Our Sustainability and Transformation Plan
Shropshire and Telford & Wrekin How Working to make our NHS and together care services strong and fit for the future
We all want Health and social care services At every step in the development As the By making every taxpayer pound These are the organisations across the country face a huge of Shropshire and Telford & work as efficiently as possible, working together in Shropshire our NHS and challenge in meeting the rising Wrekin’s STP we will want to talk organisations more can be done and done and Telford & Wrekin. They care services to demand that is and will continue about the future shape of services working on the better than at present. include clinical commissioning to be placed on them. As more with the people of the county and groups, which plan and buy continue to look people live longer and also as those in mid-Wales who also use plan in Shropshire For example, rather than treating health care and are led by GPs. more people are becoming very them. the symptoms and effects of ill after us. To make overweight, more are developing and Telford & health we want to help people ĥĥ Shropshire Clinical sure that happens serious health problems. This This document explains our Wrekin, we are all take greater control of their own Commissioning Group challenge will only get tougher. thoughts on how we could meet health and wellbeing so they ĥ we need to make these challenges, improve services convinced that don’t fall ill in the first place. ĥ Telford & Wrekin Clinical some changes The government has asked for local people and make the better services can Encouraging and helping people Commissioning Group organisations such as the NHS and most of the latest developments to lead healthier lives, re-shaping ĥĥ Shropshire Community Health now. social services to work together to in care and technology. be provided with how services are delivered, and NHS Trust produce a plan for their local area the resources we linking health and social care for the next five years. more closely together will help ĥĥ The Shrewsbury and Telford have. people stay healthier for longer Hospitals NHS Trust These plans are called and recover quicker if they do fall ĥ Sustainability and Transformation ill. ĥ Robert Jones & Agnes Hunt Plans (STP) and there are 44 Foundation Trust throughout England. This will mean change. It will ĥĥ South Staffordshire & mean selecting the best locations Shropshire Foundation NHS for services to get the best results Trust for patients rather than delivering them everywhere. ĥĥ ShropDoc (GP out of hours service) ĥĥ Shropshire Council ĥĥ Telford & Wrekin Council ĥĥ Powys Teaching Local Health Board ĥĥ Voluntary Sector (soon to join) Shropshire Partners in Care (SPIC) 02 03 An alarming majority of adults carry too much weight Why - 71.9% in Telford & Wrekin and 65.2% in Shropshire, our health adding up to 256,000 across our patch who are and care services consequently at higher risk of cardiovascular (heart and need to change blood vessel) diseases and certain cancers.
In Shropshire and It is important to ensure our We have done extensive research services are medically safe. into demand for services in our Telford & Wrekin Recruitment has become rural areas and now have a much demand for increasingly difficult and is now better idea of the differences in compromising patient safety, demand between different areas. health and social with a pressing shortage of A&E consultants. In Shropshire and Telford & Wrekin care services is two hospitals provide care for a outstripping the Demand on services continues population of around 550,000 to rise at a greater rate than the including almost 70,000 from funds available money available, which puts more Powys. Our population supports by £131.4 million pressure on services, especially a full range of acute general hospitals, GP surgeries and social hospital services, but the way by 2020/21. It is care. We have a growing number services are currently arranged is clear that change of older people and many have inefficient and expensive. more than one health condition is necessary. We (for example diabetes or breathing We want to focus on the different need to make sure difficulties) lasting many years. communities in our area because Also, more people are developing working at a more local level will we are making the conditions linked to being severely help us to tackle the causes of overweight. This means there poor health. best use of every is a greater need for particular pound available to services. By working together we hope to ensure people get the best us. With these rising demands treatment - whenever and changes are needed. Change will wherever they need it - and to also help us to take full advantage share patient information more of the rapid progress made in effectively to avoid duplication treatments and technology. and wasted effort.
While similar issues are being experienced across the country, we have the extra challenges of many people living in isolated Between 2004/05 and 2014/15 the rural communities. number of people diagnosed with We also need to consider the diabetes doubled to reach 6.6% bordering communities in Powys/ of our population. On top of the mid-Wales who use our services. 24,690 people in our area with diagnosed diabetes, we estimate that 47,000 people are at risk of developing the disease because of excess weight, poor diet and lack 04 of physical activity. 05 Tackling the financial and staffing challenges
Our plan identifies At the same time, the organisations that provide local where £74 million NHS services aim to save £62 might be used million by improving efficiency. differently and We are working with Health Education England to design new more effectively roles, train more nurses, doctors to provide more and other healthcare staff and ensure we keep and invest in our care for the same existing teams so we can address money. our local staffing challenges. This should all lead the local NHS and care services into a good position at the end of the next five years, providing more sustainable services and meeting the public’s health and care needs more effectively.
