Members of Cornwall’s Health and Adult Social Care Overview and Scrutiny Committee have raised serious concerns over some aspects of the Outline Business Case for Cornwall’s Sustainability and Transformation Plan and the way the engagement process has been carried out.
In effect it has rejected the Outline Business Case (OBC) for Cornwall’s Sustainability and Transformation Plan (STP), which is due to set out the plans for funding and delivering services for Cornwall health care for the next five years.
The Government has set Cornwall NHS services a target of saving £277m over the next three years by 2020/21. The business case that has been rejected included reviewing how urgent care services and the community hospital network work, looking at how specialist services such as cancer treatment are provided, and bringing in new ways of working to create greater efficiencies.
While the statement from the sub committee supports the strategic intent of the Sustainability and Transformation Plan, it raises concerns over a range of issues, including the viability of the financial plans, the quality of the engagement with members of the public and with staff and key stakeholders, a potential reduction in beds, the lack of information about mental health services and services for children and young people, and the timeframe for publishing the Final Business Case.
It concludes, therefore, that although the Outline Business Case met the requirements of NHS England, it was not fit for purpose as a public document. It also concluded that the engagement process was poor and ill judged.
Commenting on the position statement Rob Rotchell, Chair of the Health and Adult Social Care Overview and Scrutiny Committee, said that the development of the Sustainability and Transformation Plan was the biggest proposed change in health and social care in his lifetime.
Liberal Democrat Cllr Rob Rotchell, Chair of the committee said “The role of scrutiny is to be a critical friend “ he said. “We are acting in the interests of the people of Cornwall and so it is right that we have raised these concerns.
“Over the past few weeks the sub committee has taken evidence from more than 40 different organisations and have spoken to a wide range of people. All this information has been taken into account in the position statement we have produced today.
Cllr Rotchell continued “The outline business case contains serious flaws both in its content and how it has been developed. Consultation with key groups such as GPs and community pharmacists has been lacking, as has meaningful engagement with voluntary groups and the workforce.”
“Underpinning the problems with the STP process as it stands in Cornwall, is the refusal by the Government to adequately fund Cornwall’s health services. Current proposal are to starve Cornwall’s NHS by £277m over the next five years, which will lead to cuts in services. Cornwall’s health and care services are already massively underfunded to the tune of £3m every month.”
“Today, by rejecting the outline business case, we have sent a message to the Conservative government in London and NHS England, that we will not stand idly by and watch Cornwall’s health and care services decline. We have demanded improvement in the plan and we will be scrutinising closely how the plans develop going forward” Cllr Rotchell said.
“We are clear that the Full Business Case must answer the concerns which have been raised and have solid, clear evidence for any proposals. It is vital that the Scrutiny Committee is involved at the start of the process to draft the Full Business Case – not at the end – and we have asked that interim reports, including reports on financial information, are brought to the Committee at relevant intervals.”
Sustainability and Transformation Plan (STP) Subcommittee
(Health and Adult Social Care Overview and Scrutiny Committee)
Position Statement on the Outline Business Case and Engagement Process
15 March 2017
We believe that the strategic intent of the Sustainability and Transformation plan is a positive. Very few would criticise the proposed investment in improving health and wellbeing and there is a commitment to the merger of health and social care in the Devolution Deal for Cornwall.
There are aspects of the Outline Business Case (OBC) and the engagement process we wish to comment upon and these are headed individually. It is expected that these concerns will be addressed in the Full Business Case (FBC).
We have serious reservations about the accuracy, achievability and viability of the financial plans and these have to be addressed. There was inadequate evidence in the OBC to support the saving figures presented. There appears to be a lack of attention given to capital costs, the cost of transformation and the future proceeds of any property rationalisation.
Engagement with the Public
In our view the process of engagement with the public was inadequate and seriously flawed. There was inconsistency of information provided dependent on the facilitator and this has to be rectified. The questionnaire contained closed questions, was ill conceived and was unprofessional. Members of the public were left feeling alienated, angry and frustrated.
We are disappointed that the report from the engagement events was not available when we were considering this issue.
Engagement with Workforce and Key Stakeholders
We are extremely concerned with the lack of consultation, awareness and engagement with key stakeholders such as GPs and community pharmacists. There appears to have been an absence of any meaningful involvement or engagement with staff across all levels of organisations. It is apparent that there has been limited engagement with the voluntary sector and care providers.
