James and the giant footprint: how the new plan for local NHS services is being prepared
James Scott is the Chief Executive of the Royal United Hospitals in Bath. He has worked in the NHS for 33 years and at the RUH for nine years. Now he has another job as well - he is the leader of the Sustainability and Transformation Plan (STP) 'footprint' (the official term) that includes Wiltshire.
Marlborough.News went to see Mr Scott on the morning of Referendum Day. With the result, the future of the NHS has just entered another period of uncertainty.
But, as June ends, one thing is certain: the STPs - all 44 of them - will now be more important than ever.
After his years in the NHS, James Scott can still smile at its way with initials and acronyms. He is, he says, the SRO of the BSW STP - or Senior Responsible Officer of the Bath and North East Somerset, Swindon and Wiltshire Sustainability and Transformation Plan. Simple really!
The STP faces a far from simple set of problems. The first problem is BSW itself. It is a very large and a very diverse 'footprint' - with urban Swindon growing very fast, and wide rural areas with aging populations. One senior NHS executive I spoke to last month called it a 'shot-gun marriage'.
While many STPs cover the same area as a county, BSW is a new concept: "This is", James Scott tells me, "the first time we've sat down to work with these three populations together. It's an artificial construct, but so is everything else."
"We are a coalition of the willing - there's risk associated with such an area, but a lot of opportunity as well."
The most important message from my interview with James Scott is probably his statement that "We are coming away from the internal market to a more collaborative model." This could change utterly the way CCGs buy services from acute hospitals.
Into the STP mix, Swindon CCG has said it may create an Accountable Care Organisation or Alliance to take over most of the town's health and care services - and leave the CCG with less work and so less staff. That will need to be 'sold' to Swindon people.
The heads of the three acute hospital (RUH, GWH & Salisbury), and of the three Clinical Commissioning Groups (CCGs), and representatives from the three councils (their Health and Wellbeing Boards and Public Health leads) meet every Friday. They have to have a draft plan by the end of June - and a fully approved plan by September 16.
They are under the cosh as regards timing - and as regards oversight by NHS England, the Department of Health and probably the Treasury too. They are being helped by management consultants - whose fees are shared by the STP's main members.
Will the STP become a permanent part of the NHS organisational network? James Scott thinks they may need a small central team to oversee delivery of their plan: "But I don't think the STP will become a mini Strategic Health Authority - personally."
"I am committed to deliver the change we need. We have a pretty strong team. It is all about partnership - 'partnership' goes right through our stick of rock. I've got no leverage myself to make it happen."
At some point, however, the STP will need some transparent governance arrangements. We know of old how quickly decisions 'made in secret' can anger local people.
This STP is concentrating on two key issues: urgent and emergency care (the A&E problem) and the workforce (recruitment gaps and safe staffing).
Finance is, he believes, not so great a problem for the BSW area which has a combined annual NHS budget just shy of £1.4 billion: "We're in a better financial position relative - relative - to some other areas - we're not a 'burning platform' in the way it is for some other STPs."
However he does say quite bluntly: "If we leave things as they are we will be in financial straits in five years time."
The plan is, of course, not complete and cannot be published. But the three big hospitals are already talking about sharing back office functions like pay roll and HR and procurement: "A pound I don't spend on the back office I can spend on a patient."
If that patient is a member of the increasingly large number of old and frail people BSW has to look after, James Scott is keen to keep them out of hospital, keep them at home: "The safest place for frail old people is at home."
He wants "...to wrap services around the citizens - around people - not just patients, and around neighbourhoods." This must, he says, involve GPs and preventative services.
And it must be explained to the public: "I see more opportunity than risk - engaging with our populations about transformation in health and care, that's what an STP should be about."
"We are working on a five year plan to deliver the right services in the right place within the resources we have." And he does not expect there to be any more money from the government this side of 2020.
Post Brexit Stresses on the NHS:
The Health Service Journal puts it very strongly: 'A firestorm of uncertainty now menaces the NHS.' The leaders of the NHS Confederation and the Mental Health Network says the decision to leave the EU will have 'far reaching implications for the NHS'.
NHS funding may be hit: if the British economy slows down - even temporarily - there may well be less money. We can almost certainly assume - and assumptions are all we have to go on now - that the fictitious £350 million a week promised for the NHS will remain fictitious and will not materialise. Not even a tithe of it. It has already been disowned - after the vote - by Nigel Farage and Iain Duncan-Smith.
Recruitment may be hit: at the beginning of June, GWH's Chief Executive, Nerissa Vaughan reported that recruitment of nurses was going well. In April they offered jobs to 157 nurses in India and to 20 from Spain and Portugal.
It may logically be asked whether the former will still want to come to a country whose population has apparently voted against immigrants in general and whether the latter will still want to come to a country that will not be a member of the Union their home country belongs to.
The current spate of racist attacks on individuals and groups of immigrants will be well reported around the globe.