Somerset’s Sustainability and Transformation Plan: an overview for people in our local area What is the Somerset Sustainability and Transformation Plan (STP)? CONTENTS

The demands on the NHS and social care are increasing, partly because there are more people who are living longer with more complex health problems such as dementia, diabetes and high blood pressure, but also because of the increasing cost of new medicines and treatments. Public demand for health and social care services is constantly growing and the only way to manage this is by thinking as one single health and social care system – rather than as individual organisations – working with patients, carers and communities. The Somerset Sustainability and Transformation Plan (STP) describes a vision for the future of healthcare in the county which has been developed by the leaders of Somerset’s hospital, community and mental health NHS organisations, Somerset County Council and Somerset Clinical Commissioning Group (which is made up of the county’s GPs). This is our joint plan. Our key priorities outlined in the plan are: To encourage and support everyone in Somerset to lead healthier lives and avoid getting preventable illnesses To move care out of hospital beds in Yeovil, Taunton and our 13 community hospitals into people’s homes wherever possible, providing care designed specifically for each patient’s needs, supporting faster recovery and, in many instances, avoiding the need to go into hospital in the first place To invest in GP teams to develop a mixture of skills and time to support the THE BACKGROUND THE CURRENT THE FUTURE increasingly complex care that needs to be given SITUATION AND SOLUTIONS To respond to the way we live now – making it easier for people to get services What is the Somerset closer to home, when they need them, using modern technology that is already Sustainability and How the health system How does health transforming other parts of our lives Transformation Plan in Somerset works now and social care (STP)? need to change? To invest more money in frontline care by being more efficient with how we The way we think it use our buildings, our equipment and our management and administration The challenge: should work Next steps why we need an STP We have recently published a detailed document which sets out some of the plans we have. You can read a full copy of Somerset’s STP proposals on the Somerset Clinical Commissioning Group’s website at: www.somersetccg.nhs.uk.

1 2 The challenge: why we need an STP at home, with your own family, pets, differently. We need to move away friends and familiar surroundings, from the traditional way of doing can speed recovery. things and instead ensure that people are able to look after themselves better We need to invest in mental health and then see the best person to meet services in Somerset and make sure their needs at the right time. Health and wellbeing – Care and quality – services that the same importance is placed on preventing ill health and that meet patients’ needs mental health needs as physical health Balancing the budget – the reducing demand needs. We also need to provide more The population of Somerset is growing. financial challenge support for people living with dementia According to the Office for National The STP offers ideas on how we can and their families and carers as well. Doing nothing is not an option. Like Statistics, our population is set to make sure that we encourage and most places across England, health increase by at least 3,000 people every support people to take responsibility for Local people are waiting too long to and social care funding in Somerset is year over the next 20 years. their own health and wellbeing, as well get some treatments, including limited, which means services are under as focusing on how we can best treat orthopaedic and cancer services. Life expectancy is also increasing and severe financial pressure. Unless we those people who are ill to get better People need to receive high-quality we have a higher than average older manage the demand being made upon as quickly as possible. services as quickly as possible to enable population. In the next two decades our health and social care services, them to have the best possible chance the number of people aged 65 and our budget will be overspent by £33 Too many of us eat, drink and smoke of a good recovery. too much and don’t exercise enough. over in Somerset is expected to increase million in 2016/17. by more than 30%. Unhealthy lifestyles can adversely affect Health and social care Every year, the gap between our our quality of life. In Somerset, we As people get older they are coping staffing budget and what we will spend will have higher than average numbers of with more long-term health problems get bigger. If we do nothing to change overweight people and levels of At the same time as demand for which need greater support from the the way we manage and provide care, obesity, and higher levels of smoking. healthcare services is increasing, NHS and social care. in the five years to 2021 we will spend We also have lower than average levels Somerset, like everywhere else in the around £600 million more than the of physical activity. More people than ever are going to country, is facing a shortage of trained funding available for the population. hospital Accident and Emergency doctors, nurses, midwives, social The health implications of this are all departments, even though some may workers and physiotherapists. However, it is not just about how much too clear. We have higher rates of high have minor illnesses and could seek Many staff are due to retire in the next it costs. It’s also about making sure blood pressure across Somerset. advice from a pharmacist or NHS 111. 10 years and there are already high the services that we provide meet We have more falls than the national levels of vacancies in many services. the needs of patients, carers and average and higher rates of hip We depend too much on hospital beds It takes a long time to train doctors, communities; even if money were not a fractures and diabetes-related and this limits the amount we can nurses, therapists and social care staff problem, we would still want to change problems, too. spend on providing support closer to and no amount of extra money can the way in which services are delivered, home. As good as our local hospitals In the past, we have not invested make this happen quickly. in order to improve the experience are, none of us wants to spend time enough in services that support people and outcomes of people in Somerset. in one as a patient unless absolutely Demand for services has grown – of all ages – to stay healthy in the first necessary. However, many people, and people’s needs have changed place. Money has been spent mainly on particularly the elderly, end up staying dramatically, but the way in which the treating people after they have in hospital longer than is necessary. NHS and social care services operate become ill. This often leads to loss of mobility has not really changed. Now is the time and independence – whereas being to look at how we could do things

