NORTH EAST LONDON SUSTAINABILITY AND TRANSFORMATION PLAN
KEY DECISION NO.
CABINET MEETING DATE 2016/17
CLASSIFICATION:
27 FEBRUARY 2017
Open
If exempt the reason will be listed in the
main body of this report.
WARD(S) AFFECTED
All Wards
CABINET MEMBER
Cllr McShane
Health, Social Care and Devolution
KEY DECISION
No
GROUP DIRECTOR
Anne Canning, Group Director Children, Adults and Community Health
1.
CABINET MEMBER’S INTRODUCTION
1.1. There’s a lot of talk at the moment about changes to health care, both in
Hackney and across the country, and with that comes a lot of uncertainty.
1.2. As Hackney Council’s Cabinet Member for Health, Social Care and
Devolution, and Chair of the borough’s Health and Wellbeing Board, I
regularly hear confusion, suspicion and anxiety expressed by residents,
patients and health professionals. Much of the concern relates to the North
East London Sustainability and Transformation Plan (NEL STP).
1.3. The Plan emphasises things which most people would agree with: a focus on
prevention, early intervention, helping people live more healthily, and
increasing the understanding of and support for mental health. Equally, few
would disagree that hospitals, GPs, councils and the many other
organisations involved in care need to work more closely together and treat
the whole person rather than individual conditions.
1.4. An integrated health and social care system based around prevention,
promoting independence and person-centred care should also be less
expensive. With an aging population and a Government reducing funding for
health and social care, we need to make the most of every pound we get.
However, the confusion around our STP and the concern being expressed is
understandable and justified.
1.5. There has been a lack of transparency and engagement with residents and
the democratically elected local authorities which represent them. Councils
deliver the public health and adult social care services fundamental to helping
prevent ill-health and supporting independence. They are also the
organisations which can embed health and wellbeing considerations into
areas such as housing, employment, transport, parks, leisure and job
opportunities - the ‘wider determinants’ of health. Given all this, our lack of
real involvement to date is worrying.
1.6. Hackney Council, Homerton Hospital, City and Hackney CCG and the many
other health organisations in the borough have a good track record of working
together. We are one of the few areas in London delivering on performance
targets and able to invest in new services. However, we are a rapidly
changing borough and still face significant health inequalities.
1.7. As far as we’re concerned, local organisations working with their residents,
patients and voluntary sector are best placed to deliver an effective and
sustainable person-centred system, alongside the wider NHS. This is why last
year we successfully applied to be a health devolution pilot. Our shared vision
for the borough covers the whole range of wellbeing - from public health
initiatives for children, timely access to GPs and community pharmacists, and
top quality hospital treatment. It also covers improving mental health services
and supporting people to remain independent in their own homes for as long
as possible. Our local residents and patients will play a key role in shaping our
proposals.
1.8. Our devolution pilot currently forms part of the STP, which is encouraging to
see but we need to make sure a top down plan doesn’t get in the way of us
doing what is right for Hackney. Hopefully we will continue to be able to
progress our local work as planned. Our position in relation to future
requirements and working with the NEL STP are set out in this report.
2.
GROUP DIRECTOR’S INTRODUCTION
2.1. This paper presents the North East London Sustainability and Transformation
Plan (NEL STP), a transformation plan for health and care services across
eight London boroughs including Hackney. Cabinet is asked to note the NEL
STP, contained in Appendix 1.
2.2. The paper sets out the concerns in relation to the NEL STP, given the likely
impact of the NEL STP on Hackney, and asks Cabinet to agree the proposed
Council’s position as set out in paragraphs 4.4.1 – 4.4.4.
3.
RECOMMENDATION(S)
3.1 To note the contents of the North East London Sustainability and
Transformation Plan, as at Appendix 1.
3.2 To agree the recommended position in relation to the STP, as at
paragraphs 4.4.1 – 4.4.4.
4.
BACKGROUND AND POLICY CONTEXT
4.1. Sustainability and Transformation Plans – National Context
4.1.1.
Sustainability and transformation plans (STPs) were announced in the NHS
planning guidance published in December 2015. NHS organisations in
different parts of the country have been asked to work with partners and
come together across a ‘footprint’ to develop place-based plans for the
future of all health and care services in their area.
4.1.2.
STPs are five year plans, being produced in 44 areas across England. First
drafts were submitted to NHS England in June and submission of the next
iteration was on 21 October 2016. Detailed delivery plans will be developed
over the coming months.
4.1.3.
