Download SSTHC Briefing on STP (PDF)
Contents
Introduction
The Northumbria, Tyne & Wear and north Durham Sustainability and Transformation Plan (NTWND STP) was finally released on November 9th as a “draft”, with “local engagement” of 8 weeks from November 23, before the final plan will be released for “consultation” with the public sometime early in the new year. This is a crucial time where, especially elected members may be expected to sign off a draft plan which will shape the whole future of health and services in South Tyneside and Sunderland before the first phase of the “clinical reviews” are put forward for consultation next year. Already, at the Community Area forums people are being told about the “rebalancing” of “duplicated” acute services to Sunderland because they are no longer “safe or sustainable”. This is being asserted without any detailed consultation on the proposals, or independent assessment, or the risks to sustainability and safety to patients if these services are moved from our hospitals. In this briefing we want to redress this balance by raising the questions and answers that show that the STP itself will not “sustain” our NHS and will not “transform” it into a safe health system for patients.
Summary
- The NTWND STP is not a sustainable financial plan. It is the largest cut to the NHS budget ever seen in its history, and is a deliberate attempt to make the NHS unsustainable so that it can be privatised and people charged for care.
- The NTWND STP will not transform our NHS into a safe health system for patients. It is full of policy objectives and models of care that have not been tested first and are not funded. It cuts vital acute services from A&E to full consultant led; ITU, emergency surgery and maternity services in our hospitals. The STP is a plan that will use NHS funding to prop-up the massive cuts to council social funding by massive cuts to health services. This will widen the crisis gap in both health and social care, and is a path to disaster.
- The NTWND STP and its projected massive cut to funding will not close but is more likely to widen the “three gaps” that the STP talks about; health and well-being, care and quality and financial sustainability. No specifics are given on how ill health prevention services that will take decades to have any effect are to be brought about. These preventative services have been slashed over recent years and new community care models have so far not reduced (in any significant way) acute admissions. They are simply advanced as a policy objective to try and justify reduced funding to acute services.
- The NTWND STP 7 Day working plan will introduce – without increased NHS funding – 7 day elective care, but at the same time the same plan will close vital 24/7 acute and emergency services. This means that those who really need access to 7 day services 24 hours will be put at risk as this funding is reduced.
- The NTWND STP not only fails to include independent impact assessments on health services (or any other service), but none of the documents and appendices that were provided to NHS England have been provided to those who are supposed to assess the impact of the NTWND STP.
- The NTWND STP makes no attempt to address the crisis in clinical and medical staff that has been deliberately created but aims to just redesign the existing and diminishing workforce.
- Whether people can self care, or not this does not abrogate the responsibility of the state to provide fully funded community, and acute mental and physical health services accessible to all.
- The NTWND STP has an ulterior aim of copying highly inefficient but highly profitable US style elective care hospitals and Accountable Care Organisations (ACOs) under the control of merged “public” and private corporations with non profitable and reduced numbers of A&E and trauma hospitals paid for by the public sector.
Summary Conclusion – The draft NTWND STP is an attempt to pull the wool over our eyes and the eyes of clinicians, non clinicians and others alike. It is an attempt to try and justify the largest withdrawal of funding and resources from the NHS in its entire history. No serious plan for the NHS can be decided upon under the threat of such a massive reduction in the budget of the NHS. No draft can be put forward and taken seriously if it starts from the direction of a major attempt to destroy the NHS, further open up privatisation and further create the conditions to make people pay for health and social services. Regardless of peoples’ views on the direction for our NHS how can we have a proper discussion on these issues in such a climate. Without establishing public bodies and public services accountable to the people and local communities to provide the services that they need, where health care is a right and its funding is guaranteed, nothing can be properly sorted out. No one should sign up to plans which are intent on massively underfunding, wrecking and privatising health care regardless of the consequence to the well-being of the people. We are calling on everyone to join with us to block these plans and organise to get people involved in the fight with us to safeguard the future of our hospitals and our NHS.