06 07 Going local
Dementia Personal nursing Enhanced End of Support Worker support Life Care By focusing most of our attention Across the county there are two The causes of poor Today people who receive on our neighbourhoods and Respiratory Teams. One based in When people become worried Mary is 74-years-old and has a a diagnosis of a long-term health are rooted the services, care and wellbeing Telford, covering the Telford & about their memories they will serious terminal illness. Mary and condition, like diabetes or heart needed, we can support all of our Wrekin area and another based in often be directed for testing. her family know she is nearing in communities disease, will often see a wide population to live well as they get Shrewsbury, covering the rest of For some this is likely to mean a the end of her life. variety of health professionals - so this is where older. Shropshire. These teams include diagnosis of having dementia. doctors, consultants, specialist the four physiotherapists and two Occasionally her condition nurses. It can be very confusing our focus needs Making the most of the skills of technical instructors delivering This can be a shock, and the first deteriorates, and several times for patients and they find it local people, communities and pulmonary rehabilitation courses thing the patient and their family in recent months her daughter to be. We need to difficult to get in touch with these organisations, we want to support across eight venues, covering often ask themselves is, “so what has called 999 and she has people if they want further advice bring care much people to lead healthier lives the four corners of the county. now?” been rushed to hospital. It’s a or support. and encourage them to care for Pulmonary rehabilitation helps traumatic experience. The journey closer to where Dementia support workers will themselves, where appropriate. improve the wellbeing of is uncomfortable, and Mary hates aim to answer the “so what A very successful model of people live. This By doing this, pressure on the people with on-going breathing being surrounded by strangers on now?” as soon as possible after community nursing developed healthcare system can be relieved problems. a busy ward. She has developed is especially in the Netherlands is helping to so that resources, particularly our a diagnosis - often on the same a real fear that she will die during solve some of these problems, important in the hospitals, can concentrate on the GPs, social care workers, day. There is a lot of support one of these hospital admissions and we want to test how it can people who most need them. This community nurses, therapists and out there, but getting the most rather than at home. rural areas where work here. is why we are proposing a more mental health workers would from it can be confusing and joined-up way of working, based increasingly work together to daunting. They can talk patients Now we are working with our travel times are Patients will be assigned a on smaller areas we are calling provide services at this local level. and their family through it. They local hospice to give people real dedicated nurse as a regular long and public neighbourhoods, to prevent ill These Neighbourhood Care Teams can arrange appointments with choice about how their life ends. point-of-contact to help with health but also to promote the would be the first port of call for support organisations. They can transport poor. their condition. The specialists will Members of an Enhanced Care support that local communities people with long-lasting health ask how people can stay as active still be there, but the community Team will talk to patients and already offer. conditions, which can normally be as possible - help to ensure they nurse - normally based in their their families. They will sensitively managed at home or locally with keep doing the things they have neighbourhood - will offer regular help develop an End of Life Plan. These neighbourhoods are NHS support. They could also help always enjoyed doing. support. This gives patients a powerful organised into several groups each people who have recently been with a population of 30-40,000, They won’t deliver any medical influence over their last months discharged from hospital. They The emphasis will be on helping with 11 in Shropshire targeting care, but they can liaise on and weeks. would be the link between health patients manage and monitor a population of 305,000 people behalf of patients to make sure and community care. their conditions successfully, and The team will get to know how and four in Telford and Wrekin, appointments are booked and on promoting a healthy lifestyle. the patient’s condition is being reaching 181,609 people. families understand what is being done to help them. With this help, experience managed, and there will be 24/7 elsewhere has shown patients Health and care services for support to call - it means 999 find their medical condition has people needing professional help, And they will be local - based isn’t the first number concerned less impact on their day-to-day but not hospital treatment, would in the patient’s neighbourhood, family members dial. Home life, they feel they have someone be based around neighbourhoods. possibly at their own GP surgery. visits by nurses can be organised they can contact easily, and both and there can even be breaks the nurse and patient benefit arranged for relatives who care from regular contact and a more for the patient. In a pilot in 2015 personal relationship. over 100 patients benefitted, with loved ones saying they really appreciated the support and the vast majority of patients not being 08 rushed to hospital. Safe Community and effective mental health hub and spoke model
