• Elimination of a projected 2020/21 deficit of £909 million;
• To improve the provision of physical and mental health services outside hospital;
• To reduce variations in care;
• To reduce the cost of administration;
• To consolidate clinical support services.

Like other areas this STP aims 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 plans some major reconfiguration of services, including consolidation of hospitals and downgrading of A&E services. However, in order to undertake the redesign of services, the STP needs around £755 million in capital funding.

The HSJ summarised the major changes for the footprint, broken down into three areas.

In August 2017, the STP leader Louise Shepherd,chief executive of Alder Hey Children’s FT, was replaced by Mel Pickup, chief executive at Warrington and Halton Hospitals Foundation Trust; Pickup will take on the role for 12 months initially .

The major aspects of the plan are part of the Healthier Liverpool programme and include the proposed merger of Royal Liverpool and Broadgreen Hospitals Trust, Aintree University Hospitals FT and Liverpool Women’s FT, and the introduction of a shared electronic patient record.

The STP also refers to a reconfiguration of 35 adult acute services across the trusts, a significant scaling up of telehealth and assistive technologies, and the development of an “accountable care system” by 2021.

There are four acute trusts in this patch, and the STP outlines the creation of four accountable care organisations, which would be overseen by a “single C&W strategic commissioner”. Back office functions will be consolidated, which could lead to reduced staff numbers.

It also suggests that Macclesfield’s elective care and women’s and children’s services would be networked or supported by Stockport FT and University Hospital of South Manchester FT, and says there is an “intention” to transfer high risk general surgery to Stockport from April.

A “remapping” of emergency and elective care is also suggested for Mid Cheshire Hospitals FT, based on a “strategic relationship” with University Hospital of North Midlands.

Countess of Chester Hospital Trust and Wirral University Teaching Hospital FT have already begun discussions over the development of single clinical services, which could include the downgrade of one high dependency unit.

The document also reveals proposals to consolidate all elective inpatient care at Clatterbridge Hospital, which is part of Wirral University Teaching Hospital Foundation Trust.

There is also work to develop a shared care record across the footprint, and reduce spending on specialised services by £35 million.

The document appears to give a range of options for reconfiguring emergency services across Southport and Ormskirk Hospital Trust, St Helens & Knowsley Teaching Hospitals Trust, and Warrington and Halton Hospitals FT.

One model suggests that three trusts retain a 24 hour “type 1” A&E, while another suggests that all sites would be 24 hours, but high acuity patients would be treated on one site. A third model suggests a single 24 hour “type 1” site, with the other sites “reprofiling” their opening hours.

All the suggested models note that “new models of A&E delivery” will be considered for Southport and Ormskirk.

The document also proposes a range of single service models across the trusts, a range of “federate” services to reduce agency staffing costs, and elective ward closures due to reduced levels of delayed discharge.

There is also a “vision” for Whiston Hospital to be the single hyper-acute provider for stroke care, and a potential downgrade of one of three high acuity paediatric units.

By March 2018, it appeared that Southport Hospital is not the target of any downgrade, with building work begun on expansion of its A&E.

Under NHS England plans all STP areas will develop into Integrated Care Systems (ICS), previously known as Accountable Care Systems (ACS). This is a new model of care that aims to integrate hospital, community and social care and could involve a new type of contract and capitated (i.e., fixed budget) funding. For further details see our pages on New Models of Care and Accountable Care Organisations.

In June 2017 the HSJ reported on discussions between NHS Improvement and NHS England on what the 14 CCG areas with the highest over-spend 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. The target areas include three areas of Cheshire - East Cheshire, Vale Royal and South Cheshire. 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.

The commissioners in the area told the HSJ that they have been told to examine “difficult decisions” and “think the unthinkable”, including modelling changes which are normally avoided as they are too unpleasant, unpopular or controversial. Some of the "difficult decisions" came to light in June 2017 via a Central Cheshire CCG document leaked to The Guardian. Overall the document makes clear that cost-cutting measures put forward by NHS England and NHS Improvement will endanger patient safety. The document lists 24 different “risks” to the care patients receive if NHS England and NHS Improvement force through their ideas. The document included criticism of the NHS England and NHS Improvement recommendations to reduce the number of endoscopies conducted in the area's hospitals by 25%, which could lead to a longer time to diagnosis for cancer patients and as a result a reduction in life expectancy.

NHS England and NHS Improvement have also recommended that the Cheshire and Wirral Partnership NHS mental health trust cancels the extra £900,000 spending on mental health care. The document notes that this would be a false economy as patients would get “inappropriate care” in A&E rather than specialist mental health facilities. This would lead to an “increased spend in hospital care” for such patients.