Sustainability
The NTWND STP is not a sustainable financial plan quite the opposite! Just looking at the health budget for all these NTWND CCGs, this budget would be reduced to an annual shortfall by 2020/21 of £641m according to the plan. This is a reduction (at the present level of funding) of between 20-30% of the budgets. To put this into perspective, this would mean for South Tyneside, Sunderland and north Durham much more than the resources to run one of the three District hospitals. However, the plan leaves North Durham to be dealt with “from 2019/2020 onwards”. Its main concentration up to that time is the South Tyneside and Sunderland and the “urgent need to rebalance services across both organisations as it is no longer safe or sustainable for either organisation to duplicate the provision of services in each location.” If almost a third of the expected funding of our National health services both locally and nationally is removed, then all of a sudden hospitals up and down the country will no longer be sustainable or safe. But then neither will it be sustainable or safe for the remaining acute hospitals to treat larger areas that include 100,000s more patients when the expected reduction in acute activity according to the NTWND STP) will only be 1%.
In other words it will not be sustainable or safe for people to travel increasingly long distances for services that will be more overstretched than they are now. The “Plan on a page” states that, “Ensuring every child has the best start in life.” Yet maximum choice of maternity care will not be maintained at our hospitals and the threat of “reducing duplication” will increase the risk and safety of mother and child if services are not available locally. Also, Accident and Emergency services are often highly used by children – again, reducing the number of full capacity A&E providers will negatively impact on children and families.
The Autumn Statement on health and social care prepared jointly by the Nuffield Trust, the Health Foundation and the Kings Fund gives the following as its conclusion on the government’s funding and plan for the NHS and its 5 year forward view:
“The Department of Health’s budget will increase by just over £4 billion in real terms between 2015/16 and 2020/21. This is not enough to maintain standards of NHS care, meet rising demand from patients and deliver the transformation in services outlined in the NHS five year forward view. The pressures on the NHS will peak in 2018/19 and 2019/20, when there is almost no planned growth in real-terms funding. While there is significant scope for productivity improvements in the NHS, the huge pressures now being felt right across the health and care system mean that the pace of change required to deliver £22 billion of savings by 2020/21 is unrealistic. New inflationary pressures are also emerging that will increase costs and make pay restraint harder to sustain. The government will need to address the NHS funding settlement in future financial statements.”
So even, whilst the direction is still the same, these think tanks are telling the government that these plans are not sustainable, or able to transform the NHS in the way that the STPs ostensibly intend. The Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry pointed out the devastating effect on the health care in one hospital where management focused on “financial issues”. Consider the implications of extending this strategy across our whole health service.
“It is clear from the evidence at both inquiries that the Trust was operating in an environment in which its leadership was expected to focus on financial issues, and there is little doubt that this is what it did. Sadly, it paid insufficient attention to the risks in relation to the quality of service delivery this entailed.”
So, by imposing unsafe and unsustainable funding for all our hospitals will not make them any safer if services are moved to a fewer number of acute hospital sites. This is not only likely to increase waiting times for more overstretched services but it means people have to travel further distances from their communities. This further impacts already overstretched ambulance services, bus services, car parking etc., further exhausting the resources of society and impacting on the most vulnerable.
If real sustainability and safety is the aim then most acute services including Accident and Emergency must be provided at the centre of our communities of South Tyneside and Sunderland (as with other similar towns and their communities) and these services properly funded as a claim of the people on the economy that should be made to serve their needs.
Another argument that is used in the STP on sustainability of services is the shortage of clinical and medical staff. Also, the number of patients that a service treats can be declared insufficient to be sustainable for clinical experience and so on. So, for example the transfer of the South Tyneside stroke unit is argued on the grounds of availability of clinical and medical staff and the number of patients it treats is too low for medical teams to gain necessary experience. However, both STFT and CHS are in an alliance so why are the two stroke units not considered in alliance and that the patients that they treat considered as one unit with one medical team, or a team in an alliance. This would have the advantage of organising clinical and medical teams that would operate both hospital stroke wards and yet would mean easy and safe access for both the people of South Tyneside and Sunderland. This already happens with other services. Once the training of clinical and medical staff is tackled, which should be part of the plan, then this could be reviewed into expanding acute stroke and stroke rehabilitation services to meet the increasing demands over the next decade. To close one overstretched stroke unit and leave another overstretched stroke unit to deal with an increased patient intake could be argued as equally unsustainable, not safe and maybe even worse! How is this direction of the STP going to safeguard the future of NHS stroke and other acute services? There is no desirability, or capacity for CHS to take the 70,000 annual attendance at South Tyneside A&E, or the capacity to absorb the consultant led maternity services from South Tyneside.
