The lowdown on #Dorset Sustainability & Transformation Plan

The 21st October  Dorset Final Sustainability and Transformation Delivery Plan is not in the public domain, since in a late change of plan NHS England instructed the Sustainability and Transformation Plan (STP) Leaders not to publish the Plans once they had sent them in to NHS England .

Instead NHS England told them to publish summaries within local organisations’ board papers by mid-December – but only after NHS England’s Communications staff have made sure they are spun in  way that  “gives the public a good understanding of the proposed changes” and that they “articulate tangible benefits for patients” in language that is “clear and compelling”.

Roger Davidson, NHS England head of media and public policy, has been in touch with Footprint STP communications leads to begin this process.

It is rather weird that NHS England is so anxious to spin the Final STPs that they won’t allow them to be published, when one of the questions they asked these STPs to set out is the “degree of local consensus among organisations” and

“how you have held meaningful strategic conversations with both NHS Boards, CCG Governing Bodies and local government leaders”.

Council leaders across England, with very few exceptions, are telling the public they know doodly squat about what’s in the STPs. (Of course, this might not be the truth.)

The other reason NHS England has told STP Leaders not to publish the Final STP Delivery Plans is because NHS England and NHS Improvement have to go over the STP figures and make sure they match the commissioner and provider financial control totals imposed by NHS England in July, in the so-called financial reset document.

When NHS England published the financial control totals in July, only the Royal Bournemouth Hospital had accepted its control total. Three other Dorset hospitals had refused.

If you are in Dorset and would like to use this info in any way shape or form to help to Stop the STP, you are very welcome. If you have any questions, please email the STP Agony Aunt, stpagony@gmail.com

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Key points from the 8th June version of the Dorset STP

The draft Sustainability and Transformation Plan presented to the 8 June Dorset Health and Wellbeing Board  shows that Dorset’s projected yearly NHS funding shortfall by 2020/21 is £158m, plus a further £56 million shortfall on NHS England specialised services. On top of that, the nine councils in the Dorset STP “footprint”  together have to “save” over £100 million over the next four years .

Given this severe funding shortfall, the Dorset STP proposes cuts and restrictions to NHS services. Although all spun as improvements.

Cuts to number of GP surgeries and hospital beds

The draft STP presented to the 8 June Dorset Health and Wellbeing Board announces cuts to the number of GP surgeries and to hospital beds.

Hospital beds are due to be cut from the 2013/14 level of 1,810 to around 1,570, although to keep pace with population changes the number of hospital beds would need to increase to 2,465 by 2020/21.

Cuts to acute and emergency hospital services

The 8th June draft Dorset STP relies on the Acute Vanguard programme to develop the clinical networks needed to make the acute hospitals “reconfiguration” work – but it also admits that the Acute Vanguard programme has only received 10% of the funding it had asked NHS England for. So how are these clinical networks going to be developed?

The acute hospitals “reconfiguration” –  code for “cuts” – aims to downsize two major Accident and Emergency (A&E) departments in Poole and Dorchester and close children’s units, maternity units and several community hospitals delivering inpatient care.

The STP proposes that the Royal Bournemouth Hospital should become the major emergency hospital in the east of the county, meaning there would be only a single A&E department in the area.

Poole Hospital would become the major planned care hospital with a 24-hour urgent care centre.  Patients who needed emergency care would have to go to Bournemouth. The STP doesn’t say anything about the fact that, as reported in Pulse online:

Poole Hospital NHS Foundation Trust, in Dorset, increased its private revenue by 83% between 2012/13 and 2015/16. It is now broadening its private services to include a range of surgical, oncological, diagnostic and outpatient tests.

How much of the proposed new planned care Poole hospital would be for private patients and how much for NHS patients”?

In the west of the county, Dorset County Hospital would remain a district general hospital and retain its A & E Department “largely unchanged” says Dorset CCG except that the most severe cases would be taken by ambulance service to the most appropriate hospital.

The Local Neonatal Unit (LNU) at Dorset County Hospital will be changed to a Special Care Baby Unit (SCBU) for infants born after 32 weeks gestation. This would change the current provision where they treat babies after 28 weeks. Those babies would go to the major emergency hospital in Bournemouth.

Thirteen community hospitals, which mainly operate as rehabilitation units and significantly lessen the pressure on acute hospitals, are going to be replaced with seven “Community Hubs” with beds and five without beds – although 3 of these would have care home beds.

The Clinical Services Review says that the 7 community hubs with beds will have 69 more beds than the 13 community hospitals – but they will have to deal with an additional 10,000 patients who are currently admitted to hospital with urgent care needs.

According to the Clinical Services Review, three community hospitals—St. Leonards, Alderney and Westhaven—will shut and the sites will be used for “other purposes.”

What are all these proposed changes if not cuts?

Dorset CCG mistakenly claims that its proposed “integrated community services” care model is “highly effective”

The 8th June version of Dorset Sustainability and Transformation Plan relies on a largely unproven aspirational model of “Integrated Community Services” to reduce hospital admissions in line with the cuts to hospital beds.

Dorset Clinical Commissioning Group’s report on its Clinical Services Review to its Governing Body meeting on 20.07.16  claims that where its Integrated Community Service care models are in place in other parts of the country, such as Torbay and North West London, “they have been shown to be highly effective in the delivery of community based care.”

