The NHS, STPs, and IT

The NHS has been told to draw up STPs. But what are they, and what do they mean for information technology? Informa commissioned an exclusive Q&A on the issues that will form the backdrop to this year’s EHI Live in November

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.

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’. Yet Parliament’s health and public accounts committees have proved that £2 billion of that had already been announced for 2014-15, which is 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 council-run social care, which is essential for keeping elderly people out of hospital. However the 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 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 frontline services are paid for and organised.

The Forward View sets 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. But, 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.

What about IT?
All the STPs identify digital technology as an ‘enabler’ of change, along with workforce and estates; although it can be difficult to pick out their precise plans. One reason for that 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 tend only to mention EPRs in passing. This doesn’t mean they won’t need to address ‘digital maturity’ in hospitals; 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 make sure everybody working in those ‘integrated’ services has access to the patient information they need.

TechUK, an organisation representing healthcare suppliers, has identified this as a major trend. Jeremy Nettle, senior advisor on health and social care, 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.”

There’s also interest in technology aimed directly at the public and patients. 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 money and 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; although TechUK thinks they could be more ambitious.

Nettle says: “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. 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, access to GP services, and patient-held records and apps. The big question is whether the cash can be found to pay for them.

Fresh out of the box: the first STPs lay out some common IT ambitions

Birmingham and Solihull STP: The first STP to be published says Birmingham has done well in consolidating its hospital services and investing in social care ‘to help people live independently for as long as it is possible for them to do so’.

However, it says it needs to tackle poverty, because ‘nearly half our population lives in the poorest areas of the country’ and ‘are more likely to have a mental health problem or die from a condition that can be supported’. It says the area needs to invest in GP and community services and innovation, which will not just improve efficiency but ‘change things for the better’.

Digital: The Birmingham and Solihull STP devotes an appendix to ‘digital’ as an enabler of its plans. This says ‘digital has the ability to rapidly transform the way in which health and social care is delivered’ and ‘the way in which citizens and patients interact with care and public health services’.

The appendix says the local digital roadmap sets out three ‘priority areas’, which it lists as ‘digital maturity’ [improving hospital EPRs so staff can work without paper notes], ‘paper free information flow between organisations’ and ‘inclusion of patients, carers and citizens in the use of digital technology’.

Birmingham and Solihull already has projects to build on. These include the ‘Your Care Connected’ shared care record, which the STP wants to reach 1.8 million people within nine months, and an electronic document transfer project, which it wants to turn into a structured data sharing platform.

The STP also says it wants ‘patients and citizens to access information through websites, apps… and [technology to] support self-management and prevention’. It identifies funding and information governance as challenges to achieving its vision.

[https://drive.google.com/file/d/0B3Dis4WSiuK_Snd0NFZsSGpZYXc/view]

North Central London STP: The second STP published says the area has ‘some excellent health and social care services’ but also some areas of ‘poor practice’.

To address this, it wants to consolidate specialist and hospital services, while ‘shifting our model of care so that more people are cared for out of hospital settings’. The STP also wants to shift attention from caring for people when they are ill to making more effort to keep them well.

Digital: The STP identifies digital as a key enabler of its plans, arguing that there is ‘a significant and immediate opportunity for digital to transform our current delivery models and seed completely new, integrated models of health and social care’.

A digital section indicates that the area’s local digital roadmap identifies a need for improved IT at its hospitals but, more ambitiously, lays out plans for a population health management system.

It says this would deliver better data or ‘insight’, which is needed to predict future demand, create new patient pathways, and ‘risk stratify’ the population [work out who is most at risk of a hospital admission, so they can be cared for in the community].

It would also support ‘integrated’ health and social care. The STP says it wants ‘seamless’ shared care records, as well as a personal health record for patients, backed up by remote monitoring and self-care tools, so they can ‘actively manage their own health and well-being’.

These ambitions come with a big price tag. North Central London says that ‘to deliver on our digital strategy we will need to invest £159 million, with a further £21 million in 2020-21’. It says this money will need to come from central pots, such as the estates and technology transformation fund, which was set up to transform GP and primary care.

[https://drive.google.com/file/d/0B7epCDw-hI0BUzhCSmNXTDdkSjA/view]