3 4 How the health system in Somerset We need to challenge ourselves to think differently about the way services works now are organised, staffed and paid for. Too much money and too many resources are put into hospital-based care instead of providing services closer Patients and carers say their current experience of health and to patients’ homes. People in Somerset social care services is varied. While there is often praise for are often in hospital for a long time staff and services, people also tell us that services are not very even when they are fit enough to go home. joined up. This can make it very complicated to find out where to go for advice or support. For people like Jack and Eileen, We know that the longer people stay from Burnham on Sea, it can look like this. in hospital, the more likely they are to experience complications. Also, it is expensive to keep someone in hospital when they don’t need to be there. As things are now, services are not as joined up as they should be. If the main reason for delay in getting Eileen has diabetes, Eileen’s carer, Jack, has people home is the shortage of memory problems and high blood pressure, heart appropriate community-based health she is at risk of falling problems and is at risk of and social care services, we need to look at doing things differently. She struggles to a stroke control her diabetes He puts his own health We want care to be better coordinated, and her memory is second and doesn’t feel he with teams of physical and mental getting worse has time to go to see his GP health professionals working closely with voluntary-sector organisations As she gets unwell, If he has a stroke, he and local communities to work flexibly she is in and out of will be unable to care for around the patient, meeting their hospital his wife and they will both individual needs. Health and social need care from others care services don’t He finds it hard to cope Key to this improvement is making sure always coordinate their with Eileen’s memory that information about people’s health support for Eileen problems is available to all those people who look after them. This is a critical part of our plan.

5 The way we think it should work

We asked people in Somerset what they most wanted from their health and care. This gave us the following Eileen’s diabetic nurse links The pharmacist delivers Jack gets support and ‘I’ statements to guide our planning with dementia services. and service design: their medication. advice to manage his high blood pressure and I want to feel part of my community take better care of his I want it to be easier to get support, health. close to my home I want to be able to find information, help and advice when I need it I am a person, not a client or a patient Jack is more confident I want my family to be supported as The early dementia team about keeping himself carers diagnoses Eileen and puts healthy and has been put in touch with a I want the best-trained care staff care and support in place. helping me men’s carers group to go to while Eileen I want to have good experiences is being looked after. when using services He enjoys the break. I want to plan my support I want to tell my story once We have used these wishes to help our future plans for delivering more joined- Eileen attends a up health and care services. Jack and Dementia Café every Eileen could be enjoying a better quality of life if the support they Support is provided by week, mixing with other The Dementia Café receive looked like this. Alzheimer’s Society and people facing the same gives Jack advice about Age UK. challenges. looking after Eileen.

7 8 How does health and social care Redesigning Community need to change? Health and Care Services Wherever possible we want to shift healthcare into the community and What are we doing about it? where patients and carers are at people’s homes. the centre of what we provide, We are developing a ‘hospital at home’ There are lots of great services in helping people to live as healthy service that aims to provide patients with Somerset, but we know things can be a life as possible. the care they need in their own homes done better. We can improve the way rather than having to come into care is planned, provided, managed Redesigning GP (family hospital, and we are changing our and paid for, simply by working doctor) services systems to support people being able together, involving staff, patients, to get home from hospital more quickly carers and the people of Somerset in We are short of GPs in Somerset and when they are ready to leave. the development of how we should want to free their time so they can deliver our services. better support their most vulnerable Redesigning district general patients. We want to bring more By thinking as one single health and services and clinics into GP surgeries hospital services social care system, rather than as so that patients can see other health We want to be clear on the type of care Next steps individual providers, we can focus on professionals, like the practice nurse, that should be provided from Yeovil creating services that are joined up and health coaches, pharmacists, and Taunton’s district hospitals in the responsive, truly meeting people’s needs. physiotherapists and mental health future. We want to develop new ways You can find the detailed plans in our workers without having to go to of delivering care, to make sure that Preventing ill health STP document which can be found hospital. some more specialist services are online at www.somersetccg.nhs.uk We want to support people to stay sustainable for the longer term. We will start by bringing a better range or by contacting 01935 385240. well, giving them the best chance to In the first instance we will look at oral live the healthiest, most independent of services into GP practices and local maxillofacial surgery (diseases affecting Publication of this draft plan marks and active life they can. communities. This will increase the time they have available for same-day the mouth, jaws, face and neck) and the start of a big programme of We will concentrate on the commonest appointments. It will also help provide urology (diseases of the urinary tract discussions over the coming months, causes of ill health in Somerset: seven-day-a-week services for patients system). We are also looking at new so that local people, patients, carers, dementia, diabetes, heart disease, who need them the most. ways of delivering musculoskeletal partners and our staff can help shape cancer, lung disease and joint and back services (problems relating to the the ideas we have into more formal problems. We will target these areas by Patients living with long-term health skeleton, joints and muscles) which will proposals. Where appropriate, these encouraging physical activity, healthy problems are already benefiting from provide easier access direct via local GPs. will be put to the whole population eating and weight management, and ‘telehealth’ care, having their blood of Somerset for consultation in the pressure, heart rate and breathing We are planning to redesign the way tackling dependence on smoking and people access emergency hospital summer of 2017. alcohol as well as providing specialist monitored through a smart phone. services and also make sure that people Look out for more information help when needed. This technology helps prevent admissions to hospital by spotting with mental health issues who attend on how to get involved in these We will talk to people and communities when a person’s health is starting to hospitals are better supported to get plans and discussions online at: to understand what matters to them worsen and getting them help from the right care. www.somersetccg.nhs.uk. and design approaches to services their GP or a community nurse. 9 10 This guide can also be provided in Braille, audio cassette disk, large print or other languages on request by phoning 01935 385240.

Somerset Sustainability and Transformation Plan (STP) NHS Somerset Clinical Commissioning Group Freepost RRKL-XKSC-ACSG (No stamp required) Yeovil Somerset BA22 8HR

Tel: 01935 385240 Email: [email protected] www.somersetccg.nhs.uk

Somerset Clinical Commissioning Group Somerset County Council Somerset Partnership NHS Foundation Trust Taunton and Somerset NHS Foundation Trust Yeovil District Hospital NHS Foundation Trust