Norfolk & Waveney Sustainability & Transformation Plan (STP)

A list of questions was submitted to Dr Wendy Thompson, N & W STP lead, by the NHS Norfolk Action Group (Norfolk NAG). They are here, with her answers, followed by a response from Dr Sue Vaughan of Norfolk NAG and KONP:

12 January 2017

NHS Norfolk Action Group
Sent Via Email: nhsnfkactiongroup@gmail.com

Dr Wendy Thomson, CBE Managing Director County Hall Martineau Lane Norwich NR1 2DH

Tel: 0344 800 8020 Email: wendy.thomson@norfolk.gov.uk

Dear NHS Norfolk Action Group

I am writing in response to your letter of 12 December regarding the Sustainability and Transformation Plan (STP) currently being developed for Norfolk and Waveney.

A report covering all the main points to be addressed in the STP was published and debated at a Full Meeting of the County Council on 17 October and is accessible to all via the Council website. In addition, the STP has been discussed by Norfolk’s Health and Wellbeing Board and the Boards of Directors of all the constituent health organisations and Healthwatch, on several occasions.

The 30 June STP submission was published along with a summary paper ‘In Good Health’. There was also a consultation seminar with 60 stakeholders earlier this summer. The 21 October submission was also published with a revised ‘In Good Health 2’ summary. So it’s simply not correct for anyone to say that the plan is being developed in secret.

Our planning for how services will change over the next five years is at an early stage. Health and social care services in some other parts of the country have been working together for longer on their plans and so are further ahead. Plans are not yet at the point where they have clear messages about things the public want to know.

We set out some ideas for improving health and social care over the next five years in our October submission to NHS England. In many cases it is too early to be able to say exactly what they would mean for people and their families. These ideas need to be tested and worked up in more detail. We need help to develop these ideas into practical plans that will make a positive difference to the health and wellbeing of local people.

We, as a partnership of local health and social care organisations, are currently seeking feedback on our vision, the case for change and the ideas set out in our October submission to NHS England. This is part of our ongoing engagement, rather than a formal consultation being run by Norfolk County Council.

Any changes made would be gradually introduced over the next five years. We will conduct formal consultations on specific changes to services as appropriate and in line with our legal duties.

We have provided responses to your questions below. Yours sincerely

Dr Wendy Thomson, CBE

Managing Director

  1. Please identify how staff have been engaged in this process? The NHS constitution states that “there should be engagement with staff in decisions that affect them and the services they provide, individually, through representative organisations and through local partnership working arrangements. All staff will be empowered to put forward ways to deliver better and safer services for patients and their families”We have established a Clinical & Care Reference Group, which has representatives from a wide range of clinical backgrounds, including consultants, GPs and social workers. They have played a key role in developing our ideas for improving health and care in Norfolk and Waveney. We have regularly updated our workforce about our progress, and we’ve also spoken with trade unions about our direction of travel and ideas.All of the partners involved in producing the STP continuously engage their staff in the development of their services. We have incorporated the views and ideas previously suggested by our staff in the development of our STP and this will continue and be extended as our proposals are developed in more detail.
  2. Please define “locally defined MINIMUM standards”. How do MINIMUM standards fit with the NHS constitution: “The NHS aspires to the highest standards of excellence and professionalism – in the provision of high quality care”It is important that as the Norfolk & Waveney system we set standards that are both ambitious but realistic. The NHS does have a number of challenges but what we cannot do is allow those challenges to affect delivery against the requirements set down by NICE, CQC and other regulatory bodies. We will always aspire to greater things but within the context of financial and quality sustainability.
  3. How can you state that the figures for year 5 are robust when you admit that further work is required to be sure of the figures in years 1-4?The original financial challenge for the STP was to achieve a balanced position in 2020/21, and therefore a major part of our focus has been on where we need to be in year five of the plan. However, all good plans need to have a timescale and subsequent phasing of those actions.The level of detail in the plans at the time of submission to support this phasing was limited and therefore a number of assumptions had to be made to allow for phasing

to be represented. As plans are worked up over the coming months, and further consultation and engagement occurs, it is expected that the phasing will change to reflect those discussions and refined assumptions.

