STPs – What are they all about? Why are we being kept in the dark?

The public haven’t been given any information about the STPs – the new area plans for changing NHS services. We have a legal right to be involved in, and able to influence, any major plans for the future of Our NHS services. Why are we kept in the dark?

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National NHS Public Voice campaign is challenging the decision by NHS England and other NHS organisations to keep the wider public out of discussions and decisions about the future of Our NHS.

There are NO leaflets to explain what the Sustainable & Transformation Plans are all about.

There IS a page on the NHS England website that tells us a bit about why they are happening.  Here’s what they say:

  • “We are now able to treat people with new drugs and clinical care that wasn’t available in the past.”
  • “As life expectancy increases, so do the ailments of old age and there are now more people with chronic conditions like heart failure and arthritis.”
  • “There are also big opportunities to improve care by making common-sense changes to how the NHS works.”
  • “Improvements that matter, like making it easier to see a GP, speeding up cancer diagnosis and offering help faster to people with mental ill health.”
  • “With services feeling the strain, collaboration between organisations will give nurses, doctors and care staff the best chance of success.”

BUT they don’t mention that the money is the problem.  It’s all because the Treasury has refused to increase the money needed by the NHS to help meet the increasing need and the new technology for diagnosis and treatments.

Nor do they mention that the Plans require all services to find ‘efficiency savings’ out of their smaller budgets.

They also leave out the fact that the average annual increase of NHS funding of 4% over 60 years since the 1950s was reduced after 2010 to an average annual increase of less than 1%.

The crisis in the NHS has been a political choice.

SO in the absence of clear information for the public from NHS sources about the STPs we, the National NHS Public Voice campaign, N-NHS-PV, have written a basic STP information sheet.  stps-what-are-they-all-about

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And here it is (with some links at the end):

 

Sustainability & Transformation Plans (STPs) – What Are They All About?

STPs are the NHS establishment’s answer to the Treasury’s refusal to increase the money for the health, and social care, services we need – with more people, and more needing care, in 2017 than ever before.  But it’s all being done on the quiet, in a rush, with no details and no democratic accountability – no legal back up so that we know who is responsible if things go wrong!

 

Why are STPs happening?

The last two Governments since 2010 reduced/cut the annual increase in NHS funding to less than 1%, after inflation, from an average of 4% over the lifetime of the NHS[1].

  • At the same time  training places for doctors & nurses have been reduced
  • And Bursaries for nurses have been turned into loans
  • All staff have had changes to their working conditions, including added workloads

BUT managers responsible for NHS services have to cope with:

  • Meeting the same quality and safety targets
  • With more people to treat & more treatments available to them
  • BUT with not enough money & not enough staff

They have asked for more money so services can still run – but the Treasury has refused

 

What have NHS leaders done to fix this?

In July 2013 Sir David Nicholson, the NHS boss, made a ‘Call for Action’ asking the public, professionals and politicians to say how could the NHS change to do the NHS cheaper

  • As the NHS had ‘increasing demand’ with ‘new technology’ but ‘flat funding’ (no more £s)
  • & if it doesn’t change, it’ll get a £30 billion ‘funding gap’ from 2013/14 to 2020/21 (7 years)

In October 2014, the new boss, Simon Stevens published his Five Year Forward View[2]

  • He said the same – but the £30 billion ‘funding gap’ was from 2015/16 to 2020/21 (5 years)
  • He suggested new ways of delivering services called ‘New Models of Care’

In January 2015 groups of NHS service providers were selected to start trying out some New Models of Care[3] – e.g. emergency services, community services, etc.

