Sustainability and Transformation

On November 23rd I attended a workshop on Gloucestershire’s plan for health and social care over the next five years. This is grandly named the Sustainability and Transformation Plan (STP). To me the plan seems vague, a loosely assembled pile of ideas for short-term tinkering rather than a real plan for sustainability and transformation.

The full STP document, published earlier this month, is called One Gloucestershire: Transforming Care, Transforming Communities.

The NHS context

The overarching NHS strategic context for Gloucestershire’s STP is NHS England’s 5 Year Forward View (5YFV), now two years old. It’s hard to see that the influence of the NHS England’s strategy on Gloucestershire’s STP has been anything but patchy. At the start of the workshop we were asked who had read the 5YFV, and maybe half a dozen hands or so went up out of around a hundred participants.

For example, in Chapter 1 of the 5YFV, NHS England sets out its “five year ambitions on quality”:

“The definition of quality in health care, enshrined in law, includes three key aspects: patient safety, clinical effectiveness and patient experience. A high quality health service exhibits all three.”

The STP does mention patient safety, but only with reference to work that’s already ongoing . There’s no plan for patient safety, no transformation, and no mention of sustainability.

The STP doesn’t mention clinical effectiveness at all, not anywhere in its 50 pages. Instead, reducing clinical variation features in several places. Checking back with the NHS England strategy, clinical variation wasn’t mentioned anywhere. Gloucestershire seems to have invented this.

The STP mentions patient experience with reference to ongoing work and vague hopes that things will be better.

An external initiative, called a Quality Academy, is said to be able to deliver “system wide learning programmes” but this looks like some kind of training programme for staff, to provide a smokescreen for the lack of concrete quality planning in Gloucestershire.

Further comparisons between the NHS England strategy and Gloucestershire’s plan reveal more of the same misalignment. Gloucestershire’s STP seems to have come adrift.

The gaps

The STP claims there are three gaps in Gloucestershire, but whoever wrote the plan doesn’t appear to know what a gap is. Normally, a gap is a distance between two things, but in the STP there’s no sense of distance between one thing and another that you could reasonably call a gap.

The health and wellbeing gap is described in terms of causes of death:

“Age is the leading risk.”

It’s unclear where we’re heading with this. Abolishing death? Abolishing age?

The three leading causes of death are given in the STP as cancer (27.9%), cardiovascular disease (26.8%) and respiratory disease (14.2%) without any references for these figures.

I looked at the latest Office for National Statistics (ONS) report on avoidable mortality in England and Wales. Only 23% in total were considered avoidable by the ONS. This total includes deaths from cancer (8%), cardiovascular disease (6%) and respiratory disease (2%).

The percentages in the STP are wildly different from the ones given by the ONS. Clearly, they are measuring different things.

It would be useful to know what the gap is between the 8% of avoidable deaths from cancer in England and Wales and the corresponding percentage in Gloucestershire, but we’re not told that. Instead, there’s a list of what are called prevention opportunities with no figures to support them.

The care and quality gap is described in terms of cost savings, not care and quality. And the cost savings are derived from an existing national programme called Right Care, not from Gloucestershire’s STP. Again, there’s a long list of what are called improvement opportunities that don’t seem to relate to the cost savings figures.

The finance and efficiency gap is the only real gap, mainly because the hospitals trust is in deficit. The STP says the size of the gap is £226 million. The plan is to close this gap completely, with well over half (£129 million) coming from “system transformation”.

In the rest of the document, however, there’s little trace of a real plan to deliver any cost savings through transformation. For example, a chart shows reducing clinical variation will save £16 million, but there’s no actual plan describing how this can possibly happen. Presumably it implies that “reducing clinical variation” is a euphemism for levelling services down to the cheapest, but it’s not spelled out anywhere.

In most places where transformation is mentioned in the STP there is no mention of money at all. In a few places the STP says transformation will cost money.

Mental health

References to mental health are sprinkled throughout the STP. For example, in the summary at the start there’s a list containing a bullet point (all capitalised, just like this):

“• Strengthening Mental Health Care and Support”

There are several references to parity of esteem for mental health through delivering the Mental Health 5 Year Forward View, a separate NHS England strategy, but many of the recommendations from that separate strategy are not clearly identified in the STP. This gives the impression that mental health has been pushed aside as a separate subject.

Improvements to mental health crisis care are promised in a couple of places in the STP, which is welcome because the Care Quality Commission’s rating of the current crisis service as “outstanding” seemed unreliable to me.

At the workshop a presenter said that the eating disorders service (which the CQC mysteriously chose not to inspect) and services for ADHD would also get attention.

New services for personality disorder, perinatal mental health and for young people are also promised by the STP. However, promises like these are often made in such documents. They do not mean much. I still have a copy of the strategic plan published in 2010, which promises a specialist personality disorder service.

Conclusions

The STP gives the impression of an almost complete absence of planning. A huge pile of uncoordinated projects has been loosely shovelled into chapters and re-jargonized with some trending buzzwords.

I have no doubt that some of the projects are good. Perhaps many of them are good. But there’s no real transformation here. This is just tinkering, and it’s how things have always been.

Real sustainability is also missing. A participant in the workshop pointed out that while funding is being allocated to some new projects, the funding for some valuable existing work is being cut. His complaint was specifically about support for carers. Although carers are mentioned plenty of times in the STP, it’s all vague niceness. It seems likely that many of the projects in the pile will turn out to be as short-term as that support for carers was.

It’s for these reasons that I now think of the STP as the Short-term Tinkering Pile.