further information about this work with Kent and Medway NHS and Social Care Partnership Trust and NHS Medway Clinical Commissioning Group (CCG) should be presented to the Committee in the New Year. In relation to the joining together of IT systems for Kent and Medway, there was not enthusiasm for this due to the difficulties previously encountered. The CCG had been allocated some money from the Estates and Technology Investment fund to look at the procurement of software that would enable existing systems to interface with each other.

The Committee agreed that Medway hospital was important for Medway and that it must be retained and not downgraded.

Decision

The Committee noted the draft Kent and Medway Health and Social Care Sustainability and Transformation Plan, the progress made to date and provided comments on the Plan, with it being agreed that an update would be presented to the Committee at the March 2017 meeting.