  1. How much did KPMG cost? With highly paid and (one would therefore hope), highly qualified and skilled corporate teams within health and social care – how can this be justified?The Norfolk & Waveney Sustainability and Transformation Plan (STP) is seeking to transform health and care services to make them fit for the future. This ambitious work requires us to call on the best available expertise. As well as working with the people, such as clinicians and staff, who actually deliver health and social care services, the STP is also drawing on external expertise including the use of outside consultants.In August, the Norfolk and Waveney STP appointed business services company KPMG for a 10 week period to help build the case for change and develop proposals in time for the national NHS England October 21st deadline. We consider that the appointment of an independent and experienced external organisation has brought added strength to our STP and will help to ensure proposals are impartial, robust and in the best interests of the whole system. KPMG’s work will be funded from the budget for delivering the STP agreed with the partner organisations across the Norfolk & Waveney health and care system. The total cost of engaging KPMG is £472k shared across 13 organisations.
  2. Staff in health and social care work under different terms and conditions. If staff are expected to work in integrated teams, how will you deal with some staff being on better terms and conditions than others whilst doing the same job?Health and social care are working in integrated teams now and have been for many years, under section 75 agreements across CCGs, NCH&C, hospitals, and NCC adult social care. As our STP plans develop we expect our health and social care workforce to come together and work increasingly in integrated teams. Working in an integrated way puts our patients and service users at the centre of their care and prevents them from having to repeat their story multiple times; allowing them to access the right care at the right time.Experience shows us that when our staff and teams don’t work in an integrated way our patients and service users, particularly those with complex long term conditions, often don’t know who to contact when unwell resulting in an increased use of emergency services. Integration does not mean duplication; working in an integrated way values the individual roles and expertise staff bring from multiple teams and organisations that reflects their different terms and conditions.
  3. What does “reducing the number of procedures with low clinical value” mean? Please give examples.Commissioners produce policies that determine which procedures are commissioned. This process includes reviewing treatments to identify those that do not offer significant benefits for patients so that resources can be allocated elsewhere. For example cosmetic surgery, treatment of minor skin conditions or the criteria which must be met before a tonsillectomy procedure can be performed.

Evidence about effective interventions has been brought together in the national programme Right Care, and Norfolk is adopting this programme like everywhere else in the country.

  1. What does “rethinking of the traditional workforce models mean”?The traditional divide between primary care, community services, and hospitals, largely unaltered since the birth of the NHS, is increasingly a barrier to the personalised and coordinated health services our patients need. And just as GPs and hospitals tend to be rigidly demarcated, so too are social care and mental health services even though people increasingly need all three.The way we train, employ and organise our workforce currently, reinforces this traditional and divided model of care. Over the next five years and beyond our local system will increasingly need to dissolve these traditional boundaries. Long term conditions are now a central task of our NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected ‘episodes’ of care.

    As a result we will increasingly need to manage systems or networks of care not just organisations; our out-of-hospital care needs to become a much larger part of what our local NHS does and our services need to be integrated around the patient. For example a patient with cancer needs their mental health and social care coordinated around them just as patients with a mental illness need their physical health addressed at the same time. We need to rethink and change the traditional workforce model to achieve these changes