An STP is intended to be a blueprint for delivering the ambitions NHS
bodies have for a transformed health service, as set out in a document
called Five Year Forward View. This document marked a step change in
the recognition of links between social care and the NHS as well as the
importance of wider services in prevention. It has become the vehicle
through which the NHS wants to address a number of national priorities,
such as seven-day services, investment in prevention and improving
cancer outcomes, as well as addressing three key ‘gaps’:

The health and wellbeing gap – the pressing need to reduce demand
on the NHS by shifting the focus towards prevention and addressing
health inequalities

The care and quality gap – to harness technology and innovation to
reduce variations in the quality, safety and outcomes in care

The funding and efficiency gap – to ensure that additional funding for
the NHS is used to improve efficiencies, transform services and
achieve financial sustainability
4.2. The North East London STP
4.2.1.
The North East London STP covers 8 local authority areas: Barking and
Dagenham, City of London Corporation, Hackney, Havering, Newham,
Redbridge, Tower Hamlets and Waltham Forest. It brings together 20
organisations: 7 Clinical Commissioning Groups, 8 local authorities, Barts
Health NHS Trust, East London Foundation Trust, North East London
Foundation Trust, Homerton University Hospital NHS Trust and Barking
Havering and Redbridge University NHS Trust.
4.2.2.
The STP for north east London has been developed by bringing together
three sets of local transformation plans. These are the Hackney devolution
pilot; Transforming Services Together (TST) for Waltham Forest, Newham
and Tower Hamlets; and the Barking and Dagenham, Havering and
Redbridge (BHR) Devolution Pilot. The local delivery plan for Hackney is
set out within the “Integrated Commissioning for Health and Social Care”
report, relating to arrangements between the London Borough of Hackney,
the City of London Corporation, and City and Hackney Clinical
Commissioning Group.
4.2.3.
The NEL STP seeks to address significant challenges faced across the
footprint. The population is set to grow by 18% in the next 15 years, and
health inequalities are high, with many residents challenged by poor
physical and mental health. This puts additional financial pressure on the
local health economy, in an area where a number of providers are already
facing significant financial challenges, particularly Barts Health which
continues to be in Financial Special Measures.
4.2.4.
These organisations have adopted a joint vision to address the challenges
faced:

To measurably improve health and wellbeing outcomes for the people
of north east London and ensure sustainable health and social care
services, built around the needs of local people.
4.2.5.

To develop new models of care to achieve better outcomes for all,
focused on prevention and out-of-hospital care

To work in partnership to commission, contract and deliver services
efficiently and safely.
The STP then sets out six key priorities to be addressed collectively:
1) The right services in the right place: matching demand with appropriate
capacity in north east London
2) Encourage self-care, offer care close to home and make sure
secondary care is high quality
3) Secure the future of our health and social care providers – many face
challenging financial circumstances
4) Improve specialised care by working together
5) Create a system-wide decision making model that enables place based
care and clearly involves key partner agencies.
6) Using our infrastructure better
4.3. The impact of the North East London STP on Council services
Services already under significant pressure
4.3.1.
The council delivers a range of services which are critical to the health and
wellbeing of local residents and the sustainability of the health and care
economy. These services are integral to the priorities of delivering
integrated community services, and the focus on prevention, as set out in
the STP. We are already working closely with health partners to deliver
community-based, multi-disciplinary care, and prevention services in
Hackney and the City through the programmes overseen by the Joint
Transformation Board and our devolution pilot.
4.3.2.
But like all local authorities Hackney is facing significant challenges to the
continued delivery of these services. Our population is growing, and people
are living longer with more complex care issues. Our public health budget
has been reduced in line with national reductions, and adult social care
faces decreasing funding despite high needs and a growing population.
There are also increasing legislative duties, ongoing difficulties in the
recruitment and retention of staff and the wider health and social care
provider market faces significant sustainability pressures over the coming
five years. The challenges faced by adult social care locally and nationally
are unprecedented. Despite its increasingly high profile and growing calls
to action, the Government remained silent on this issue in the recent
Autumn Statement.
The need to shift resources across the system, sharing risk and reward
4.3.3.
As the STP has been developed council representatives have argued
strongly that the plan has to reflect the impact that changes to NHS
services will have on council services. The STP emphasises the need for
more out-of-hospital care, reducing hospital admissions and the amount of
time that people spend in hospital when they could be at home. This will
inevitably increase demand for social care services. The STP process
needs to reflect the operational and financial impact of this, and articulate
how resources will shift across the system from acute to social care, given
the significant financial pressures already faced by local authorities.
4.3.4.