It doesn’t say that in NW London the Councils were so concerned about the inadequate performance of these care models that they set up an independent commission to review them. On completion of its work in December 2015 the independent commission, headed by Michael Mansfield QC, called for an immediate halt to the “Shaping a Healthier Future” programme that was setting up this care model.

In Torbay, this care model has not relieved pressure on A&E as intended, and as the 8th June version Dorset Sustainability and Transformation Plan claims will be the case.  NHS Improvement has threatened Torbay and South Devon Foundation Trust with special measures for not not meeting A&E waiting time targets. One of the first “integrated care organisations” in the country, in June 2016 the Torbay hospital trust was also rated “requires improvement” by the Care Quality Commission.

£63m “savings” from “bringing down high intervention rates”

The 8th June draft of Dorset Sustainability and Transformation Plan shows “savings”  – ie spending less than would be the case if the Dorset NHS wasn’t underfunded to the tune of £158m/year by 2020/21 – of £63m from commissioners; this includes “bringing down high intervention rates” –  presumably code for “providing a lot of services and treatments” and stopping some outpatients work and moving care closer to home. How is this going to be cheaper, other than by reducing the amount of services patients can access?

Dorset’s June 8th draft Sustainability and Transformation Plan says NHS providers have to cut their costs by 2%. Presumably this is year on year. It is a big ask and depends on “maximising effectiveness across the workforce” – which sounds like code for “putting even more pressure on frontline clinical staff when they are already working as hard as they can”.

Sustainability and Transformation funding is only allocated to Trusts that accept and stick to NHS England’s financial “control totals”

The 8 June draft STP shows that Dorset is expecting £53m sustainability and transformation funding from NHS England by 2020/21.

But NHS England’s  21st July STP financial reset document shows that 3 of 4 Dorset hospital trusts had refused the  financial control totals imposed by NHS England. Accepting and sticking to these control totals is a condition of receiving NHS England’s Sustainability and Transformation Fund allocations.

Dorset County Hospital NHS Foundation Trust had not accepted NHS E’s control total when the document was published on 21st July. The control total is a deficit of £9.163m. That means the deficit can’t exceed that amount. Because at the time of publication the Dorset County Hospital NHS Foundation Trust had not accepted NHSE’s control total, it had also not accepted the allocated Sustainability and Transformation Fund of  £4.7m.

The same goes for Dorset Healthcare University NHS Foundation Trust, which had not accepted NHS England’s control total. In this case the control total is a deficit of £5.039m and allocated but unaccepted Sustainability and Transformation Funding is £1.92m.

Poole Hospital NHS Foundation Trust is also in the same boat. NHSE’s financial control total, which the Trust had not accepted, is a deficit of  £12.406m and the allocated but unaccepted Sustainability and Transformation Funding is £7.9m.

Only the Royal Bournemouth and Christchurch NHS Foundation Trust had accepted NHS England’s financial control total, which is a deficit of  £1.223m, and it has accepted the allocation of £7.6m Sustainbility and Transformation Funding.

The NHS England financial reset document says (para 6.8) that NHS Improvement is working with provider organisations that are planning a deficit and have not agreed their control totals – but if they can’t resolve the issue, NHS Improvement will trigger the imposition of special measures.

What has happened regarding the refusal of the three Trusts to accept NHSE’s financial control total?

And what will happen next financial year when the financial control total will apply to the whole Dorset STP “Footprint”, not to individual NHS organisations?

Will the position of Royal Bournemouth and Christchurch NHS Foundation Trust remain secure or will there be pressure on it from across the region in order to help meet the region-wide control total imposed by NHS England?

NHS Dorset CCG has a control total of £1,136,895. Is this enough for the CCG to carry on commissioning NHS services as before? Or is it having to look at cuts of various kinds?

The England-wide context

NHS England’s 28 June 2016 letter to Chairs and CEOs of NHS Foundation Trusts and Trusts explains that the total provider deficit in 2015/16 was around £2.45m, with the underlying position around the £3bn mark. For 2016/17, the aggregate planned provider deficit is £550m. This takes into account £1.8bn of Sustainability and Transformation Funding, most of which but not all is earmarked to help reduce the deficit.

Assuming for the sake of argument that all of it is earmarked to reduce the deficit, if my arithmetic is right that still leaves a need for cuts or so-called efficiency savings of £1,199,450bn if the deficit is to be limited to £550m.

The arithmetic is here if you want to check

screen-shot-2016-11-03-at-20-13-23

Privatisation

As for privatisation – although Bournemouth Council might not be discussing NHS privatisation, as Council Leader Cllr Beverley Dunlop states,  the extra Sustainability and Transformation funding that the government announced in the Autumn 2015 Comprehensive Spending Review comes with the explicit condition that it must be used to increase opportunities in the NHS for private health companies.

The 8 June 2016 draft Dorset STP says on one page that the intention is for one or more Accountable Care Partnership will manage and deliver integrated health and social care across Dorset. On another page (19)  the draft Dorset STP says that there are plans to set up 3 Accountable Care Partnerships. Whether there is one or three, Accountable Care Partnerships are vehicles for public/private partnerships like PFI, but for services as well as buildings.

And there is that fact that Poole Hospital NHS Foundation Trust increased its private revenue by 83% between 2012/13 and 2015/16 and is now broadening its private services to include a range of surgical, oncological, diagnostic and outpatient tests. What does this mean for NHS patients’ access to the new Poole planned care hospital that the Dorset STP proposes?

Updated 7 November with info about Poole Hospital NHS Foundation Trust’s increase in private revenue between 2012/13 and 2015/16.

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