  2. How will you achieve responsibility for self-care in areas with levels with high deprivation?At this stage, detailed plans for self-care have not been developed for any area and we recognise that there may be specific barriers to achieving this in areas with high levels of deprivation. We will look to tailor our approach in these areas in order to have the most impact.
  3. How will people have better access to GP’s when there is such difficulty in recruitment and retention of GP’s in this area?Recruiting GPs is a national issue and we are engaging with national bodies to help address this. Not every patient needs to be seen by a GP for all primary care issues. Our plan is predicated on building a range of clinical and care roles working alongside GPs in the community.
  4. How will you stop people going to A&E when the reason they often go is because they cannot get a GP appointment?Our plan is to build a variety of primary care options in the community. In addition we plan to have better advice for patients in communities so that they can better self- manage the most minor ailments that currently present to A&E. One way will be through increased access to pharmacy advice and support.
  1. Where are all the extra GP surgery staff going to work from within GP buildings where all rooms are already fully utilised?We will need to look at flexible options and our Estates strategy for Norfolk & Waveney will assess the accommodation needs and build a plan that optimises existing buildings and is acceptable to primary care and their communities.
  2. What does “faster discharge from hospital from criteria led approach mean”? Surely there is already a criteria used to establish safe discharge?This refers to senior medical staff establishing the criteria under which other professionals may permit a patient to be discharged. An example would be where a patient no longer requires medical treatment on a Friday, but does need to see a therapist before discharge. The consultant would approve the discharge subject to the criteria being met that the patient is seen by the therapist on Saturday before discharge. In this example this benefits the patient in being able to return home earlier without needing to see a consultant again.
  3. What are the plans beyond 2021 given that funding will continue to reduce and the population will continue to increase? At what point do you turn to Government and say that it cannot be done?Our aim is to achieve financial sustainability that will take us reliably into the future. As we undertake the detailed planning for 2016-2021 we will be able to identify the financial issues for beyond 2021. At this stage we do not know what the national economy will look like after 2020/21, how the government at that time will be funding the NHS, or what impact any proposed changes will have had.
  4. What is the current void land value?The current total void land value will be calculated as part of the work to develop the Estates Strategy.
  5. What does “developing ways staff can work to the top of their licence mean”?We have a workforce that is highly skilled and highly trained to deliver complex health and social care in a variety of settings. Often because of increasing demand or staff shortages we find these same highly skilled staff performing basic tasks that could be completed by new or different workers, in other words they are not working to the “top of their licence”.This effects staff morale making individuals feel under-valued when not practising at the level for which they have been trained. As part of our plans we are looking at ways of bringing together practitioners with complimentary skills, often referred to as “skill-mix”, to ensure that our workforce is as efficient and productive as they can be through working to the “top of their licence”.
  6. How do you achieve a more resilient workforce? What does more resilient mean in this context?A more resilient workforce is not just prepared for the changes we need to make as we dissolve the traditional divide between primary care, community services, and hospitals but is actively engaged in driving these changes and improving the

outcomes for our patients and service users. To unlock the innovation that is within our workforce we will invest to give them the tools and techniques to support them through the changes they must make to their working practices.

A more resilient workforce is achieved through continued development of individuals and teams and engaging them in the design and implementation of the changes we will make to the way we deliver health and social care over the next 5 years and beyond.

17. How is care at home going to be provided when it is often the difficulty in providing the appropriate care packages that currently delays discharge? What is going to change for workers in this sector to recruit and retain?

Delayed transfers of care are an issue for health and social care systems across the country. However, Norfolk’s overall rates of delays, and recorded rates of social care delays, mean that we are around the average for the region.
Norfolk County Council has been undertaking work with the domiciliary care (home care) market over the last year to understand and act on issues limiting the provision of domiciliary care. Actions taken include:

  •   Patch based sourcing – this involves working with providers of home care who commit to deliver in an area and to work together to ensure capacity is galvanised and maximised through a more efficient approach to training, response times and travel times. A key driver for this collaborative approach has been the prevention of hospital admissions.
  •   Preventative and asset based approach – in line with the council’s Promoting Independence strategy, a new approach to assessing people has been adopted with a focus on keeping them independent based on their strengths and what is working well in their lives as well as the gaps. This approach seeks to identify alternative solutions that engage with community wide services such as befriending services or the use of the British Red Cross Home from Hospital Service to prevent readmission. This service supports people moving back into their homes following hospital discharge with practical things like heating, bills, shopping, transport and pet care.
  •   New home support model – a new model across all of Norfolk that is focussed less on strict timelines and more on outcomes related to specific support needs that are designed to keep people out of hospital. These needs may include having a healthy meal or attending hospital appointments.
  •   Market development fund – a grant funded opportunity has been established to support behavioural shift of providers to the new model of care focusing on rehabilitation, enablement and promoting independence.
  •   Workforce development, recruitment and retention – NCC has funded a recruitment specialist to focus on recruitment within the care sector in partnership with providers and a recruitment campaign will be launched in Feb/March 2017.
  1. Has an Equality Impact Assessment been produced on the STP – if not, why not? If so can you send it to us?Sustainability and Transformation Plans are intended to address equality issues, by improving the health of the population and the quality of care for patients. Although we haven’t produced a document called an Equality Impact Assessment, we have considered equality issues when writing our submissions to NHS England. As always, we will write Equality Impact Assessments for specific projects. These will be informed by the engagement and consultation that we will conduct on specific changes to services.
  2. When is the STP going out to full public consultation? If it is not, why not?In Good Health has been published and invites views from the public and there are a series of events planned in the community. CCGs and Trusts have discussed the STP submission in public meetings and it has also been discussed at meetings of the Health & Wellbeing Board and Norfolk Health Overview & Scrutiny Committee.We, as a partnership of local health and social care organisations, are currently seeking feedback on our vision and the ideas set out in our October submission to NHS England. This is part of our ongoing engagement.

