Cambridgeshire and Peterborough Sustainability and Transformation Plan / Fit for the Future Programme Frequently Asked Questions Second Edition Contents Introduction to the Sustainability and Transformation Plan... 2 The STP priorities... 5 Fit for the Future Programme... 5 What the Fit for the Future programme means for the different areas in Cambridgeshire and Peterborough... 8 Finance... 12 What the Fit for the Future programme means for staff... 13 Leadership and structure... 16 The first Frequently Asked Questions were issued in March 2016, and can be found here 1 P a g e
Introduction to the Sustainability and Transformation Plan About our five-year plan to make Cambridgeshire and Peterborough Fit for the Future The NHS and local government officers have come together to develop a major new plan to keep Cambridgeshire and Peterborough Fit for the Future. Our plan aims to: improve the quality of the services we provide encourage and support people to take action to maintain their own health and wellbeing ensure that our health and care services are financially sustainable and that we make best use of the money allocated to us align NHS and local authority plans. It has been developed by our health and care organisations. We are working together and taking joint responsibility for improving our population s health and wellbeing, with effective treatments and consistently good experiences of care. Local doctors and other clinicians are leading this work, supported by NHS England and NHS Improvement, the organisations that oversee our local NHS - ensuring that the views of patients and local people shape key decisions. Fit for the Future sets out a single overall vision for health and care, including: supporting people to keep themselves healthy primary care (GP services) urgent and emergency care planned care for adults and children, including maternity services care and support for people with long term conditions or specialised needs, including mental ill health. What is the Sustainability and Transformation Plan (STP)? To deliver the Five Year Forward View, every health and care system has been asked to develop an STP. There are 44 across the country. The STP is a five-year plan which sets out the steps through which local organisations should deliver sustainable, transformed health services. This means improving the quality of services, encouraging and supporting people to take action to maintain their own health and wellbeing, and bringing NHS finances into balance. The STP is shared and produced in partnership by local NHS and local authority care providers and commissioners, and must be agreed by all partners. Which organisations are part of the health and care system? The main organisations which are partners in the STP are: Cambridge University Hospitals NHS Foundation Trust (CUHFT) Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) Cambridgeshire Community Services NHS Trust (CCS) Cambridgeshire County Council Hinchingbrooke Health Care NHS Trust (HHCT) 2 P a g e
Papworth Hospital NHS Foundation Trust Peterborough and Stamford Hospitals NHS Foundation Trust (PSHFT) Peterborough City Council. In addition, primary care organisations, including general practices, pharmacists, and others, across Cambridgeshire and Peterborough play an important role. What is the Evidence for Change? Ours is one of the most challenged health systems in England. Our Evidence for Change document (March 2016) identifies the source of our challenges and our STP (June 2016) is our five-year plan to address these challenges. The Evidence for Change document sets out where current health and care services in the area differ from our vision for the future, and how they could be better. Overall, the evidence shows we need to change the way we deliver care (our model of care ) if we re going to provide high quality services that are both clinically and financially sustainable. There are four main reasons: local needs are growing and changing the current system does not meet the standard of care we seek recruiting and retaining staff is difficult across the area the system s financial challenge is significant and growing. What has happened so far? In developing the STP, our team of clinical leaders worked to identify the main challenges faced by the health and care system for Cambridgeshire and Peterborough, and potential solutions. This included short term opportunities to improve cost effectiveness of services, as well as options to create a sustainable Cambridgeshire and Peterborough care model for 2020 and beyond. The STP was submitted on 30 June 2016 for review by NHS Improvement and NHS England. What other initiatives are aligned with and/or incorporated into the STP? There are several initiatives underway across Cambridgeshire and Peterborough. While these pre-date our STP, they are included within it. Hinchingbrooke Health Care NHS Trust and Peterborough and Stamford Hospitals NHS Foundation Trust have agreed to pursue a merger. An ambitious health campus is being considered for the Hinchingbrooke Hospital site, to make better use of the existing estate, to meet the needs of Huntingdonshire residents. Current plans include building staff and student residences, an elderly care village with supported housing, and a medihotel for patients who need support but not a hospital bed. A team is looking at improving the use of land and buildings across the system, focusing on primary and community estate, as well as Hinchingbrooke Hospital. Papworth Hospital is due to relocate to the Cambridge Biomedical Campus in 2018 to secure, sufficient, fit-for-purpose space. 3 P a g e
