39. Bristol, North Somerset and South Gloucestershire
What does the STP mean for your area?
Health planners are trying to reduce NHS deficits and think about ways to re organise care. However getting the large deficits under control could prevent facilities being developed that can cope with the health and care social needs of local people.
Analysis of the STP shows that the aim is to reduce the number of acute beds in the area by 30%.
At a council meeting in January 2017, the council concluded that the STP's aim to cut £305 million from the Bristol area's NHS funding will result in fewer hospital beds, closure of services and less frontline staff.
This area contains some high-spending CCGs that NHS England has targeted with suggestions for additional cost-saving measures to ensure they remain within their 'control totals' (or budget) for 2017/18; this is part of what is known as the Capped Expenditure Programme (CEP). These measures include increasing waiting times, closing wards and theatres, stopping funding for some treatments or rationing, reducing staff and selling property. As a result:
- IVF services have been cut to save money in 2017/18 and rationing by age (30-35) is under consideration for the service.
- Cuts planned by South Gloucestershire CCG include in the areas of cancer diagnostics and treatment for children with complex needs and longer waiting times for patients as the 'referral to treatment times are relaxed.
What are the proposed aims of the STP?
- Elimination of a projected 2020/21 deficit of £305.5 million;
- Elimination of duplication of services across the region;
- Implementation of a new model for prevention, self-care and early diagnosis;
- Implementation of integrated primary and community care;
- To reduce the use of the acute care sector.
Like other areas they plan to transfer services out of hospital and into the community. The concern is that financial pressure will mean that cuts in hospital care will be made, helping to achieve savings, but without proper investment in community health services.
The STP is lacking vital details about how the plan will be realised. In December 2016, the chief executive of Weston Area Health NHS Trust – which runs Weston General Hospital – James Rimmer admitted details in how the plan will come to fruition were lacking, and he said it is ‘being worked through and will follow in due course’. He added: “The plan is incomplete and does require alterations. It’s not uncommon not to have all the answers five years in advance. There’s still work to be done.”
Projects are underway investigating changes to the care pathways in the areas of: musculoskeletal (MSK); trauma & orthopaedic; and stroke. Other areas being investigated for savings are pathology, consolidation of corporate services, urgent care and specialised services.
With hospitals in the area, of most concern for campaigners is the Weston General Hospital, which is suffering from staff shortages. In July 2017 its overnight A&E service had to be closed due to a lack of staff and many campaigners believe that it may not reopen; as of October 2017 it was still closed at night. A report by the Bristol, North Somerset and South Gloucestershire clinical commissioning groups (CCGs) in October 2017 highlighted how unsustainable certain services at the hospital were, including maternity, critical care and A&E; this cast further doubts on the future of the hospital.
A major focus of the STP is the integration of primary and community care. The plan is to develop facilities in the community to allow mental and physical health services to be delivered locally from “Clustered” GP Premises. These centres may be embedded within the premises of other public sector bodies.
The STP notes: "at the core of our approach to integration of health and social care is the development of cluster based care, operating with community multi-disciplinary teams and improved care coordination, focused on proactive case management of those at greatest risk within our population."
The says that 27% of patients now visiting their GP will be seen instead by nurses, pharmacists and physiotherapists.
The plan also aims to reduce the numbers of home visits, surgery visits and outpatient appointments by up to 15% by using home monitoring and remote consultation.
Changes across the area
In June 2017 the HSJ reported on discussions between NHS Improvement and NHS England on what certain high-spending CCG areas will be required to do to enable them to spend less money and remain within a budget known as a 'control total' for 2017/18 under the 'capped expenditure process' or CEP. The 14 target areas include Bristol, South Gloucestershire and North Somerset. The measures under discussion include the following:
- Limiting the number of operations carried out by non-NHS providers so the funding stays within the NHS. Considerations differ between areas but include both limiting patients’ choice of providers, and reducing work which is outsourced by NHS trusts. In some cases it would require the NHS to find the capacity to carry out more operations.
- Systematically drawing out waiting times for planned care, including explicit consideration of breaching NHS constitution standards. Some plan to target delays at specialties/areas where waits are currently lower than average.
- Stopping NHS funding for some treatments, including extending limits on IVF, adding to lists of “low value” treatments, and seeking to delay or avoid funding some treatments newly approved by the National Institute of Health and Care Excellence.
- Closing wards and theatres and reducing staffing, while seeking to maintain enough emergency care capacity to deal with winter pressures.
- Closing or downgrading services, with some considering changes to flagship departments like emergency and maternity - though these would normally take too long to deliver savings this year.
- Selling estate and other “property related transactions”.
- Stopping prescriptions for some items, as suggested by NHS Clinical Commissioners earlier this year.
In September 2017 The Guardian reported on the cuts that are planned by the CCG in South Gloucestershire to make a total of £4.8 million in extra savings under CEP; this £4.8m is roughly a quarter of the £17.2m savings required from the whole STP.
The vast amount of the savings will be made by a “reduction in RTT [referral to treatment] performance”, which effectively means that there will be longer waiting times and a reduction in independent sector treatment. Other savings will come from cancer diagnostics, neurological rehabilitation and children’s continuing care policy for those with complex needs arising from disability, accident or illness.
Bristol City Council believes, among other things:
- That the cuts demanded by central government of £305 million are unfeasible and that there is no safe way of implementing such reductions.
- That the only way to provide adequate integrated health and social care is through adequate funding.
- That central government should increase NHS funding to at least 10.1% of GDP, to match the average of other EU countries.
- That the government must address the crisis in social care funding, to allow councils to provide the adult social care needed to keep people well in their own homes and reduce the unnecessary costs of keeping people in acute hospitals when they could be supported in the community.
- The STP does not have democratic accountability.