    Any changes made would be gradually introduced over the next five years. We will conduct formal statutory consultations on specific changes to services as appropriate and in line with our legal duties.

  3. When is the STP going to be scrutinised by the Health Overview and Scrutiny Committee? If it is not why not?We’ve regularly reported to the Health Overview and Scrutiny Committee about the development of our STP. Most recently, they scrutinised the full submission in public on Thursday, 8 December 2016.
  4. As the STP involves cuts and changes to NCC adult social care provision can you outline how and when local accountability and scrutiny will be exercised by Norfolk County Councillors?No decisions about adult social care cuts are made in the STP, or as a consequence of its proposals. Spending on adult social care has been a topic of public debate nationally, and most recently the subject of changes to council tax regulations announced in the local government finance settlement. Budget decisions related to Adult Social Services will be decided upon by NCC’s Adult Social Care Committee, and included in the annual budget-setting at the full Council in February 2017.County Councillors discussed our STP in public at their full Council meeting on 17 October 2016. We’ve also regularly reported to the Health and Wellbeing Board, and the Health Overview and Scrutiny Committee, about the development of our STP. Both of these have Norfolk County Councillors on them. We have also provided written updates and held a briefing open to all County Councillors.
  5. Page 3 There will be significant time lag between investing in public health and actually improving health to the extent of cutting demand for acute beds by 35%. How will acute services be guaranteed to meet need before the real improvements to the public’s health materialise?The plan proposes a reduction in avoidable acute bed days, against the forecast demand in 2020, not against the current years bed days. Prevention activities are not the sole means by which demand for acute services will be managed. There is a

dedicated work stream on out-of-hospital services and also a work stream on mental health, both of which will have a significant contribution to the management of acute demand, i.e. enabling patients to be treated in the community and closer to home, offering benefits to the patient and reducing demand on and length of stay in the acute hospitals.

23. P4 Why is there no RTT (referral to treatment time) target for mental health?

Waiting times for mental health are measured differently to those of Acute services. There is no 18 weeks referral to treatment in the mental health system nationally, however we do monitor the mental health system working in line with this time line. The national waiting times that have been introduced for mental health are as follows.

  1. P6
    IC24 http://www.ic24.org.uk/why-ic24/our-history/ are independent providers represented on the Board. How will conflicts of interest be managed to ensure fairness of contracts and promote public confidence in the board?Governance arrangements are currently under review to ensure that representation from statutory bodies and stakeholders (including independent providers) is appropriately defined on the relevant board or boards as we move into the next stage of detailed planning. These governance arrangements will take into account the risk of conflict of interest.
  2. Would public health or local authorities have powers to influence advertising and selling of sugary drinks and foods in order to achieve obesity targets for adults and children?Local authorities do not have these powers but we will continue to encourage, influence and support others to ensure that all possible measures are taken to curb the advertising and sales of products that are detrimental to health.
  3. P7 & 35 what are the issues where there is no consensus? How will the public be asked their views on contentious issues?As stated in the October submission, there is a good understanding of the key issues facing the footprint and a high level of consensus regarding the solutions required to address these.

CAMHS (Children & Adolescent Mental Health Services) – Eating Disorders – NICE concordat treatment should start within a maximum of 4 weeks from first contact with a designated Health Professional for routine cases and within 1 week for urgent cases. For emergency cases we have a standard response locally of 4 hours, the national standard is 12 hours. This target is to be shadowed in 2016/17 for implementation from 2017 onwards with a tolerance of 95% by 2020

IAPT (Improving Access to Psychological Therapies) – 75% of people referred to the IAPT programme will be treated within 6 weeks of referral and 95% will be treated within 18 weeks of referral . This target was implemented in April 2016

Early Intervention in Psychosis – More than 50% of people experiencing First Episode of Psychosis will be treated with a NICE approved package within 2 weeks of referral. Most initial First Episode of Psychosis occur between early adolescence and age 25 but the standard applies to all people of all ages. This target was introduced in April 2016

Norfolk Independent Care (a trade body for private providers) and

27.