In December 2015 a new Planning Guidance[4] introduced the idea of the STPs

In 2016 local NHS planners, CCGs[5], had to work together in 44 areas across England to plan services for the next 5 years (till 2021) across bigger populations, extra work

BUT all NHS services have to make large ‘efficiency savings’ to help fill the ‘funding gap’

 

What is an STP?  (Sustainability & Transformation Plan)

  • It’s a PLAN to TRANSFORM health & care to be SUSTAINABLE for the next 5 years
  • England has been split into 44 areas, of up to 3 million people, for NHS & care decisions.
  • Each area has to SAVE money by making ‘efficiency savings’ with target sums to save
  • Local NHS planners, CCGs, joined up to PLAN health & care for a bigger area = the STP
  • A ‘Local Place Based Plan’ describes how services will look in each CCG’s local borough

BUT the joined up CCGs ‘committees’ have NO legal status to decide all our services & are NOT accountable, NO-ONE knows yet who WILL BE accountable if things go wrong!

 

What services will be in this STP?

  • Each STP covers NHS services, Social Care and Public Health
  • Each STP includes services provided by many organisations in the area it covers
  • NHS – GPs, Hospitals, Community nurses, Mental Health, Dentists, Opticians, Chemists..
  • Others – Councils ( Social Care & Public Health), Charities, AND the Private sector

Such as a South Yorkshire & Bassetlaw STP (of 5 CCGS working across 5 boroughs) it has a target sum to find, £571million savings before 2021

 

What will they mean for hospital services?

  • There won’t be enough money to keep things as they are – so things will have to change
  • To meet quality & safety targets services are being centralised – local services will close
  • This will put pressure on the centralised services – more people to treat – who are more ill
  • This will mean their mortality rates are likely to go up = more people will die
  • Nationally the plan is to reduce staffing and reduce hospital beds – to save money
  • So more hospitals will have to close to new patients – they will become full more quickly
  • This will ‘clog’ the system as the space & staffing will be overstretched – more often
  • Many medical staff are retiring early or leaving because their workload is impossible

 

What will they mean for community services?

  • There isn’t enough money to keep things as they are – so they won’t set up more services
  • As hospitals take fewer patients there will be more people needing community services
  • Services will have to see more people & still meet quality & safety targets – no extra cash
  • Rather than increase waiting lists, it’s likely they’ll change who can use the services
  • There is no more money for more services so existing services will be overstretched
  • Many smaller services that help keep people well may not continue to be funded
  • Many smaller services that help people when they are unwell may not be funded
  • Mental health service support will only offer time limited services, open access will go
  • People may not have the mental services they trust available when they are reaching crisis
  • Many medical staff are retiring early or leaving because their workload is impossible

 

What will they mean for patients & the public?

  • We will lose many of our local services that we trust, we rely on and we know the staff
  • We will have to travel further for treatment, even in an emergency – with greater risks
  • Our families will have to travel further to visit us or be with us in an emergency
  • This is at a time when public transport is less subsidised, less available & more expensive
  • Centralised hospital services will be very busy, we’ll wait longer and we may not get a bed
  • Evidence finds that centralised emergency services admit more patients who are more ill
  • Evidence finds a need for more beds in trauma centres – but bed numbers are being cut
  • Evidence finds more inpatients die in centralised hospitals near A&Es that have closed
  • WE ARE HAVING TO DEMAND ANY INFORMATION AND TO BE INVOLVED IN ANY DISCUSSIONS ABOUT THESE PLANS

  • BUT CCGS MUST, LEGALLY, INVOLVE US!

 

NOTES – to explain some of the information 

[1] See the Kings Fund’s article on historical increases & analysis of figures on NHS budgets for last two decades

[2] See the Five Year Forward View which includes information about the New Models of Care

[3] See the New Care Models pages of the NHS England website

[4] See the Planning Guidance that introduced the STPs (Sustainability & Transformation Plans)

[5] CCGs=Clinical Commissioning Groups – they receive NHS funds to pay for services needed in their Local Authority area

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NHS England’s broken promise & forgotten legal duty – to involve us, the public, in decisions about NHS services.

N-NHS-PV (National NHS Public Voice) has seen how NHS England has broken its promise to involve the public in all decisions about services – and is now treating their legal duty to do so as ‘optional’. We’ve also seen how we, the public, are now excluded from influencing any decisions about services and the future of OUR NHS.