Alex Scott-Samuel in a recent British Medical Journal Blog entitled Tory plans for NHS privatisation released during parliamentary recess concludes that:
“it is no coincidence that the House of Lords is currently calling for evidence to be submitted to its new select committee on the long term sustainability of the NHS. This inquiry, supported by government ministers, is likely to make recommendations that will legitimise the aims of Stevens’ five year plan, including the ‘inevitability’ of top-ups, co- payments, charges, and of the short term personal health budgets and longer term health insurance system that would be required to fund them. This toxic combination of an increasingly insurance based and increasingly privately provided health service will signal the final dismantling of what was once our National Health Service in England – a horrific and destructive act, which we now know to have been first proposed by Prime Minister Theresa May’s predecessor Margaret Thatcher in 1982.”
The NTWND STP is not a sustainable financial plan. It is the largest cut to the NHS budget ever seen in its history, and is a deliberate attempt to make the NHS unsustainable so that it can be privatised and people charged for care.
Transformation
Whilst the NTWND STP is a massive downsizing of the budget of the NHS threatening its sustainability is it a transformation plan? Far from it! Health Trusts are simply signing up to these plans to survive and cover the short falls that they have been forced into by the annual cuts to their budgets dressed up as “efficiency savings”. So, any “transformation” will be paid for by massive cuts to the acute and hospital services that they now provide. For example, the 2015/2016 independent auditors report for City Hospitals Sunderland pointed out:
“The Trust expects to have sufficient cash for at least 12 months from the date of our report (31 March 2016) to meet its liabilities as they fall due, but this is contingent upon the achievement of a Cost Improvement Plan (CIP) target of £14.0m (of which £4.9m is yet to be identified) and receipt of additional Sustainability and Transformation Funding (STF) of £10.6m. This STF is contingent upon the achievement of a number of conditions. There is no certainty over the achievement of the 2016/17 CIP nor the conditions attached to the STF, either of which could have a significant adverse impact on the financial performance and cash flows of the Trust in 2016/17 to continue as a going concern.”
In other words, without the cuts to their spending via the “cost improvement plan” and the income “transformation money” from the STF the Trust will no longer be able to meet its cash flow at the end of March 2017. This demonstrates that the Sustainability and Transformation Funding will struggle to be sufficient to enable City Hospitals Sunderland to “continue as a going concern” let alone transform itself to meet a new population of 150,000 from South Tyneside accessing its acute and emergency services.
Delayed transfers, delays to patients in hospital awaiting transfer to further NHS acute and non-acute care, or delays to patients awaiting transfer to social home provision, or awaiting community care packages in their own home are all in crisis because of the massive cuts to local authority social care budgets. According to the government’s statistical service:
“There were 196,200 total delayed days in September 2016, of which 134,300 were in acute care. This is an increase from September 2015, where there were 147,700 total delayed days, of which 97,700 were in acute care. The 196,200 delayed days this month is the highest figure since monthly data was first collected in August 2010.”
The data goes on to show:
“The proportion of delays attributable to Social Care has increased over the last year to 34.4% in September 2016, compared to 30.8% in September 2015.” and, “The main reason for Social Care delays in September 2016 was “patients awaiting care package in their own home”. This accounted for 24,800 delayed days (36.7% of all Social Care delays), compared to 15,900 in September 2015. The number of delays attributable to this reason has been steadily increasing since February 2015.”