With regard to integrated commissioning, integrated structures are in place with teams of integrated commissioners operating across the county and in each CCG locality and there is a good understanding of the shared pressures that systems is under. Health and social care commissioners in Norfolk & Waveney have for example published a single set of commissioning intentions for 2017/18 and 2018/19.

A review of commissioning structures with a view to reducing duplication and increasing impact is desirable and discussions regarding the nature and timing of further integration are ongoing but at this stage there is no firm model being developed.

The public will be engaged in the resolution of contentious issues through further engagement activities and formal consultations on specific changes to services as appropriate and in line with our legal duties.

P9 How will competing providers integrate?

Our hospital Trusts are already working together; they are for example sharing clinical staff across organisational boundaries. But there are opportunities to develop this further. Our three acute hospitals are liaising and working together as the Norfolk Acute Hospital Group and will develop ideas for greater clinical integration where appropriate.

Our health and care organisations are developing detailed plans for helping patients to be treated nearer to home by doing things differently in the future. Our detailed planning will help identify those opportunities.

How secure is the promised investment? What guarantee is there that success in cutting costs will not result in demands for even further cuts?

Prior to submission of the STP on 21st October, we were informed by NHS England that there would be a process to bid for central funds in respect of national priorities (such as Mental Health, General Practice and Seven Day Services). While there is no guarantee regarding the level of funding, or the ability to access it, to date all formal communications have suggested that this funding is still available.

To answer the second part of this question is not possible, as we do not know what the national economy will look like after 2020/21, or how the government at that time will be funding the NHS and social care.

Where will the hoped for volunteers come from, given the rise in retirement age and benefit sanctions for younger volunteers who are not sufficiently available for work.

Volunteers are an important part of the health and social care system and play a vital role in providing much needed support to patients, carers and service users alongside our employed workforce. For our system we see the role of volunteers as a means of improving quality rather than reducing short term cost.

We also know from the volunteer workforce that we already have that not all volunteers fit the demographic of retired or young unemployed; many of our volunteers come from a range of backgrounds, some seeking opportunities to prepare them before they enter professional health or social care training. As we implement our plans we don’t want to simply grow our volunteers in an ad hoc way

28.

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but will develop a whole system approach as we set out our workforce strategy over the coming months.

  1. What will be done to reverse the difficulty of recruiting and retaining healthcare staff, given that we are not able to re-instate bursaries for student nurses, or migration uncertainties, or the demand for weekend work without weekend allowances?Key to our success in delivering better outcomes to our patients and service users in the next five years and beyond will be moving away from our traditional models of care and so we must adopt the same approach to workforce and workforce supply and not be constrained by the models of pre and post registration training that we have relied upon in the past.By working together as a system we will be better able to manage the movement of staff across our system both to reduce cost but also increase productivity and, by adopting a managed approach, improve retention at the system level. Allowing our staff to move around our system in a managed way improves their resilience and increases retention, as staff have greater opportunities to develop beyond the bounds of one organisation supporting our intention to integrate services.

    We will also harness the opportunities that new funding arrangements bring, such as the apprenticeship levy, to enable us to develop work based “grow your own” education programmes locally and become less reliant upon traditional higher education training programmes that would have attracted bursaries in the past and on overseas recruitment.

  2. Can staff be assured that upskilling is not the same as down-banding?Our staff are absolutely key to us delivering our plans and improving the outcomes for our patients and service users across Norfolk and Waveney. In order to meet the rising demand for services we are facing, our staff need to be trained and skilled to meet ever more complex needs for patients with multiple long term conditions and by developing our assistant and associate staff we are able to free up our trained professionals to work to the “top of their licence”. Therefore this is about the development of and investment in individuals and not about reducing their terms and conditions.
  3. P10 How will patient data be protected from hacking, and services from power outages?Information Governance toolkits are submitted by all NHS and local authority providers, giving evidence to NHS England on compliance with national information governance and IT security standards. Members of the public have access to a report on the assessments of all participating organisations.
  4. Will the CCGs guarantee not to sell ANY patient information for commercial purposes? (Insurance, employment, credit agencies, advertisers etc. would find even names useful)The CCGs are only permitted to process patient information under explicit consent in accordance with the Data Protection Act, subject to a legal requirement, or within the

boundaries of the current Section 251 Application under the NHS Act 2006, approved by the Secretary of State and covering the following main areas of work:

