David Pearson: Sustainability and transformation plans - where next?

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David Pearson, STP lead for Nottinghamshire and Deputy Chief Executive of Nottinghamshire County Council, gives his response to The King's Fund's report, Delivering sustainability and transformation plans, and discusses STPs from a local government perspective.

Transcript

Okay thank you very much Chris. And I would like to first of all welcome The King's Fund report because I think it is quite a nice balance of different issues that have come forward. So the challenging context, the funding, the rising need and the speed of this given the complexity of the systems that we are working with, but also the recommendation of safeguards around closing hospital beds which I will return to in the Nottinghamshire context, and also the importance of having the capacity and capability in order to deliver quite significant changes across a very large set of public services.

I think as the only serving director of adult social care as an STP leader you will hopefully forgive me for painting this in the context and elaborating a bit on the local authority and social care context. And I think the key here is that we do have the greatest level of rising need in terms of health and care in certainly my fairly lengthy career. And in relation to public health and social care the report rightly brings attention to the cuts and the reductions and for social care we are in the slightly post factual situation where we are moving from 1.2% of GDP being spent on social care to 0.9% by the end of the parliament as needs are rising exponentially.  And it is worth rethinking what that’s about.  So a 57% increase in the numbers of people over the age of 85 who are a large contingent of the older people that local authority social care departments are serving.  But what’s often not well understood is that about half of the social care budget is spent on younger adults with disabilities, and there is to be it a 21% increase in the number of people with learning disabilities by 2030.

So as important as it is to ensure that while using all our resources across the nation well in terms of meeting the needs of older people, it is also important that we don’t lose sight of what is an effective way of making sure that people have good lives amongst all citizens, and that is a very important thing as we move towards the continued debate about the sufficiency of health and social care funding which in my view should continue to rage.

So going back to the STP issue specifically, I will return to local government right at the end of this presentation, it nevertheless seems to me as a long serving health and care professional, that it was the right question to consider at a local level how we best address the health and wellbeing of our populations, the care and quality and the financial sustainability. It is not a contradiction to need to have a good plan for our population, whether it be in Nottinghamshire or anywhere else. And in fact every advanced economy in the world is grappling with similar issues.  There is a debate about the money, but the two are not a contradiction, they are complementary.

So thinking about that in the context of Nottinghamshire, we are privileged to have five vanguards in Nottingham and Nottinghamshire. People have suggested that we have got more vanguards that the north west frontier and that we are a bit greedy about this. But I think the tremendous advantage we have is that for every one of the particular challenges that have highlighted through the STP process, we have got someone, somewhere in Nottinghamshire working on the solution, and to an extent having made some progress.

So in terms of our priorities, we have highlighted five key priorities in terms of promoting wellbeing, prevention, independence and self care, across our 1.1 million population, a £3.7 billion economy, 43,000 staff. And we do have an aspiration to improve the healthy life expectancy of people of Nottingham and Nottinghamshire by three years during the life of the plan, which the two directors of public health have modelled very carefully and have argued very strongly amidst considerable challenge that if we all do the right thing in terms of prevention, we can have that kind of impact. And of course when we contemplate the fact that the hospitals are 70% full of over 65s, and that in 1947 the average life expectancy of a male was just short of 64 years, we have some idea of the challenge that we face, and that for every year of extra life we spend a third of it with disability or long term condition.  So pushing that threshold back is pretty important for not only the health and care system, but for the outcomes of our citizens.

So clearly it’s important that we strengthen primary community care and care of services including obviously social care where the market challenges of home care have been highlighted nationally strongly. But when we do need urgent and emergency care we want it to be world class, we want it to meet our needs in the best way possible. So it has to be effective, utilising the best standards of care.  We have got an ambition to deliver technology enabled care, so we have got probably one of the best digital road maps according to NHS England centrally in Nottingham and Nottinghamshire.  We are over 90% records are identifiable with the NHS number.  And I didn’t actually think I would see the day in my career where we managed to pull this off, and the ability to share across so that people don’t have to tell their story 16 times across the major statutory organisations has to be a good thing.

But more than that there is fantastic opportunities through assistive technology and utilising apps that enable people to manage their own long term conditions. And Jane has mentioned standardisation, and there is a fair degree of evidence that not the best practice is used in every situation, there is too much variation from the best practice which is both not good for our citizens, but is also not cost effective. Allied to this we have obviously got enabling work streams around the workforce which is absolutely critical, and housing and environment which is a bit of a USP for Nottingham and Nottinghamshire.  Because actually if we want to keep more people at home and care for them we have got to make sure that housing is significantly addressed, and I think for the first time in the recent white paper the needs of people who have disability or long term conditions was in that, probably too late, but nevertheless sacrament of the moment, it’s good that it’s being mentioned as being addressed.

So that shift to community and primary care services is absolutely critical that Chris has referred to. And going back to the 200 beds, the basis of this was that at the Nottingham University Hospital we have a fairly sophisticated database which has recently been developed which was featured in The Guardian recently, which tells us that if there were alternative community based services there were probably over 200 people every day who could be cared for in an alternative setting. People whose needs are not well met in a hospital setting for the reasons that we all know in terms of deterioration in capabilities, risk of infection and so on.  So it’s important though that we do have those services in place and in mid Nottinghamshire we have got a good example of where that has happened through the vanguard with the formation of multidisciplinary teams in primary care addressing the needs of those most at risk.  And in mid Nottinghamshire the Sherwood Forest Hospital Trust was a Keogh 14 Trust with poor quality, poor A&E delivery and often difficulties with actually access to the right services at the right time.

Through the Better Together programme which isn’t called the STP but is a programme of working together and the implementation of these new services, the A&E performance went up to amongst the best in the country. The care and quality was judged having been inadequate by CQC to be good and last financial year 107 beds were not used that were previously used. Now clearly the challenge of winter has led to a bit of a blip in that, but what it does demonstrate is that if you do do the right thing together, you can make better use of the public purse.

So finally I want to just quickly return to the local government angle. The rising challenge in terms of need and resources not keeping pace with that need does mean we need to work better together than we ever have done before. We need to engage in a cultural change programme across organisations and with a conversation with our public that probably the NHS and local government have never had before to this extent.

And in order to deliver this we will need to focus on the imperative of the change, we will need to free up the space and capacity in order to focus as much on the change programme over a number of years as well as the day to day challenges that every health and care organisation faces. So creating that capacity and that focus is going to be very important. And it’s a very complex system in Nottingham and Nottinghamshire we haven’t quite worked on this footprint before.

Going back finally then to local government. One of the two chairs of the Health and Wellbeing Board said to me very early on, or indeed to health colleagues as well, because I think I knew this, ‘When I am not consulted early I become capricious’. And I think that shows how important it is that local politicians are involved in this from a very early stage.  And of course the NHS is nationally accountable through the NHS mandate to parliament and the Secretary of State, but local government is locally accountable.  So what that means we need to find governance arrangements that reflect that symbiotic relationship.  And for members it seems to me that what they want is something that is citizens focused where there is transparency and clarity about the money, because it is certainly in short supply in local government, and have influence over the plans and the way forward.

Finally on the issue of integrating health and social care, it seems to me that the NHS has done a fantastic job over the last 70 years in keeping us all alive for longer, fixing us when we need it and helping us to get on with the rest of our lives. Social care when it is properly funded provides that person centred co-ordinated care that people with long term conditions and illnesses need in order to lead those effective lives that we referred to. Integration is not the point, there are two leaky buckets, but it is an enabler to a transformed model that is more appropriate to the needs of modern Britain in the 21st century. Thank you.

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