Council officers have sought to understand the likely impact of, and
opportunities created by, the STP. Whilst we are already working closely
with our health partners to integrate and improve health and care services
for residents, the STP is broader, both geographically and in the challenges
it is trying to address. In that sense it provides a significant opportunity to
transform the health economy in north east London. However, its aims
cannot be realised without significant investment in local authority services,
shifting resources from the acute to community services. Furthermore, it is
officers’ views that all partners should share the risk and reward, to
incentivise investment in preventative services, as well as collaborate in the
commissioning of social care to optimise pricing and capacity. This would
be a radical change in the way local authorities and health partners work
together across a region.
The need to invest in prevention, early intervention and integration
4.3.5.
It is recognised that high cost hospital admissions can only be reduced by
re-orientating the entire health and care economy towards prevention and
integration. Without expanded re-ablement, homecare and independent
living services, or increased supported housing and nursing home capacity,
it will prove difficult to move patients with long-term conditions out of
hospital and into the community. Funding should also be made available to
support ongoing innovation in developing new preventative and early-help
solutions to help our most vulnerable residents live longer and better quality
lives closer to home, including the ongoing development of initiatives such
as social prescribing, estate-based wellbeing and digital health initiatives.
Finally, without increased investment in system-wide public health
initiatives, such as those we are delivering to tackle obesity in Hackney, it
will be extremely challenging to make the required population-wide
changes that will ensure we can manage demand effectively over the longterm. The broad range of the council’s services is therefore fundamental to
the priorities set out in the STP, but additional investment is required to
realise this potential.
4.3.6.
The initial potential indicative investment requested from NHS England for
NEL is £136m over the 4 years from 2017 to 2021. However, it is not yet
clear how much transformation funding will be available to north east
London, where that funding will come from, nor how those monies will be
split between different organisations.
4.4. The current position on the STP
4.4.1.
Hackney is committed to ensuring everyone in the borough enjoys a quality
life. This means working with our partners to improve the health and
wellbeing of the local people and ensuring that they can access high quality
health and care services when they need them. The principle of placebased collaboration with local partners and the vision and aspirations set
out in the NEL STP are in line with these commitments.
4.4.2.
However, there are many variables within the STP process and
unanswered questions about how the STP will be delivered, for there to be
a recommendation to Council that it should fully sign up to the STP at this
stage. There are a number of outstanding issues which underpin efforts to
improve the health and wellbeing of local people which officers feel have to
be addressed if the STP is to be successful:
1) There must be clarity on the implications for all acute Trusts and Mental
Health Trusts in north east London arising from the Plan, including
Homerton University Hospital Foundation Trust (HUHFT). HUHFT is
an essential component of a well-balanced health and social care
economy in Hackney. Financial pressures facing Acute Trusts and
other partners across the wider NEL footprint present a challenge to
our local stability, not least the poor financial health of Barts Health.
Whilst the potential benefits of initiatives such as shared back office
functions are well-recognised in local government, we require further
detail on the financial and other implications of other proposals such as
specialised commissioning and surgical hubs as well as reassurance
regarding financial stability across north east London.
2) There must be a coherent plan for estates across NEL that recognises
the principle of subsidiarity when it comes to decision-making on their
use. A default assumption of local decision-making will allow us to
maximise benefits and links wider economic development, and thus
bolster our joint priorities around prevention and social care. For
example, only 17% of the 94 properties with mixed public ownership
across health and the local authority within Hackney have more than
one use at present. Local decision-making on the use of those estate
properties and land would enable us to deliver priorities agreed in the
Hackney devolution pilot such as fit for purpose general practice
buildings and a strong focus on housing, linked to prevention and social
care.
3) There must be a robust plan for resourcing the increased demand for
social care services. The unprecedented pressures on adult social
care, locally and nationally, must be addressed. The recent
announcement by the Government that councils can bring forward
increases in the council tax social care precept, alongside a DCLG
Adult Social Care Grant, will only scratch at the surface of the issue
and will not raise sufficient revenue in the low-income areas that need it
most, many of which are in north east London. As the system shifts its
focus from acute services to out-of-hospital community care and
prevention, there has to be a corresponding shift in resources – either
from within the NEL health and care economy, or from central
Government.
4) There must be investment in prevention and early intervention public
health programmes. Our prevention and early intervention initiatives
are a key part of the integrated commissioning plans in Hackney, but
wider systemic change is required for the long-term benefits of
prevention and early intervention to be realised. To achieve the vision
set out in the STP of reducing hospital admissions by focusing on
prevention and early intervention, there must be a significant
investment in the public health programmes across the footprint which
support this, not just through public health budgets but in the way a
organisations tackle essential issues such as smoking, physical
inactivity, housing and employment.
5) There must be consultation on the changes set out in the STP with
residents, staff and partners. The rushed process and tight deadlines
has not yet enabled any meaningful engagement, and must be
addressed before the STP is finalised. We welcome the publication of
the NEL STP as a first step.