 

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In 2013 NHS England created NHS Citizen as a way of involving the public in decisions about our NHS.  BUT in 2016 they decided to redesign it.  They closed it without telling us. They didn’t share their planned new design with us.  They took it straight to the Board for approval without us knowing what was in their new design.  They are NOT involving us in decisions – not even about NHS Citizen – which is supposed to be a ‘service’ to ‘enable’ us to be involved in NHS England’s decisions about services!

NHS England was created in 2013 by the Health & Social Care Act 2012, but first called the NHS Commissioning Board, to take responsibility for the arrangements of NHS services in England.

The NHS in Scotland, Northern Ireland and Wales is run by their own ‘devolved’ parliament or assemblies.

The Act also says they must involve the public in their decisions about NHS service planning – a legal duty to involve us.  At first, NHS England (NHSE) made a number of commitments to work with patients and the public to make sure we were involved in planning NHS services.

Commitments, or promises, such as:

  1. The NHS Constitution which gave us rights and NHSE made some pledges
  2. NHSE Patient & Public Voice – legal duty to involve us in decisions about services
  3. NHSE to be held to account –  by a Patient & Public Participation Oversight Group?
  4. NHS Citizen & Assemblies – to enable us to be involved & have influence

BUT – things started changing during 2014 and changed completely in 2016

A.   NHS Citizen Workshop – didn’t work with us, to improve NHS Citizen – did it ‘for us’

B.    NHS England Board decided a ‘new approach’ for NHS Citizen – no public involved

C.   NHS Citizen Programme Board created – but the public was not involved or even told

1. NHS CONSTITUTION:   nhsconstitution

The NHS Constitution is a Department of Health pledge to the people, updated every ten years. It says “The NHS belongs to the people” and NHS England promised to abide by its principles and values.

What NHS ENGLAND promised:

  • To follow “[Principle] 7. The NHS is accountable to the public, communities and patients that it serves.” …..  “The system of responsibility and accountability for taking decisions in the NHS should be transparent and clear to the public, patients and staff.
  • to provide you with the information and support you need to influence and scrutinise the planning and delivery of NHS services (pledge);

What we got:

The ‘responsibility and accountability for taking decisions in the NHS’  is NEITHER transparent NOR clear to us:

  • We don’t know who represents us – the patients & public – in decisions
  • We don’t know what they say and do ‘on our behalf’
  • We can’t share our views with them – and they give us no feedback
  • Records of decisions they make ‘on our behalf’ are NOT in the public domain

2. NHS ENGLAND Patient & Public Voice:

What NHS ENGLAND promised:

  • To meet their legal duty to involve individuals who use services (patients), or who may use them (the public), in service decisions and NHS planning – as stated in the Health & Social Care Act 2012 Section 23. 13H & 13Q.
  • To have regular progress ‘Patient & Public Voice’ reports at all Board meetings on how these legal duties are met

What we got:

  • NHS England started to involve us via NHS Citizen ‘Gather’ (see 4. below)  – but now does NOT involve individual members of the wider public at all
  • NHS England now ‘engages’ stakeholders such as voluntary sector service providers, social enterprises (e.g. Healthwatch), patient groups (e.g.the ‘seldom heard’) but NOT with the public
  • NHS England selects and pays people (who are NOT accountable to the public) to act ‘on our behalf’ – as Non-Executive Directors or as Patient & Public Representatives
  • The ‘Patient & Public Voice’ regular progress report at each NHS England Board meeting only happened between December 2012 & May 2014 –  then it was STOPPED

3. NHS ENGLAND HELD TO ACCOUNT:

What NHS ENGLAND promised:

  • To show that it DOES involve the public in decisions about planning services by a having a ‘Patient and Public Participation Oversight Group’ check that they do
  • This group includes patient & public representatives
  • It reports to the NHS England board to reassure them the public ARE involved in service planning decisions, and in the development of any proposals to change services

What we got:

NHS ENGLAND’s Patient & Public Participation Oversight Group does NOT:

