The NHS, STPs, and IT

Summary: The NHS has been told to draw up sustainability and transformation plans. But what are they, and what do they mean for information technology? ehi LIVE commissioned an exclusive Q&A on the issues that will form the backdrop to this year’s event later this year.

Introduction: It’s impossible to turn on the television or pick up a newspaper without being told that the NHS is under enormous pressure this winter. Forty-four sustainability and transformation plans have been published to try and address this pressure over the next five years.

The STPs give a key role to healthcare IT, to provide better data for commissioners, to help hospitals, primary care and social care provide joined-up services, and to help the public access help and advice in new ways. This means the plans could provide a significant boost for attempts to digitise the health service; if the money can be found.

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What’s the background to the STPs?

The financial pressures on the NHS are not new. In October 2014, the chief executive of NHS England, Simon Stevens, published his ‘Five Year Forward View’ plan to try and close a gap between funding and demand that could otherwise reach £30 billion by 2020-21.

The Forward View calculated the gap could be closed if the NHS made £22 billion of efficiency savings and the government put in £8 billion. The Chancellor at the time, George Osborne, said he would deliver this money in his autumn statement in 2014.

Hasn’t there been a big row about government funding?

Yes, there has. Prime Minister Theresa May has said the government is putting in £10 billion, which is “more than the NHS asked for.”

However, Parliament’s health and public accounts committees have proved that £2 billion of that had already been announced for 2014-15, the year before the Forward View started. MPs have also shown that just £4.5 billion of the £8 billion is ‘new’ money, since £3.5 billion is being diverted from other sources, such as public health.

Also, the most of the money is going in this year, with hardly any next year or the year after. And there’s another funding crisis in social care, which is essential for keeping elderly people out of hospital. However this money is counted, though, the NHS still needs to make £22 billion of efficiency savings.

Where is the NHS going to find £22 billion?

The Forward View says £7 billion of these will come from central bodies, which is why the Department of Health has just announced a big round of job cuts, and the remaining £15 billion will be made by the local NHS.

A lot of that £15 billion will come from trust efficiency programmes. Some is due to come from the reorganisation of ‘back office’ services (such as finance or HR but also pathology). And some will come from changes to the way that frontline services are paid for and organised.

The Forward View set out new ‘models’ for managing the care of whole populations, and for creating ‘integrated’ health and social care services; and these are already being tested out by ‘vanguard’ projects. In December 2015, NHS England launched the STP process to try and drive change everywhere else.

How were the STPs drawn up?

Local organisations were left to club together to form STP ‘footprints’. In the event, 44 were formed, ranging in size from 1.2 million to 300,000 people. NHS England asked them to consider more than 50 questions, grouped around three themes: improving quality and developing new models of care; improving health and wellbeing; and improving the efficiency of services.

STP areas were asked to submit draft plans by June last year and final plans by October. NHS England hoped to review these before they were published, but councils started putting the plans on their websites as soon as the deadline was up.

Birmingham and Solihull was first, with North Central London following almost immediately. Both STPs include plans that affect local hospitals; and councils argued that local people had a right to know what was being proposed.

What are the big, common themes?

Hospital closures and reorganisations are a feature of many STPs. However, in an early analysis the Nuffield Trust think-tank said these tend to form part of bigger plans to shift as much care as possible to community and primary care services or to other settings, including people’s homes.

In another early Q&A, the King’s Fund think-tank said this meant the STPs “cover a broad range of themes” from the need to “strengthen primary and community services” to the need to “integrate NHS and social care services” to more ambitious ideas to “improve the broader health and wellbeing of their populations.”

What about IT?

All the STPs identify digital technology as an ‘enabler’ of change, along with workforce and estates. However, it can be difficult to pick out their precise plans.

One reason is that before the STP process got going, clinical commissioning groups were asked to put together local digital roadmaps for their areas, and the STP footprints and LDR boundaries do not match (there are 44 STPs but 84 LDRs).

Also, the LDRs that have been published include sections on the need to complete the roll-out of electronic patient record systems in hospitals, while the STPs only tend to mention EPRs in passing. This doesn’t mean they won’t need to address digital maturity; or find a way to fund it.

What technology do the STPs want?

As the Nuffield Trust analysis notes, there is a lot of interest in business intelligence and analytics, starting with data to ‘risk stratify’ populations and then target services at people most at risk of being admitted to hospital or needing expensive treatment.

Also in “creating single, local records with read-write capability” to share information between different parts of the NHS, and between NHS and social care. That’s both to remove the costs and inefficiency associated with paper and to underpin those non-hospital, ‘integrated’ services.

TechUK, an organisation representing healthcare suppliers, has identified this as a major trend. Its senior advisor on health and social care, Jeremy Nettle, says: “With the introduction of the 44 STPs we are seeing a focus on interoperability – which means data being shared from primary to secondary to social care.

“There are a number of [shared care record] initiatives that are underway at a local level, but the STP target architecture is more about showing how these kinds of activities can be brought together into an overall, managed framework to improve the delivery of care to the citizen.”

Also in technology to create new, digital routes into the NHS. The Nuffield Trust analysis says: “There is interest in redesigning access to services, for example via 111, and in web and telephone-first models of service, where patients use standardised entry routes for urgent or other forms of care.”

It’s not just big plans or hospitals then: the STPs cover primary care?

They certainly do. A lot of STPs emphasise the need to “strengthen” primary care, and to make sure people can get access to a GP service when they need one. That might mean making more use of systems that already exist to enable patients to book appointments and get prescription refills.

But it might also mean using newer technologies, such as remote consultations. Many STPs also mention telehealth, remote monitoring, websites and apps as areas for investment; so patients can take more control of their own health and wellbeing; although TechUK thinks they could be more ambitious.

“One area where we feel there is greater opportunity to scale is online digital solutions for patients suffering from poor mental health, such as bipolar, eating disorders, or people who have been abused,” says Nettle. “This is one area in which the ‘digital revolution’ could make a significant change in provision.”

Will the STPs help to digitise the NHS?

They should, because the STP process is much more than a future planning exercise. NHS England and NHS regulators are starting to treat STPs as administrative areas; the footprints will be given their own performance indicators this spring and could be given collective financial ‘control targets’ in a year or so. 

As long as the NHS gets through the winter, and central and local organisations then buy into the reform agenda, this makes it much more likely that the plans will be delivered. However, digital investment will have to be paid for, and most of the STPs are looking for central funding.

The Treasury put aside £4.2 billion for NHS IT in the spending review, but a lot of this money is earmarked for infrastructure, security, and the ‘paperless’ agenda in hospitals. Meanwhile, NHS England has created a sustainability and transformation fund to kick-start change, but a lot of the fund has been diverted to deal with acute trust deficits.

So the big question is the money?

Absolutely. The STPs recognise the importance of digital technology to the NHS, and they identify some specific priorities around data and analytics, shared health and care records, GP services, and patient held records and apps. The big question is whether the cash can be found to pay for them.

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