The Deputy Director of Finance at South Tees Hospitals NHS Foundation Trust and Chief Officer and Director of Finance at South Tees CCG were in attendance to provide a presentation on the financial implications of the DDTHRW STP for acute service delivery in Middlesbrough. The Chair made reference to a meeting of the DDTHRW STP Joint OSC on 8 November at which the STP Lead Officer had acknowledged that the NHS was 'broken and underfunded'. The DDTHRW STP plan effectively no longer existed. The Deputy Director of Finance at South Tees Hospitals NHS Foundation Trust advised that the world had moved on significantly over the last 2 years and it was not about ignoring what had previously been produced but rather recognising that the NHS was facing a different landscape, with new challenges, and there was probably a need for a refreshed plan. As alluded to at the Joint OSC there were also an opportunity in certain areas to undertake work across Cumbria and the North East that would benefit from additional focus. It was acknowledged that the STP footprint was being revisited and much of the work around what was needed on a South Tees basis was already being undertaken.
The Chief Officer at the CCG advised that the STP had been a bit of arbitrary process that had been agreed nationally and the reason the DDTHRW STP footprint was determined had been on the back of the Better Health Programme (BHP) work. However, there was increasing recognition that for specialised services the patient flow went beyond the DDTHRW STP. For acute services there was also a need to think about improved patient flow to the North and South of the region and plans needed to be made on a bigger footprint. There was also a greater focus on services being delivered outside of the hospital environment, for example, in GP surgeries and much more focussed around localities. There was a need to build on the DDTHRW STP and much of the South Tees Integration work had been taking place before and it needed to continue. It was about the provision of the right services on the right geographic footprint.
In terms of the DDTHRW STP work continued, however, it was not at a point where a public consultation exercise could be undertaken. At present it was a case of a number of options being considered and debated. This process was ongoing and they were beginning to layer on additional complexities. Some of which needed to considered in the broader context of the North East. The question was posed in light of the above, as to which services were fragile / vulnerable. It was acknowledged that there were particular issues in respect of breast services, workforce challenges, specialised services, interventionist radiology, maternity and paediatric provision.
In terms of the financial implications of the STP it was advised that the funding would still come to the Trust unless there were changes nationally in the legislation. NHS England currently had a tariff based system in place but collaborate effort were being made to ensure that all organisations worked together in a way to make best use of the South Tees pound. Nationally there was also a strong drive on working more collaboratively. Demand for health services across South Tees was significant and that high level of demand needed to be provided for in this locality. Demand was driving the finances and ideally the best outcome would be to reduce that demand. A delicate balance between the delivery of elective, non-elective and specialised services needed to be maintained.
Reference was made to JCUH and the need for it to retain a number of services, including maternity, oncology and neurology in order to maintain its trauma status. It was explained that although the unit price for elective surgery such as hips, knees and cataracts is lower, the stay is lower and therefore it does not necessarily follow that a change on through put is detrimental. It is about working out what you should be dealing with and it was advised that it is a delicate balance in terms of resource planning.
It was again emphasised that there were significant financial challenges and the STP had been based on 2016/17 plan. However, the outturn had been different to the plan and therefore the underlying position had changed. It was confirmed that the STP lead officer had been seconded to the post 4 days per week and it was important to have a local system leader leading that change. The rest of the systems role was to hold him to account.
The Chair queried the issues of interest that the panel should be focussing on. The Deputy Director of Finance at the Trust advised that since the publication of the STP the challenge had become greater because of the outturn verses the budget. Business cases would be prepared and an assessment needed to be made around how to obtain that visibility. It was emphasised that the STP was not the business case and that work still needed to be produced.
The point was made that with the Trust in financial measures there were significant challenges in the system and it was about looking at how we all worked together to address them. We had to live within our means and use our resources in the most effective way. It was acknowledged that the various organisations were all separate statutory bodies. However, there were some really strong relationships in place, which afforded us a fighting chance to meet these challenges.
Reference was made to the £58m, for example, spent on medication and it was emphasised that there was still significant waste in our prescribing of medicines.
The point was made that in some respects it was a bit too early to answer the questions the scrutiny panel wanted answering. It was advised that it would be around spring time before a more meaningful debate could be held at a South Tees level around which services were particularly vulnerable and fragile.
Accountable Care Organisations (ACOs)
The Chief Officer at South Tees CCG advised that there were so many different definitions of ACSs but from a national perspective 8 systems had been identified as ACOs. All had been determined nationally and it was not possible to compare one with another. There was an array of different ACOs and in some instances they involved pooled budgets. From an NHS perspective there was no blueprint about how any it would be determined. It was very much driven by a desire to explore new models of care and there would not be a prescribed model. It was up to each local system to determine the best model for them.
At the moment the question locally was whether there was sufficient interest within Cumbria and the North East, to explore working in an inner system. Northumberland had a different care model in place and so there was a further question around whether we could share what was happening in Northumberland, the North East and Cumbria. It was emphasised that each ACO was different, some had agreed pooled budgets across health and social care but there was no single response. The Chief Officer at South Tees CCG advised that it would be possible to share some of the ACO approaches adopted with the panel and explain what the benefits of the different systems maybe. It was emphasised that the Manchester Model was not an ACO and each part of the country was developing its own model.
In terms of the current position in relation to the STP the view was expressed that the whole plan needed to be refreshed in line with the 5 year Forward View. The refresh would be undertaken once some of the work around the acute sector / bigger picture had been completed. The view was expressed that it could be beneficial for the panel to invite some of the people who had been working on the Northumberland ACS model to attend a future meeting of the panel. With a view to providing an overview of the work that undertaken in respect of the ACS in their region.
The Chair expressed the view that it felt some of the changes taking place in the various health sectors was a part of the STP, for example, the section on learning disabilities including the proposed co-production of new service models, as well as the agreed bed closures. The Chief Officer at STCCG advised that many of the principles included in the STP were in line with the 5 year view and particularly the need to tackle the issue of sustainability in the acute sector. The concern was raised by the panel, however, that as time goes on certain areas were becoming more stretched and thereby the service redesign would occur by default rather than design. It was also emphasised that the issues highlighted in the STP were still the main areas that needed to be addressed. The STP was an aggregation of all of the measures which needed to be happening across our footprint. The point was made that all of these planning processes had been in place since the inception of the CCG.
The Chair thanked the attendees for their attendance and made the point that elected Members were concerned about what would be happening in 5 years/ 10 years time regarding acute service provision.
AGREED as follows:-
1. That an invitation be extended to those working on the Northumberland ACO to attend a meeting of the panel to provide Members with an overview of challenges and opportunities ACOs presented.
2. That lobbying be undertaken to ensure that local CCGs be given the ability to make proper planning irrespective of whether a more traditional model was adopted.