  • Meet in public
  • Make their meeting agendas or minutes public (for us to see what they say)
  • Tell the public who the patient & public representatives are on this group
  • Report to NHS England’s Board Public Sessions so their findings are on public record
  • Add their ‘assurance’ on public involvement to the NHS England Annual Reports
  • EXIST – maybe not – there’s no public record of its existence, except in the Policy document ‘Statement of Arrangements and Guidance on Patient and Public Participation in Commissioning’ (on P25 Point 4.5)

(APOLOGIES – This document has been moved or deleted from NHS England’s website)

4. NHS CITIZEN & ASSEMBLIES

NHS CITIZEN – was created in 2013 by NHS England to involve members of the public in their work.  An NHS Citizen website was set up with some ‘Gather’ pages that allowed public conversations online about people’s NHS concerns and ideas for improvements. NHS England regularly made promises to develop NHS citizen by working with the public.

What NHS ENGLAND promised:

  • To ‘enable’ public involvement ‘without seeking to control’ (6/11/14 NHSE Board report P8,point 14)
  • To allow public influence by posting and discussing concerns/ideas on ‘Gather’
  • Issues would be voted on and a few discussed fully at an NHS Citizen Assembly of members of the public and members of NHSE Board
  • To be held to account by holding  NHS Citizen Assemblies each year for ‘citizens’ (the public) and Board members to agree actions for the Board to take
  • The Board would give feedback on the agreed actions taken
  • To evaluate the NHS Citizen programme by working with the public
  • To continue to develop public involvement online via NHS Citizen‘Gather’

What we got:

  • NHS Citizen became ‘controlled’ by staff who were NOT ‘facilitating’ or ‘enabling’
  • Few decisions were influenced and ‘Gather’ was very tightly controlled – ‘top down’
  • Public votes selected a number of issues – but the staff selected a shortlist and a citizen panel to choose the final five to go to the NHS Citizen Assembly
  • NHSE Board FAILED to report actions taken after the LAST NHS Citizen Assembly held in November 2015, despite discussing five issues in full with ‘citizens’
  • The NHS Citizen website & ‘Gather’ was CLOSED, with NO warning in May 2016
  • The Participation Team REFUSED to meet with concerned ‘Gather’ contributors
  • The NHS Citizen Learning Report was written by staff, NO public contributors to NHS Citizen were involved in either the analysis or the recommendations
  • There is now NO public forum for ‘citizens’ to discuss NHS matters together

In 2016 things changed – more control – less involvement

A. NHS CITIZEN WORKSHOP

This was planned for September 2016, after some contributors to NHS Citizen ‘Gather’ contacted the Participation Team when the site had been closed with no warning in May 2016.  We were told the workshop would be staff working together with people involved in NHS Citizen so far, to look, together, at how to improve NHS Citizen. 

This Workshop is discussed in full in our recent post What really happened at the NHS Citizen Workshop – September 2016.  However the key points are repeated briefly below.

What NHS ENGLAND promised:

  • To concerned ‘citizens’ they’d only invite NHS Citizen contributors to the workshop
  • To plan the workshop with NHS Citizen contributors able to say how it should be run
  • To share ideas staff had already shared with NHS England and add any ‘citizen’ ideas
  • To work collaboratively with those attending to agree the future of NHS Citizen
  • To give written feedback from the workshop to people attending
  • To create a steering group with the public to plan the future of NHS Citizen
  • To give feedback from the Sep. 2016 NHS England Board on the plans for NHS Citizen

What we got:

  • They invited providers & commissioners taking up places so some public couldn’t go
  • The workshop was NOT planned jointly with NHS Citizen contributors
  • Only a BIT of the Participation Team’s NHS Citizen plan shared with the workshop
  • We ASKED for nhsc-workshop-slides-handout – got it, incomplete & very much later
  • The workshop was VERY controlled and ‘citizen’ ideas were not discussed openly
  • The workshop was NOT asked for decisions or if they agreed with what they were told
  • NO written feedback from the workshop was sent out to people who attended it
  • NO steering group was set up – or if it has been it’s a SECRET
  • NO feedback was sent out about the Plan discussed at the 29/09/16 Board meeting
  • The NHS Citizen Plan presented to the Board was NOT shared with the public  (unless you know to look on the NHS England website Board pages for the agenda item document)

B. NEW NHS CITIZEN PROGRAMME

A plan was presented to the NHS England Board meeting in September 2016, written by the Participation Team, and didn’t include any suggestions from people involved in NHS Citizen.  They described it as a ‘new approach’ for improving the quality of customer insight through NHS CITIZEN.