The logic of the government is to supplement the fast disappearing social care budget with the NHS budget which is itself unable to meet the needs of NHS services. The NTWND STP admits the “limitation and risk” that: “Local Authority funding pressures and the potential for additional costs across the health and social care economy with respect to such issues as increases in DTOC (Delayed Transfers) have not been modelled in the financial plan.” Therefore what they are advocating in this STP is a further transfer of funds from the NHS budget to social care. This can only further deplete the NHS budget, causing even more chaos and delayed health and social care for patients of all ages. The NTWND STP will not transform our NHS into a safe health system for patients. It is full of policy objectives and models of care that have not been tested first and are not funded. It cuts vital acute services from A&E to full consultant led; ITU, emergency surgery and maternity services in our hospitals. The STP is a plan that will use NHS funding to prop-up the massive cuts to council social funding by massive cuts to health services. This will widen the crisis gap in both health and social care, and is a path to disaster.
The Three Gaps
Mark Adams lead for the NTWND STP project claims that: “As a footprint, NHS and Local Authority organisations in Northumberland Tyne and Wear and North Durham (NTWND) have come together to work in collaboration on closing the three gaps of health and well- being, care and quality and financial sustainability.” According to Mark Adams the gaps the NTWND STP addresses are:
- Health and Well-being
- Care and quality
- Financial Sustainability
If the NTWND STP is not a financially sustainable plan that funds sustainable transformation it cannot close the other gaps the STP talks about. This is also confirmed by the Autumn Statement of the Nuffield Trust, Health Foundation and Kings Fund (ibid) in the comments above. The NTWND STP consists of a long wish list of health policy objectives that have been articulated previously almost in the exact same terms over many years and have never been realised. In fact the health and social care measures that achieved some advances in preventative health and primary health care in the community have over recent years been almost completely destroyed by the government’s irrational austerity agenda and cuts to health, local government public health and social services budgets. For example the reduction of patients with Chronic Obstructive Pulmonary Disease (COPD) are hardly going to be achieved when smoking cessation teams have long been closed down in the period of this and the previous Parliament. No specifics are given on how local clinical services for this will be brought about. The same can be applied to diet, alcohol and many other health improvement initiatives spearheaded by primary health and public health over recent years which have now in the main ceased or been greatly reduced. At the same time, the NTWNDSTP fails to recognise that the cause of chronic illnesses in the northern region is not just down to “lifestyle choices” but to the centuries of industrial production and the harsh environment it produced for working people.
So, how is it when the health and social care funding has been massively reduced can we believe that the NTWNDSTP will suddenly make a break through on these fronts and greatly reduce the number of hospital and acute admissions when such preventative medicine takes decades and sometimes generations to make a difference.
For example, on November 23 at the Prime Minister’s Question Time when questioned by the leader of the opposition in Parliament Jeremy Corbyn, Teresa May claimed that the Social care precept and the Better Care Fund would help halt hospital admissions for an underfunded NHS. Every councillor knows that the Social care precept is insufficient to halt ongoing social care service cuts. In July, the House of Commons Health Select Committee pointed out in its report that: “The cuts to public health budgets set out in the Spending Review threaten to undermine the necessary upgrade to prevention and public health set out in the Five Year Forward View. We believe that cutting public health is a false economy, creating avoidable additional costs in the future.” Things are no better with the Better Care Fund. In South Tyneside the Better Care Fund uses existing budgets from our hospital and local authority and has not only gone over budget but has not reduced hospital admissions according to the figures released in any significant way.
In other words the claims made in the NTWND STP that there will be a significantly high reductions in hospital admissions are not based on evidence but are highly speculative and should not be trusted.
The NTWND STP and its projected massive cut to funding will not close but is more likely to widen the “three gaps” that the STP talks about; health and well-being, care and quality and financial sustainability. No specifics are given on how ill health prevention services that will take decades to have any effect are to be brought about. These preventative services have been slashed over recent years and new community care models have so far not reduced (in any significant way) acute admissions. They are simply advanced as a policy objective to try and justify reduced funding to acute services.
