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Section One: the Context Shropshire and Telford &Wrekin Sustainability and Transformation Plan 2016-2021 Version 5.0 Version control Date Version Notes August 2016 V1.1 Initial draft compiled from June STP December 14th 2016 V2.0 Discussion at STP Partnership Board. Prioritised actions. Timescales revised January 11th 2017 V3.3 Discussed at STP Partnership Board. Additional actions agreed January 25th V4.1 Review of updated content by work-stream leads. Further amendments agreed January 31st 2017 V5.0 Resubmitted incorporating changes and feedback from NHSE 31/01/2017 Shropshire and Telford & Wrekin Sustainability Transformation Plan 2 Coverage Geography Key Footprint Information Name of Footprint and Number: Shropshire and Telford & Wrekin (11) Midlands and East Region- NHS England Region: Shropshire and Telford & Wrekin Nominated lead for the footprint: Simon Wright, CEO Shropshire and Telford Hospitals Contact Details (email and phone): [email protected]; 01743 261 001 Organisations within the footprint: Shropshire Clinical Commissioning Group Telford & Wrekin Clinical Commissioning Group Shropshire Community Health NHS Trust The Shrewsbury and Telford Hospitals NHS Trust Robert Jones & Agnes Hunt Foundation Trust South Shropshire & Staffordshire Foundation NHS Trust ShropDoc Shropshire County Council Telford & Wrekin Council CCG boundaries Powys Teaching Local Health Board • NHS Telford & Wrekin CCG • NHS Shropshire CCG Local Authority Boundaries • Telford & Wrekin Council: Unitary Authority • Shropshire County Council 31/01/2017 Shropshire and Telford & Wrekin Sustainability Transformation Plan 3 Contents Section Page Foreword 5 Executive Summary 6 Our Vision 9 Our Priorities and Plans 16 Our Enablers 70 Communications & Engagement 76 Governance & Leadership 86 Implementation 92 Support we Need 101 31/01/2017 Shropshire and Telford & Wrekin Sustainability Transformation Plan 4 Foreword This plan is ‘a work in progress’ and sets out our approach to transforming our local health and care system across Shropshire and Telford &Wrekin . We have been working together as a health and care system to align our vision and approach for our population. Our aim is to materially improve the health and well being of the populations we serve by focusing on: Building support for people in our local neighbourhoods to choose healthy lifestyle choices Supporting patients to self-care and be actively engaged in managing their conditions Providing access and support through joined up health, social care and wellbeing services. Ensuring our services provide high quality care that is affordable and sustainable. Since the October submission of our STP, a number of important changes have occurred in our system. Of particular note, the commissioners of healthcare in the Shropshire CCG catchment area are under severe financial pressure leading to a significant resource gap which is challenging our ability to meet the needs of some of our populations. In light of these changes we have reviewed our STP plan to consider whether our current plans are of sufficient ambition and scale to return our system to balance. It is clear to us that we need to urgently revisit a number of our key programmes to ensure we are taking the necessary actions to ensure our populations continue to have access to quality care that is affordable and sustainable. In particular we plan to: Strengthen our plans to improve population health and community resilience Review and redesign our place based plans (neighbourhoods) where neccessary to ensure we have robust models of integrated primary and community services to enable us to reduce the demand for acute based services across our county. Revise our financial plan to describe how we will address Shropshire CCGs financial deficit position. In recognition of our significant challenges, we have begun to strengthen our partnership arrangements to ensure that we have the necessary capabilities and governance in place to transform the health of the communities we serve. 31/01/2017 Shropshire and Telford & Wrekin Sustainability Transformation Plan 5 Executive Summary It is nationally agreed that in order for our NHS to continue to provide services for the future, changes need to be made now. In 2015, organisations were asked to work together to produce Sustainability and Transformation Plans (STPs) outlining how they are going to develop and deliver viable health and social care services over an agreed area. In Shropshire and Telford & Wrekin, our leadership team comprising of eighteen health ands social care organisations have been working together in partnership with our communities to develop local plans to address the causes of poor health and well being in our population. Our plan is a ‘work in progress’ and we have started to engage and communicate this with our patients, publics and partners, our workforce and our wider stakeholders to help us develop our plans further and to agree how to implement them in the best possible way. The challenge we face is significant. Our services are not keeping pace with the changing needs of an ageing population and people with