hospital care Barry is a 47-year-old man with a long history of mental health problems. He has spent long periods in hospital settings and is now living in the community. He receives some support from mental health nurses but can go for weeks without seeing them. Three hundred For patients who do need hospital The proposed changes to the care, two ‘centres of excellence’ organisation of hospitals, with He frequently feels anxious, isolated clinicians have are proposed; one specialising in more resources dedicated to and unsupported. His first port-of-call been involved emergency care and the other in emergency care and planned when he feels like this is to make an routine surgery or planned care. surgery, would improve care and appointment to see his GP. He is one in developing reduce waiting times for patients of the surgery’s most frequent visitors. the proposals for Using consultants and other and underpins the Future Fit resources most effectively would programme. The model would When he feels especially bad he hospital services. help patients get better quicker. significantly reduce the risk of will cut himself and go to A&E for One central Emergency Centre cancelled operations, create treatment. His wounds are never As the people (trauma centre) would work ‘infection-free’ surgical units, and serious but he feels reassured just by who deliver NHS closely with more local urgent care strengthen vulnerable services to being at the hospital. services. Two new 24-hour Urgent protect them for the future. services day-in- Care Centres, one in Telford and Soon Barry could benefit from having day-out, these one in Shrewsbury, would see and Recently, hyper-acute stroke access to a “mental health hub” run treat most of the patients who services have been consolidated by the community mental health team clinicians believe currently go to the accident and onto one hospital site, greatly with help from volunteers. The hub the proposals offer emergency departments. improving outcomes for patients. will have “spokes” operating from The proportion of patients community venues in neighbourhoods. the best solution Most assessment, diagnosis and now receiving thrombolysis They will have extended opening to the challenges follow-up would be done closer to has increased from 7% to hours, including weekends. The hub people’s homes. Neighbourhood 13%, a potentially life-saving will be a place where Barry can get facing our Care Teams would play an improvement. support close to home. There will be hospitals. These important role in this. volunteers he can talk to. changes are also He can take part in activities and also access training courses. He will receive what patients have help to get work - either voluntary said they want. or part-time paid. It won’t affect his benefits but will help him keep busy and build up both his CV and his self- esteem.
Barry will feel there is someone he can regularly turn to for support. His busy GP will have more time to see other patients, and those visits to A&E will become a thing 10 of the past. 11 Into How the future you can be involved
We are looking We believe that around 35,000 Communities themselves would We will not be making outpatient appointments a year be able to support vulnerable at how we can could be done via video link. people, with the professional any decisions before better use recent backing of Neighbourhood Care talking to local people. We are introducing some trial Teams where required. Fewer developments in projects in rural areas, including people would need to go to There will be plenty the introduction of Point of Care hospital, and those who do would technology so Testing which allows GPs to be discharged quicker. of opportunity to get that people do carry out a range of tests so that involved in helping to patients do not need to go to This pledge to work together will not have to make hospital. This has the potential to reduce duplication and free up shape local health and long journeys dramatically reduce waiting times the resources needed to provide care services for the for some results. the best possible care at all times. - especially Working together in this way future. As well as improving services and across NHS, social care and the important for making them stronger for the voluntary sector will ensure the We want to hear the views of as many people future, we believe all the changes people living in best possible outcomes for the as possible and we expect to hold what is we are proposing would make the people of Shropshire and Telford & formally called a ‘consultation’ for some the most remote experience better for patients. Wrekin now and in the future. programmes of work such as Future Fit. The rural communities date for this will be in the New Year and we in Shropshire and will publicise the details nearer the date. Powys. As part of the Future Fit programme we have already undertaken extensive discussions with local people on our plans to transform hospital services. This has included 43 “pop- up” events in public places and presentations to groups ranging from parish councils to senior citizen forums. We have a large and growing contact mailing list and an online video describing the programme has been viewed almost 10,000 times. 12 13 You can read our full Sustainability and Transformation Plan online by visiting a website of any of our partner organisations. If you would like a hard copy of the plan please contact a partner organisation.
If you have any comments or questions regarding the Sustainability and Transformation Plan please send them to [email protected] or contact one of the partner organisations.
Shropshire and Telford & Wrekin Sustainability and Transformation Plan partner organisations: Shropshire Clinical Commissioning Group www.shropshireccg.nhs.uk Telford & Wrekin Clinical Commissioning Group www.telfordccg.nhs.uk Shropshire Community Health NHS Trust www.shropscommunityhealth.nhs.uk The Shrewsbury and Telford Hospitals NHS Trust www.sath.nhs.uk Robert Jones & Agnes Hunt Foundation Trust www.rjah.nhs.uk South Staffordshire & Shropshire Foundation NHS Trust www.sssft.nhs.uk ShropDoc (GP out of hours service) www.shropdoc.org.uk Shropshire Council www.shropshire.gov.uk Telford & Wrekin Council www.telford.gov.uk Powys Teaching Local Health Board www.powysthb.wales.nhs.uk Voluntary Sector (soon to join) Shropshire Partners in Care (SPIC) www.spic.co.uk