  • Accredited Safe Havens;
  • Risk Stratification; and
  • Invoice ValidationThe CCGs can therefore guarantee that patient identifiable information will only be processed in accordance with their Fair Processing Notice, which excludes the use or sale of information for commercial purposes.Reference to the CCGs’ responsibilities to data security are made within section 9 of their Constitution.
  1. P11 Recognising social determinants of health is welcome, but will the Norfolk and Waveney NHS:
    1. a)  Be able to support the agencies it wants to signpost people to, that are seeing reductions in support from cash-strapped local authorities, e.g. benefits advice?
    2. b)  Advocate for non HS preventive measures, such as clean air, active travel, road safety, grit bins (to reduce falls on icy roads)We have not planned to increase investment in the voluntary sector but are looking to use its resources more effectively.We do advocate for non NHS preventative measures and seek to work closely with other responsible agencies e.g. district councils on these issues, and consider them vitally important. However as these are up stream actions we have not included them in the STP which seeks to directly impact on NHS activity. Further information regarding this can be found in the work of the Health and Wellbeing board and the Public Health strategy for Norfolk.
  2. P12 what plans are in place to meet ongoing need if demand reduction is less than anticipated? When will this be reviewed?Our plans are currently only in outline form. Our detailed planning will model the range of options depending on the demand that is placed on services. The impact of any service changes will be reviewed on an ongoing basis. If demand is not reduced adequately then the changes may need to be refined or further changes may need to be considered.
  3. P13 what alternative care delivery pathways are envisaged? How will capacity be ensured?There will be detailed planning with the public and clinicians to evaluate current care pathways and to identify those that can be delivered in a different way, preferably closer to home where that is appropriate or at centres of excellence where that is needed.
  4. p17 & 45 What has been learnt from the PFI experience, especially with regard to long-term debt servicingNorfolk & Norwich University Hospitals continues to work closely with its PFI partners to ensure a high quality, clean and safe environment for our patients. The hospital

scores well against national benchmarks for patient assessment of cleanliness, privacy, condition, appearance and maintenance of its estates.

  1. How will conflicts of interest be made transparent in the search for 3rd party funding?Any process that pulls money into or out of the system will be subject to existing NHS best practice regarding bidding for new funds or tendering for alternative or new services. Any such process will follow strict governance around delegated authorities and declarations of interests.
  2. How will estates promote care closer to home while disposing of assets?The use of assets is directly linked to the requirements of the STP workstreams specifically with Primary, Community & Social Care and Mental Health. The Estates strategy proposes a full review of any assets prior to any disposals and due consideration will be given to exploring the full potential of the assets before disposal. It has been proposed that no new builds are considered and that existing stock is used for rebuild or refurbishment.
  3. P18 Workforce planning assumes that tuition fees will not impact the number of clinical students. Where is the evidence for this assumption?Workforce planning only tells us the predicted demand we have for staff. The key to ensuring we continue to attract students into our universities and then following training into employment is about the way the organisations within our system work together to make Norfolk and Waveney an attractive place to pursue a career in health and social care.We already have a track record of working very effectively with our universities, particularly UEA and University of Suffolk, to attract students and retain them in training. We are now working together to develop both placement opportunities whilst in training and employment opportunities when qualified that reflect the needs of our patients and service users as our new models of care are developed and as our new self-funding students enter training next year.

    Now that the Government has moved non-medical education over to self-funding it has removed the artificial cap that a commissioned model created and so we are confident that by working together as a system we can attract and retain increased numbers of healthcare students in to Norfolk and Waveney. The creation of the apprenticeship levy and the development of work based education for nurses, through the nursing apprenticeship standard which has recently been published, also means we expect to see further professions develop work based routes in the future as we move to a market led system.

    These new and exciting opportunities to attract our future generations of health and social care workers gives us greater opportunities to address the gaps in our workforce going forward than we have had in the past.