7 Day Working
One of the prime recommendations in the NTWND STP is the move to a 7 day NHS. For South Tyneside and Sunderland it says page 29: “The Path to Excellence programme will continue to work to develop plans to deliver better quality care across the local populations and enable the delivery of 7 day services so that key quality standards can be achieved, which will ultimately allow financial stability for both organisations.” It says for the “vision” on page 5 “Maintain and improve the quality hospital and specialist care across our entire provider sector- delivering highest levels of quality on a 7-day basis.”
On this subject the whole document is as confusing as Jeremy Hunt the secretary of state for Health! Non-elective acute care is already a 7 day 24 hour service barring consistent access to some services such as MRI scanner, etc. at some hospitals. If the STP is proposing to make elective care on a 7 day basis then that is another story. But is such a service going to be funded, or will this lead to the reduction of 7 day 24 hour non-elective acute care. This seems to be the implication and what is being proposed with the downgrading of A&E services to non 24 hour Urgent Care Centres, or closing them altogether. It is both unacceptable and ironic that in order for Jeremy Hunt to declare a 7 day NHS so that the NHS can perform elective work at the weekends, without proper funding those that really need access to 7 day 24 hour services will be put at risk as this funding is reduced.
The NTWND STP 7 Day working plan will introduce – without increased NHS funding – 7 day elective care, but at the same time the same plan will close vital 24/7 acute and emergency services. This means that those who really need access to 7 day services 24 hours will be put at risk as this funding is reduced.
Risks
Apart from admitting that there are “Local Authority funding pressures and the potential for additional costs across the health and social economy”, there is no independent risk/impact assessment on all of the “top down approach ” of the NTWND STP. The Kings Fund points out; that they “need to be ‘stress-test’ STPs to ensure that the assumptions underpinning them are credible and the changes they describe can be delivered.”
The NTWND STP not only fails to include independent impact assessments on health services (or any other service), but not of the documents and appendices that were provided to NHS England have been provided to those who are supposed to assess the impact of the NTWND STP.
Workforce
In the NTWND STP aim for health staff there is no attempt to address the chronic lack of clinical and medical staff. It suggests that the aim is just to redesign the existing and diminishing workforce. The workforce summary profile shows that “we will see a reduction in the overall workforce from 42,057 to 40,386. This is a reduction of 1,671 (Whole Time Equivalent) WTE (4%). This will be largely delivered by removing current vacancies, not replacing staff on a like for like basis when they leave in the future and also by using staff in a revised skill mix but within existing staff groups (e.g. nursing assistants, assistant practitioners, advanced practitioners etc.).” They continue that it “still requires an efficiency gain within the hospital based workforce of circa 4% to avoid the current reliance on agency staff to fill current vacancies.”
In the community the aim is to “ensure a vibrant Out of Hospital Sector that wraps itself around the needs of their registered patients and attracts and retains the workforce it needs.”
But will the NHS attract and retains the workforce it needs? The Autumn Statement of the Nuffield Trust, Health Foundation and Kings Fund (ibid.) points out:
“It will also be very hard to deliver this change without a stable and engaged workforce. Around a quarter of the £22 billion is expected to come from capping pay increases at 1 per cent a year. NHS employees’ pay has already fallen by 10 per cent in real terms between 2009/10 and 2014/15. With the fall in the value of the pound over recent months, most economic forecasts now expect inflation to increase. This will make pay restraint harder to maintain as the gap between rising living costs and earnings widens. With the service already struggling to recruit and retain enough staff and morale low among large parts of the workforce, it will be critically important to provide strong support for the 55,000 EU nationals working in the NHS to ensure as many of them as possible stay in the UK.
In this context, with limited funds available to support service changes, cost pressures increasing and huge pressures now being felt right across the health and care system, the pace of change required to deliver £22 billion of savings by 2020/21 is unrealistic.”
How is staff recruitment and retention to be improved against this backdrop? The NTWND STP makes no attempt to address the crisis in clinical and medical staff that has been deliberately created but aims to just redesign the existing and diminishing workforce.
What is “self care”?