The Board Paper is discussed in more detail in our recent post The last NHS England Board agreed a new ‘NHS Citizen plan’- to involve the public – that didn’t involve us in deciding what was in it!

The content of the NHS Citizen Programme is discussed in another recent post Will the New NHS Citizen Programme involve citizens (people)?

However the key points of both are repeated briefly below.

What NHS ENGLAND promised:

  • The workshop was told a ‘skeleton idea’ was shared with the NHSE Board early in 2016
  • There was ‘NO DONE DEAL’
  • The Board Paper would be shared with ‘citizens’ at the workshop – once written
  • A steering group would be set up to help decide how NHS Citizen develops

What we got:

  • It was NOT a ‘skeleton idea’ – we were NOT told of the ‘revised model’ of NHS Citizen developed in 2015/16 – see the Board paper  P2 point 5
  • The workshop was NOT given detail of the ‘new approach’ for NHS Citizen
  • They were NOT asked to support any of it
  • There is NO written record of the workshop to prove this
  • The Board Paper WAS a ‘done deal’ – a new NHS Citizen service is imposed on ‘citizens’ who had no say in its content
  • NHSE Board members were misled – the workshop was NOT asked to support a plan
  • They were misled again – NO suggestions in the Board paper are from NHS ‘citizens’
  • And misled again – they were NOT told the learning report recommendations were NOT agreed with the public
  • This ‘new approach’ for NHS Citizen has NOT been shared with the public
  • It has still NOT been sent to the people who were at the workshop
  • The steering group (see P 5 of the Board Paper, point 18.iii) has still NOT happened
  • OR if it has – it’s a BIG SECRET

C. NHS CITIZEN PROGRAMME BOARD

This was mentioned in the Board paper but was news to everyone who had been involved in NHS Citizen over the last three years or more.  It was not mentioned at the September workshop.

Invitations to the public to apply to be an Expert Patient Adviser Board Member were circulated to ‘citizens’ via the In Touch emailing, and advertised on the NHS England Involvement Hub.

But there was only three weeks to apply, and if you didn’t have strategic experienced you were put off applying. (see the application pack including the new Board Terms of Reference – citizen-prog-board-info-pack.)

We discussed this in a recent post New Public NHS national Board members will be accountable to an NHS England manager – and NOT to Patients or the Public and our conclusions are repeated below.

We cannot say WHAT NHS ENGLAND PROMISED as:

  • The existence of this Programme Board is news to us
  • It has been imposed on us and we cannot influence it in any way
  • The Expert Patient Adviser Board members are not accountable to us
  • They are ‘managed’ by the Director of Patient & Public Voice & Insight
  • We do not know who they are, or if they understand meaningful involvement
  • The meetings are not in public – we do not know when they met
  • The minutes and agendas of the meetings are not shared with us

OUR CONCERNS (from the recent post on this subject) ARE:

This is not acceptable!  It is not honest – and it is disrespectful to the public.

  • The invitation to apply  to be an Expert Patient Advisor misleads people
  • The members of the public on the Board are not accountable to the wider public.
  • They are not required to be experienced in patient and public involvement.
  • These public Board members are not able to act independently in their roles.
  • The Director of Patient & Public Voice & Insight (PPV&I) selects them and manages their performance and how they carry out their duties.
  • The Director of PPPV&I has total control over patient and public involvement.
  • There is no collective, independent, inclusive and representative NHS Public Voice.

We now have no say in the future of our Public Voice.

We now have no Voice in OUR NHS.

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