Find our latest guidance and information on coronavirus (COVID-19)

Community Partner E-bulletin – Issue 1

What is the STP?

The Five Year Forward View, published by the Chief Executive of the NHS, Simon Stevens, is a compelling vision and strategy for the NHS.

The vision described the opportunities and challenges facing the NHS for the future, expressed as three key ‘gaps’: the Health and Wellbeing Gap, the Care and Quality Gap and the Finance and Efficiency Gap.

In line with this, we have been developing our local five year Sustainability and Transformation Plan (STP) for Gloucestershire which is currently in outline form. It describes our overall approach to achieving an improved and more sustainable health and care system.


The challenge

Our plan needs to help us meet a number of major challenges:

  • a growing population with more complex needs
  • increasing demand for services and rising public expectations
  • the escalating cost of drugs and new medical technology
  • retaining and recruiting enough staff with the right skills and expertise
  • considerable pressure on NHS and social care finances – the health and care community is facing a financial gap of circa. £270m over the next five years unless we make radical changes to the way we deliver services and support for local people

What do we want to achieve and how can it be done?

The long-term ambition is to have a Gloucestershire population which is:

  • less dependent on health and social care services
  • living in healthy, active communities and benefitting from strong networks of community services and support
  • able to access consistently high quality, safe care when needed, in the right place, at the right time

In order to deliver this, we need to stay true to the principles set out in our ‘Joining up your Care,’ programme which was shaped by local people.

However, it is clear that if we are going to meet the growing challenges set out above, we will need to accelerate the pace of change and be even more ambitious and innovative in how we organise services and use the money and other resources available to us.

Moving forward we will need to:

  • place a far greater emphasis on prevention and self-care, supported by additional investment in helping people to help themselves
  • reduce variation – ensure doctors and nurses right across the county are following best clinical practice and that we always make wise decisions on use of medicines
  • place a greater emphasis on joined up community-based care and support, provided in patients’ own homes and in community centres, supported by specialist staff and teams when needed
  • continue to bring together specialist hospital based services and resources into ‘Centres of Excellence’


STP priority areas

Enabling Active Communities

We will work with communities to ‘build capacity’ – developing networks of community-based services and support and making it easier for voluntary and community agencies to work in partnership with us.

We will deliver a shared self-care and prevention plan to close the health and well-being gap. This will also address how individuals with mental health needs can access ill-health prevention screening and health support.

The STP also builds on our system’s approach to social prescribing, which will mean more members of the public with non-medical needs can be referred by their GP to sources of community and social support.

We will also strengthen carer support.

Initiatives include:

  • promoting healthy workplaces through the Workplace Wellbeing Charter
  • adopting a range of innovative technologies to enable individuals and communities to self-care i.e. Diabetes
  • working together with our local authorities leading on a programme to tackle obesity supported by  Leeds Beckett University and Public Health England
  • training primary schools to support the ‘Daily Mile’
  • supporting over 2,500 individuals through our social prescribing programme
  • supporting the whole of Gloucestershire’s health and social care workforce to ensure they have the skills to promote health improvement and self-care
  • ensuring a range of carer services are commissioned across the county in line with the Care Act
  • investing an additional £1.7 million to support our prevention and self-care plan


One Place, One Budget, One System

The 30,000 ‘Place based’ model

We will pilot a new ‘Place based model’ in Gloucestershire.

This is a local community model with GP practices at its core working with health, social care and the voluntary and community sector, covering populations of around 30,000 people.

Alongside this, we are also reviewing urgent care services across the county with joined up services at a local level.

The 30,000 model will be big enough to give scale e.g. input from service providers and small enough to support the feeling of a coherent community that can meet local needs and support local people.

Urgent care services

Alongside this, we are also reviewing urgent care services across the county with joined up services at a local level.

We aim to provide better support for self-care and prevention and help people with urgent care needs get the right advice in the right place, first time.

We will ensure that those people with more serious or life threatening emergency care needs receive treatment in centres with the right facilities and expertise to maximise chances of survival and recovery.

Our outline plan includes:

  • development of our 30,000 model community pilots in areas of Gloucestershire
  • further development of social prescribing (see Enabling Active Communities)
  • development of a network of integrated urgent care centres across Gloucestershire
  • development of an Urgent Care clinical hub that can provide signposting, advice and guidance to patients and book appointments
  • an urgent care digital platform providing 24/7 access to service information for both the public and health and social care staff
  • provision of a responsive mental health crisis service


The Clinical Programme Approach

This is about developing and improving countywide, ‘joined up’ care pathways (the person’s journey through care) so that patients receive the right advice, care and treatment at the right time.

Each Clinical Programme Group (CPG) covers a condition or group of conditions e.g. cancer, eye health.

We want to ensure patients get the right treatment when they need it, but also receive the right self-management or self -care advice and support at an early stage.

Our STP includes a focus on the respiratory care pathway. One of the reasons we are looking at it is because of the high and increasing number of respiratory hospital admissions.

Other priority areas we have identified are: Dementia, Circulatory conditions and Diabetes.

Our approach to these programmes will be informed by the learning from current pathway work.

Our outline plan includes:

  • completing implementation and lessons learned from our Eye Health, Musculoskeletal (MSK) and Cancer clinical programmes
  • developing and implementing the new pathways
  • in the longer term, systematically reviewing key programmes of care based on best practice evidence


Clinical variation

This means promoting best clinical practice by all health and care professionals working right across the county so that patients consistently receive high quality, cost effective care.

It also means using the money available for medicines wisely. This includes prioritising what is spent based on what will achieve the maximum health benefit, ensuring that the right patients get the right choice of medicines and ensuring patients take medicines correctly and avoid taking them unnecessarily.

We also want to promote conversations between clinicians and patients so that patients understand the risks, as well as the relative benefits of treatments, choose care that is evidence based and work together to reduce duplication (e.g. tests and follow up appointments).

Our outline plan includes:

  • designing a new and joint ‘Best use of Medicines’ programme
  • developing a public ‘Choosing Wisely’ programme covering medicines and treatment/care choices
  • reviewing rates of outpatient follow up care and reviewing diagnostic provision
  • carrying out reviews and learning programmes to reduce clinical variation


Other areas of work that support all priorities

Our STP also sets out a number of supporting programmes we are working on to support these priorities across the health and social care community.

This includes:

  • a Quality Academy – to support quality improvement, service development and innovation. We will deliver learning programmes, coaching, on-line resources and education materials
  • Joint IT Strategy – development of a local digital roadmap for Gloucestershire, including a public facing website and directory of services
  • Primary Care Strategy – to support our goal of joined up care in communities – including urgent care, help address current workforce challenges in GP practices and increase access to appointments for patients.
  • Joint Workforce Strategy – to help develop a sustainable local health and care workforce.
  • Joint Estates Strategy – to make the most of our estates and shared accommodation.


What is the current status of our plan?

Our STP is currently a draft outline plan.

Following review by NHS England, we anticipate receiving clarity on dates for the full plan in July and currently expect to submit it in the autumn.

We expect to develop proposals based on STP priorities for discussion with the public over the course of the year and we will be working on a public guide to the STP this Summer to start to aid conversations.

The size of the challenge is great and we can’t do it alone. We will need to work in collaboration with community partners, patients, carers and the public to develop the detailed proposals for change.

Download a PDF version of this bulletin