4.4.3.
The Council has endeavoured to engage with the development of the STP
and to work together with health partners and our neighbouring boroughs to
address the challenges faced by the health and care system in north east
London. We are committed to this collaboration, but until the concerns
outlined above are addressed officers are not able to recommend to
Council that there is a full signing-up to the North East London STP. The
next stage in the continued collaboration and engagement is the signing of
a Memorandum of Understanding between all the NHS organisations and
local authorities involved. This is not legally binding and does not represent
Hackney fully signing up to the STP at this time. The Memorandum of
Understanding is attached at Appendix 3.
4.4.4.
It is proposed that Cabinet note the draft STP as at Appendix 1, and agrees
that the Council’s position in relation to the STP is as set out above.
Officers will bring further reports to Cabinet by way of update.
4.5. Equality Impact Assessment
4.5.1.
An equality screening has been carried out by the NEL STP programme
team and is attached at Appendix 2. The scale and scope of the STP
programme means that there is the potential for many equalities impacts,
relevant to all groups sharing protected characteristics, and/or people living
in deprivation. Some of these will relate to small numbers of
patients/people with multiple, complex needs and communities. Where
relevant, the STP programme will need to ensure that these are considered
in a proportionate and timely manner to inform service design.
4.6. Sustainability
4.6.1.
As referenced throughout this report relates to improving the health and
wellbeing of residents.
4.7. Consultations
4.7.1.
5.
There has been no public consultation on the North East London STP to
date. The plan is draft and detailed delivery plans are currently being
developed. NHS partners have stated that there will be public consultation
as service changes come forward. As set out above the rushed process
and tight deadlines for developing the STP has not yet enabled any
meaningful engagement, and this must be addressed before the STP is
finalised.
COMMENTS OF THE GROUP DIRECTOR OF FINANCE AND
CORPORATE RESOURCES
5.1. It is not clear that endorsing the NEL STP at this stage would serve the
Council’s immediate interests without adequate reassurance regarding the
concerns expressed in this report. The London Borough of Hackney has
made a firm commitment to joint working with local NHS partners as part of an
agreed devolution pilot for integrated commissioning of health and social care.
Delivering the devolution pilot has required the council to accept the financial
and other risks of pooling a significant portion of its budget with the City and
Hackney CCG in a shared governance structure. As it stands, the NEL STP
does not provide confidence in those risks being either reduced or managed
in the interests of Hackney’s health and social care economy.
6.
COMMENTS OF THE DIRECTOR OF LEGAL
6.1. The Sustainability Transformation Plan is not a statutory plan in the same way
that the Health and Wellbeing Strategy and Joint Strategic Needs Assessment
are. There is no legal obligation upon the Local Authority to enter into an STP.
Should the Council consider that it is in its interests to enter into the STP
Cabinet should recommend approval of the STP by Full Council.
6.2. As set out in the report, one aspect of the STP relates to 'integration' between
health and social care. The 'integration' of health and social care does have a
statutory footing under the Health and Social Care Act 2012 under which the
Health and Wellbeing Board (HWB) has been created. One of the duties of
the Health and Wellbeing Board is to encourage integrated working between
commissioners of health services and commissioners of social care services
in particular to provide advice, assistance or other support for the purpose of
encouraging use of flexibilities under NHS Act 2006. The HWB has a power to
encourage closer working between commissioners of health or social services
and commissioners of health-related services. A testament to the Council's
willingness to work jointly with other commissioners of health and social care
services is its proposal to enter into a section 75 Agreement to pool budgets
with the City and Hackney CCG on integrated commissioning as part of an
agreed devolution pilot.
6.3. CCGs have a statutory duty to involve HWBs in preparing or significantly
revising their commissioning plans including consulting HWBs on whether the
plan has taken proper account of the relevant Joint Health and Wellbeing
Strategies. Any arrangements entered into by any of the participating bodies
within an STP would not alter these statutory powers and obligations.
APPENDICES
Appendix 1 - NEL STP
Appendix 2 - NEL STP Equality Screening
Appendix 3 - NEL STP Governance Memorandum of Understanding
BACKGROUND PAPERS
In accordance with The Local Authorities (Executive Arrangements)
(Meetings and Access to Information) England Regulations 2012
publication of Background Papers used in the preparation of reports is
required
Description of document (or None)
Five Year Forward View:
https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
Report Author
Gareth Wall
 020 8356 3029
Comments of the Group
Director of Finance and
Resources
Ian Williams
 020 8356 3003
Comments of Director of
Legal
Yinka Owa
 020 8356 6234