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 ĥ 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. 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 ĥ 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 ĥ 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. Robert Jones & Agnes Hunt Plans (STP) and there are 44 Foundation Trust throughout England. This will mean change. It will ĥ 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. ĥ ShropDoc (GP out of hours service) ĥ Shropshire Council ĥ Telford & Wrekin Council ĥ Powys Teaching Local Health Board ĥ 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.