Plans for the future of the NHS in Wiltshire are not 'contentious' - first glimpse of the 'STP'

Written by Tony Millett.

It took the hint of future hospital and A&E closures in England to get the Sustainability and Transformation Plans (STPs) onto the front page of the Daily Mail.  But the STP for the area that includes Wiltshire will probably not make any front pages - yet at least.

In their new scheme to get the NHS both better and more cost effective - and hopefully save it from complete collapse - NHS England divided the country into 44 'footprints' which have to produce STPs.   The one for our area links Bath and North East Somerset, Swindon and Wiltshire or BSW for short.

BSW leaders have now published a Summary of their plan - and it had its first outing at Wiltshire Council's Health Select Committee on Tuesday (November 15.)  The STP leader, James Scott (Chief Exec of RUH, Bath), told the committee that the plans were not 'contentious', but the details of implementation would probably not be known for another six months.

Despite the fact that they had consultants on board to help get BSW's STP process started, Mr Scott made it clear to councillors that all those involved - from three Clinical Commissioning Groups, three Councils, three acute hospitals, three Healthwatches and more besides - had their 'day jobs' to do and time given to work on the STP was on a voluntary basis.

There has been much criticism nationally that this STP process is being carried out in secret - secrecy ordered by NHS England.  James Scott told Wiltshire councillors: "If I'd had my way it would have been public a long time ago."

The Daily Mail headlines were triggered by a report on the STP process by the highly respected King's Fund.  They criticised the process for not involving NHS staff or patients, but seem to have raised some false fears about closures.

About ten STPs at various stages of development are now fully in the public domain.  They have either been leaked or published by councillors cross that STPs are being put together behind closed doors with no accountability and very little if any consultation.

The STP message for Wiltshire is clear - 'Keep Calm and Carry On'.  Or in the words of the Summary: "Although the future challenges are considerable, we are in a better place to deal with them as our 2015/16 position was relatively strong when compared to the national position."  

So no major closures in Wiltshire - and no major capital improvements either [see below].

The BSW area - with the three acute hospitals markedThe BSW area - with the three acute hospitals markedWhy publish a summary now?  "This summary sets out our approach, emerging priorities and proposed activity so everyone can see and have their say on what is being proposed."

The full Summary can be read here.  And on page twelve it tells readers 'How to get involved in our STP'.

The introduction to the summary states " and care organisations across [BSW] have begun working together in an exceptional way to meet the many challenges facing the health and care system." 

One of the challenges is about money: the STP leaders say that if nothing is done to save money, there will be a "... gap between our patients' needs and available health care resources of approximately £300m by 2020/21."

They have produced a diagram showing 'How we plan to close the gap'.  The major saving (45 per cent of the total) will come from 'organisational savings plans'. 

There is also a section of the pie chart called somewhat opaquely 'Local government gap' - at 16 per cent.  This chart should perhaps have been titled 'Where we hope to close the gaps' rather than 'How...'

Under the headline 'Our emerging priorities' the document sets out the areas in which NHS leaders are 'planning to change services' over the next five years;
1.    Transforming primary care
2.    More focus on prevention and proactive care
3.    Making best use of technology and our public estates
4.    A modern workforce
5.    Improved collaboration across our hospital trusts.

Along the way this summary reveals some alarming statistics:  
•    each year BSW's NHS estate (land and buildings) costs £175 million to run
•    in BSW the combined annual spend on healthcare per person is about £1,570 (2015-16) - by 2020/21 it will be about £1,760, but the available money will be £1,650 per person - that is 'the gap'
•    By 2026 Swindon's population (now 221,000) is predicted to rise by ten per cent to 243,000
•    Swindon is currently short of 25 GPs  (The figure for Wiltshire is not given)
•    Wiltshire has a higher than average number of people with hypertension (or high blood pressure)

The published summary is designed to be long on intentions and short on how to implement them.  But we can legitimately ask one or two pertinent questions:

Why is there is no mention of dementia - now revealed to be the leading cause of death in England and Wales - with about 167 people dying from dementia every day.

Why is there no sign that BSW needs any capital spent on improvements.

Great Western Hospital, which primarily serves Swindon and north and north-east Wiltshire, is patently too small. We have heard people talk of their shock when GWH  was being built and they heard Swindon councillors boasting how good it was that it would be smaller than the Princess Margaret Hospital it was replacing.  Since then Swindon's population as ballooned.

It is said that hospitals are best and most safely run with bed occupancy at 85 per cent.  Beyond that level safe treatment is less easy to guarantee and risk of infections rises. At times during recent months GWH has been running with bed occupancy at over 100 per cent - that means patients are put in temporary beds and in temporary wards.

Swindon's population is continuing to increase and the leaders of the STPs have been told not to rely on extensive capital expenditure and so any radical improvements appear to be ruled out.

Although the work done by Wiltshire CCG with their community care projects and then by the CCG and Wiltshire Council under the Better Care Plan, has made some inroads into the numbers of the elderly needing hospital treatment, the number of emergency admissions to GWH stays at unsustainable levels.

At the other end of the journey through hospital, beds blocked by patients ready to leave but needing further care out of hospital care or care at home, have now risen nationally to record levels and in some parts of BSW remain stubbornly high.

Nobody wants to own up to the fact that an increasingly large number of the growing cohort of frail and elderly with increasingly complex and long term conditions (such as dementia), will continue to need treatment in hospital.  Not to mention the growing numbers with diabetes and weight related problems and those suffering from air pollution

As this graph (below - prepared by from OECD statistics) shows, the UK is way down the league table for the number of hospital beds per 1,000 of population. Japan's position at the top of this list is not simply a matter of their aging population.  However, more than a quarter of Japan's population is aged over 65 and that percentage will rise to 40 per cent by 2055.  (For the UK the figure was 16 per cent in 2011.)