  1. How will we reduce agency costs while selling NHS Professionals to the private sector?Norfolk & Waveney health providers are successfully reducing their reliance on agency staff through a range of measures.
  2. How will the goal of self-funding by 2017 impact on the delivery of care remaining free at the point of deliveryThe self-funding referred to on page 18 relates to how clinical training will be provided in the future and how students will take out student loans to cover the cost of training in the way students currently do in other professions. It does not relate to individual patients paying for their treatment which still continues to be free at the point of delivery.
  3. P23 the Estates Team is expected to be established in 2018, yet much of its work will have been done. Please explainThis relates to the proposal to create a centralised estates team across Norfolk & Waveney which would provide a depth of knowledge and sharing of expertise and would be aligned to the One Public Estate initiative. It would bring sustainability for the long term for the STP. In the meantime a temporary Estates team drawing on existing resources within the STP partnership will be completing the work in 2017/18 as outlined on slide 23.
  4. P25 All of the risks are very real. A net impact of each scheme is given, but please clarify and state best and worst case, and most likely scenarios, as a single figure suggest far more certainty than should be assumedThe numbers used in the financial bridge are based on the most appropriate assumptions available at the time. Due to the complexities of some solutions it was not possible to perform sensitivity analysis on all solutions to cover all possible outcomes. However, for the major components of financial impact, high level sensitivity was calculated and included on page 30.
  5. P28 How realistic is the assumption of £45.5m after 6 years of ‘efficiency’ cuts?The £45.5m was the estimated gap for social care in years 4 & 5 of the STP. Norfolk County Council budgets in 3 year cycles so at the time that the STP plan was put together, the national funding position and our own detailed plans were not available so the £45.5m was the best estimate at the time.We have now heard from Whitehall how ministers plan to help address the problems facing these vital services. Government has now acknowledged the need for additional funding, and we have welcomed in particular the one-off grant. Councils have also been given extra flexibility around the amount that can be raised from council tax to fund adult social care. While it is hoped that these measures will help over the next few years, this is not new money and the long term position remains the same.

    NCC is spending more on adult social care each year, not less. These increases are not sufficient to keep up with cost inflation – such as the introduction of the living

wage and increased volume and complexity of service demand. Whilst we are all of aware of the pressures on social care and the difficulties that the target savings represent, this is the reality of the estimated savings which need to be found. Delivering this level of savings will be challenging and can only be achieved by coming together and addressing these challenges as a whole system.

Full details regarding Norfolk County Council’s financial projections for adult social care, its Promoting Independence programme and its role in the shift left, and the management of the risks associated with this programme are regularly and publicly reported to the Adult Social Care Committee.

  1. P36 what changes have been made so far as a result of public engagement?All of the partners involved in producing the STP regularly conduct research and consultations and engage with the public, their patients, service users, staff and the organisations with which they work. Here are just a few examples of the broad range of services we have recently engaged patients, services users and the public in when we are making improvements to our services.
    •   Norwich has had an excellent community heart failure service for many years. It helps to keep people well and out of hospital. However it became clear the service was overstretched and did not cover all of Norwich. As part of our commissioning process we spoke to patients to ask what they thought. As a result of talking with patients and clinicians, the CCG has recently recommissioned the service with more resources.
    •   Norfolk County Council invested an additional £1.1 million in Norfolk First Support (NFS), a service which helps people regain independence, for example after a stay in hospital. This was, in part, a response to how people have told us that they would like to be cared for.
    •   NHS North Norfolk CCG co-produced a new Musculoskeletal (MSK) Physiotherapy service with members of their community engagement panel, which includes adults with learning and physical disabilities. They made changes to the service specification to make sure the service was as accessible as possible.
    •   Norfolk County Council co-produced the Personal Budget Questionnaire with service users to make it easier for people to complete. This is a list of questions about how an individual lives their day to day life. The questionnaire helps the council and person assess the care and support they require.
  2. Local authorities have lost 1/3 of their funding, how will this impact on the shift left?Please refer to the answer provided for question 45.

Response by Dr Sue Vaughan:

Norfolk NAG
Our questions about the STP
19th January, 2017.

Dear Dr Thomson,

Thank you for your response to the questions we submitted to you in December concerning the STP document released to the public on 18th November.

We understand that as a civil servant you see that your job is to try to steer health and social care to a new model with the budget that the government has indicated will be available. Why the budget is so small and whether the plan can reasonably be expected to deliver a solution to the rising demand for care fuelled by an ageing population and the obesity epidemic are questions that it is not appropriate for you to address. The same could be said for most of the STP Executive members, though perhaps not for the GP members.