If there is a word that stands out in the NTWND STP it is the use of the word “self-care”. It is used in an extremely vague way and seems to go with the idea of “home as the hub” and “safe and sustainable health and care services that are joined up, closer to home and economically viable.” It seems it is not referring to putting a sticking plaster on a cut, or taking a paracetamol for a headache but much more serious conditions.
In the 2013 consultation to close acute mental health services in South Tyneside and move them to Sunderland, a similar promise was made to provide more accessible community mental health services closer to home. Many mental health patients would probably agree that they are now “self caring.” However, many would probably interpret this as not “self care” but “fending for oneself” without professional support most of the time because the service is so overstretched. In fact the NTWND STP in its section on Transforming Mental Health admits that by 2020/21 only “at least 35% of CYP patients with diagnosable mental heath conditions will receive treatment from NHS funded community Mental Health services” and only “at least 25% with common NH conditions will access psychological therapies each year.” This is why it is difficult to believe the NTWND STP when it uses the word “self care” and the claim that we will become “empowered and supported people who can play a role in improving our own health and well being.”
Whether people can self care or not, this does not abrogate the responsibility of the state to provide fully funded community and acute mental and physical health services accessible to all.
What is the Aim of the STPs?
The NTWND STP has an ulterior aim of copying highly inefficient but highly profitable US style elective care hospitals and Accountable Care Organisations (ACOs) under the control of merged “public” and private corporations with non profitable and reduced numbers of A&E and trauma hospitals paid for by the public sector.
Conclusion
The draft NTWND STP is an attempt to pull the wool over our eyes and the eyes of clinicians, non clinicians and others alike. It is an attempt to try and justify the largest withdrawal of funding and resources from the NHS in its entire history. No serious plan for the NHS can be decided upon under the threat of such a massive reduction in the budget of the NHS. No draft can be put forward and taken seriously if it starts from the direction of a major attempt to destroy the NHS, further open up privatisation and further create the conditions to make people pay for health and social services. Regardless of peoples’ views on the direction for our NHS how can we have a proper discussion on these issues in such a climate. Without establishing public bodies and public services accountable to the people and local communities to provide the services that they need, where health care is a right and its funding is guaranteed, nothing can be properly sorted out.
The plan whilst hiding all the detail of the “Alliance” between South Tyneside Hospital and City Hospitals Sunderland, claims that there is “the urgent need to rebalance services across both organisations as it is no longer safe or sustainable for either organisation to duplicate the provision of services in each location.” SSTHC believes that this is an untrue statement that is deliberately misleading and should be removed from the document immediately. It seems to reveal a systematic intent to close down all services that are duplicated at our two hospitals by claiming that they are “unsustainable” and “unsafe”. No such claim has been made by the South Tyneside Foundation Trust, City Hospitals Sunderland or by the inspection body Care Quality Commission (CQC). On the contrary South Tyneside Hospital won a 2016 award and was in the top 40 performing hospitals. Our stroke unit which has already been transferred on a “temporary basis” has won an award for its care over recent years. Our consultant led and community maternity services also are among the top performing in the region. Our staff were praised in the STFT annual report by “recognising the outstanding level of care provided by our staff” which was highlighted in particular by the recent Care Quality Commission inspection. It is the cuts driven by the NTWND STP which is clearly calling for the loss of all consultant led acute services including maternity services and not the sustainability and safety record of our hospital. The resulting loss of acute services will be a disaster for the people of South Tyneside and also for the people of Sunderland whose access to acute services will also be under even further pressure by the closure of acute services in South Tyneside.
No one should sign up to plans which are intent on wrecking, massively underfunding and privatising health care regardless of the consequence to the well being of the people. Far from being Sustainability & Transformation Plans it is these plans that will create an unsustainable health service with people travelling further and further for even more diminishing NHS services. Health care is a right and the people should decide on the basis that it is a right and it is a claim on the economy that must be guaranteed. We are calling on everyone to join with us to block these plans and organise to get people involved in the fight with us to safeguard the future of our hospitals and our NHS.
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