We want to be assured that there is meaningful consultation with all providers of health services to residents of Cornwall and the Isles of Scilly, and this should include services located in Devon. The impacts of any changes Devon undertake as part of their STP and/or Success Regime should be considered and risk assessed by those responsible for the STP in Cornwall and the Isles of Scilly. This matter should not be retrospective or reactive.
The parity of esteem is not evidenced within the OBC and this needs to be addressed as a matter of urgency.
Others not Visible in the OBC
It is recognised that the ‘One Vision’ plan for services to children is being developed, but more information regarding this must feature in the FBC. We do not believe that those aged under 25 are visible in the document, and there is little evidence of those who have co-morbidities, who are not frail elderly.
Kernow Clinical Commissioning Group
The Interim Chief Officer at Kernow Clinical Commissioning Group acknowledged that they have severe financial challenges, and are still in discussion with NHS England. The increasing debt level within Kernow Clinical Commissioning Group is worrying and the impact on the whole system needs to be addressed.
Closure of Beds
Any proposals within the FBC to reduce the number of beds across the system must clearly demonstrate that they will meet the criteria for bed closures as set out by Simon Stevens. Whilst the test applies to ‘significant’ bed numbers this does not appear to have been nationally quantified as yet. We believe that reduction in bed numbers across the landscape resulting from the STP process would on the basis of aggregation meet this requirement. We wish particularly that it is unmistakably demonstrated that sufficient alternative provision will be in place alongside or ahead of bed closures, and that the new workforce will be there to deliver it.
Governance and Democratic Accountability
We believe that there is a weakness and a lack of clarity in the governance of the STP. The OBC does not adequately address these aspects. The FBC needs to be clear and will need to evidence how the STP programme is governed and how it will be democratically accountable.
We need to be assured in the FBC that there is full engagement with middle managers and they reflect the needs of the final plan. This cannot be ignored as it will increase insularity.
Accountable Care System/Organisation
There is a lack of clarity with regards to the mandate to create, and the future development of, an Accountable Care System/Organisation. We acknowledge that the current structure split by purchaser and provider is not suitable however; we are concerned about the lack of detail about how the Accountable Care System/Organisation model would be applied to the NHS and Social Care provision for Cornwall and the Isles of Scilly. The FBC needs to evidence how this model would work and what differences it would make, including for those who do not use Royal Cornwall Hospitals Trust as their main provider. If there are legal or national organisational barriers to the progression of the discussions regarding an Accountable Care System/Organisation, these should be progressed through the Devolution Deal negotiations.
Strategic Workforce Planning
We are anxious at the apparent dichotomy of workforce planning and the strategic direction being set in the OBC. The forecast reduction in the workforce across the system, especially within primary care, does not seem to be considered as responsibilities and service provision alters. There must be a comprehensive and long term strategic workforce plan within the FBC.
Definition of System Models
In evidence we received, there was obvious concern about replacement service models to those that currently exist. The FBC must contain details about the services and facilities that will be offered to localities across Cornwall and the Isles of Scilly. This detail should include clear specifications for urgent care centres and locality hubs in order for patients to fully understand the options they are being given.
Comprehensive Impact Assessment (CIA)
We are concerned that a CIA was not progressed with the development of the OBC. This should be completed and made publically available with the FBC.
The Use of External Consultants
We are worried about the use of external consultants and have concerns that funding has been taken from local NHS and Social Care budgets in order to pay for this work. We suggest that if such work is required in the future, instead of taking money from the system and spending it externally, the allocated monies should instead be invested locally to release experts within organisations to take forward the work.
The currently proposed timescale for the publication of the FBC is unachievable if it is to be the document required to effectively take forward the programme. We need clarity on when the FBC will be available, and information on any risks or impacts that a delay in its creation will bring. We will need assurance that the timeframes being given are realistic and whether there are alternative plans in the case of any significant risks.
Therefore, as a result of our considerations, concerns and research and the compelling information provided to us, we conclude that the OBC was not fit for purpose as a public document although it met NHS England requirements. The engagement process was poor and ill judged.
The FBC must answer our concerns and have solid, clear, evidence for any proposals.
The role of scrutiny is as a critical friend, and we request that as the FBC is drafted, interim reports are brought at relevant intervals. These reports should include financial information.
Members of the STP Subcommittee
Councillor Rotchell (Chairman)
Councillor Eathorne – Gibbons