It seems that elected representatives at County level have weakened their response to the presentation you gave to the HOSC on 8th December, removing one comment from the summary of that event, which we find disappointing . (In addition to looking to design the whole system approach around the amount of money that was available, emphasis should be placed on the importance of lobbying Government at the political level for additional resources to fill the funding gaps.)

If our elected representatives think it is too political to lobby for the proper funding, we have to conclude that we will have to continue our campaign to get the government to recognise the enormity of the crisis, the damage being caused to so many lives and the cost to the economy of underfunding health and social care.

One other point in the HOSC response questions whether acute services will be able to meet demand before real improvements to the public’s health materialise and also questions the reliability of the modelling used as the basis of the plan. This faint criticism reflects many strongly worded reports by a range of bodies, from the Kings Fund, the Nuffield Trust, the National Audit Office, the Health Select Committee, the medical bodies and others.

How much we should spend on health and social care is indeed a political choice in which we all should have a say. How the money should be gathered and distributed is also being discussed, including by a House of Lords committee. There has been a suggestion that this topic needs resolution by referendum. We certainly need to be thinking seriously about the options and their implications. The NHS got away for years with a smaller amount of money per head than was spent in most comparable countries because of the simplicity of the deal, funding through direct taxation, free at the point of use, no bills, no debts and less than 5% on bureaucracy. Over 20% is squandered on the fragmented marketised system we have now and the STPs have nothing to say on this. I was interested to hear you say that NHS spending is shrunk to about 6% of GDP, a sharp drop from 9% in 2011, though I realise there are many ways in which this figure is derived, accounting for the scatter of values given by various sources and the apparent 50% reduction may be an artefact..

Points from your response to our questions..

1. There seems to be no intention to offer face to face meetings with the public. The next step is meetings for stakeholders, which will be notified through the HW website. The consultation that the public can contribute to is the “discussion”, accessed via the In Good Health page of the Health Watch website. No joy for those without internet access then. The consultation closes on 22.1.17

What level of input have Trade Unions had?

We have contacted Health Watch and they say that no decision has been taken about public consultation but that this may be considered at the next board meeting of the STP Executive. We still feel strongly that there should be public meetings so that the public can ask for explanations for some of the proposals and where the plan is heading next.

3.The STP  has no detailed plans in it. How do you intend to keep HOSC and the public informed about developments? Can we ask that a summary be made available to the public at say 6mthly intervals? Or will you make the minutes available? You say the planning has not been secret, can there be more transparency in future? Most importantly, how will the public be notified about any cuts you may feel you have to make?

10. Role for  clinical pharmacists emphasised again but their funding is being cut. They think they can do more in their pharmacies rather than being relocated within GP surgeries. They have strong links with GPs but also want to continue to develop their public health role.

28. How secure is the promised investment?
The NNUH were told by NHSI that they would never see the £14m earmarked for them. Was that a hollow threat or are they still facing this sanction?

30 and 31. New kinds of staffing. It’s a matter of faith what view is taken on the new categories of health and care  workers and time will tell whether predictions will be realised of a lightly trained workforce being expected to do tasks beyond their range and on poor terms and conditions of employment.  What is clear though is that there are not going to be sufficient staff of the calibre we have had up to now, for all the well rehearsed reasons and we are slowly killing the ones we still have.

37. Can we be assured that the capital costs incurred over the next 5 years will be centrally funded, not by entering into a new round of PFI agreements?

45. Funding for County Council spending on social care is clearly desperately precarious still. We are referred to the Promoting Independence programme and its role in the shift left.
The next meeting of the Adult Social Services committee is on 23rd January and we hope to learn more about the plans.

From you I learned that of patients arriving by ambulance who are admitted, 30% have come from care homes. What analysis has been done to understand this?
Is the shortage of nurses in care homes leading to a reduced capacity to keep residents in their care homes?
Is it partly due to a failure to discuss and document end of life choices and to make sure these wishes are followed?
How long will it be before the link to more medical support for care home staff is in place? Will this really be better than a paramedic response?

I hope that steps will be taken to enable debate about the plans for health and care in Norfolk over the coming 5 years but in the meantime I hope you will be able to continue to clarify things for our group.

Yours sincerely,
Sue Vaughan on behalf of Norfolk NHS Action Group.

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