multiple long term conditions. It is becoming increasingly difficult to ensure local people have access to consistently high quality care that is affordable and sustainable. Local health and social care services are under severe financial pressure and we have a significant resource gap in part of our system which is challenging our ability to meet the needs of our populations. This plan sets out our strategic vision and our intention to work together to mitigate the growing demand, and cost, of providing care. Our vision is materially improve the health and well being of our populations. Our focus is on addressing our ‘triple challenges’ which are: To address the wider determinants that result in poor health and well being in our communities To reduce unwarranted variations in care to ensure that everyone has the best outcome and experience of health and care possible We risk not being able to afford all the services our population need unless we take urgent action to avoid future costs and create a sustainable health and care system that helps our communities to thrive and prosper. We want to prevent ill health where possible by making the most of the skills of local people and organisations, supporting people in our communities to lead healthier lives, and promoting self-care are beneficial in their own right, as well as relieving pressure on the healthcare system. This is why our STP focuses on a more joined-up way of working, based on smaller areas we are calling neighbourhoods to prevent ill health and promote the support that local communities already offer. Our neighbourhoods will be used as the basis for providing health and care services for people who need professional help, but not hospital treatment. GPs, social care, community nurses, therapists and mental health workers would increasingly work together to provide a consistent range of services at a local level. These Neighbourhood Care Teams would be the first port of call for patients with diabetes and other long-term conditions . patients who might otherwise have to go to hospital but who don’t need emergency services; and patients who have recently been discharged from hospital. They would be the link between clinical and community care. 31/01/2017 Shropshire and Telford & Wrekin Sustainability Transformation Plan 6 Executive Summary For patients who do need acute hospital care, we propose to create two centres of excellence, one specialising in emergency care and the other in routine surgery or planned care. We have involved 300 clinicians in developing the proposals for hospital services because they know what is best for their patients. Our aim is to improve the outcome for patients by using consultants and other resources most effectively. One central emergency centre would work closely with more local urgent care services. Most assessment, diagnosis and follow-up would be done closer to people’s homes. Neighbourhood Care Teams would play an important role in supporting this. We believe that making these changes would deliver clinical improvements and make the experience of using services better for patients. Communities themselves would be able to support vulnerable people, with the professional backing of Neighbourhood Care Teams where required. Fewer patients would need to go to hospital, and those who do would be discharged quicker. It is clear to us that our current ways of operating are unsustainable. Under our plan, individual organisations and partnership will continue to make the improvements and efficiencies that are directly within their control but the overall scale of opportunity will be transformed by the our working together as a single system with a shared imperative We have committed to work together to ensure our STP works in the best interests of local people. As a leadership team we have listened carefully to feedback and have acted accordingly to strengthen our partnerships and build our leadership capacity and capability to lead these changes. We have also enhanced our programme management infrastructure to provide us with the necessary structure, processes and tools required to deliver complex change. We will also be working with our regulators to secure expert advice and support where this is needed. Working with the national and regional bodies and engaging with our communities, we will act with urgency to maintain momentum achieved through a accelerated STP process to ensure that each of our priorities delivers against our system objectives. We have listened carefully to feedback we have received from stakeholders and we recognise that we have to make some critical decisions about the way our services will be provided in the future and we accept that this will challenge existing models and approaches however we also acknowledge that these concerns must be managed if we are to achieve a sustainable and transformed health and care system for the people of Shropshire and Telford and Wrekin Finally we want to ensure that the approximately 470,000 people living in Shropshire and Telford and Wrekin understand these proposed changes, and are involved in designing new services.
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