Does the STP relate to the UnitingCare contract? Not directly. However, there remains support for the principles within the UnitingCare model of care and we are working with patients, stakeholders, and providers to ensure that we can deliver as much of this as possible within the resources available. Implementation of the STP will take account of any changes to older people s and adult community services. How is this different to the previous System Transformation Programme? This STP is different from previous programmes in that: the STP focuses on the system as a whole, rather than on individual organisations or services it is led by clinicians all the organisations in the system are partners on the Health and Care Executive patients and the public have been, and will continue to be, involved to a much greater extent it has constant support from the relevant national regulatory bodies, NHS England and NHS Improvement. How are patients, carers, and local people involved with the STP? Patients, carers, the voluntary sector, and the public have been involved in the programme. As members of the Clinical Advisory Group and each of the Clinical Working Groups, their role is to ensure that the work designed by the teams reflects the concerns and needs of the public. Additionally, there has been a range of engagement opportunities for local people residents, patients, and staff to get involved, including attending existing stakeholder meetings. A number of Public Involvement Assemblies were held in autumn 2015 and during March 2016. Once the STP has been agreed, there will be opportunities for local people to be involved in co-design of detailed plans for service changes. Some elements of the STP may also require formal public consultation. 4 P a g e
The STP priorities What is the 10-point plan? Our STP outlines how we want to act as one system to integrate health and care, and be jointly accountable for improving our population s health and wellbeing, with effective treatments and consistently good experiences of care. The solutions in the STP have been developed by colleagues from across our health and care organisations and our ambition is to continue to work collaboratively, but more formally. We have identified four priorities for change and developed a 10-point plan to be delivered as our Fit for the Future programme. Fit for the Future Programme At home is best Safe and effective hospital care, when needed We re only sustainable together Supported delivery 1. People powered health and wellbeing 2. Neighbourhood care hubs 3. Responsive urgent and expert emergency care 4. Systematic and standardised care 5. Continued world-famous research and services 6. Partnership working 7. A culture of learning as a system 8. Workforce: growing our own 9. Using our land and buildings better 10. Using technology to modernise health Fit for the Future Programme How will our STP be implemented? The STP will be implemented through our Fit for the Future programme, which led by the Health and Care Executive. Over the first year, a System Delivery Unit will be created, with clinicians and managers able to coordinate and support work across the system to achieve the changes required. There will be opportunities for a wider range of frontline clinicians to be part of this, to ensure that solutions draw on knowledge and experience. We will continue to form stronger relationships across organisations to foster trust, improve communications, and embed a culture of learning and improvement. What will At home is best mean for patients? We will encourage and support choices which will help people to stay healthy, with campaigns on issues such as smoking and healthy eating, and promote services which can play a greater role in prevention, such as pharmacists. We know that good information and advice helps people to look after themselves better and we aim to use technology such as smartphone apps and the new e-care record. 5 P a g e
When people become ill, we want them to remain in control of important decisions about their health and care as active partners with their doctors and nurses. For some, this could mean support and tools to enable them to manage their own conditions. Innovative technology will play an important role, for example in smart homes and telehealth where patients with long-term conditions may manage their own medication and regular testing. How will patients be supported to remain living independently at home? Achieving these changes will require clinicians and other professionals to think afresh about their services and their own roles, and how they can enable patients to make well-informed, confident decisions. We know that continuing to live as independently as possible is good for our health, especially for older people or those with complex needs. We will involve carers and family members, so that care is tailored to the needs of the individual, is well coordinated, and brings together the range of health and care support necessary to maintain people living successfully at home. We also recognise that people are supported by a network of formal and informal care. We aim to work in partnership with community-level organisations such as faith groups and the voluntary sector. What will Fit for the Future mean for primary care? We need to invest in primary care in the short term to ease operational pressures, and in longer term to provide capacity to keep people well and at home more often. Where people have long term health conditions, such as diabetes, a care plan which is shaped around the needs of the patient will drive the work of a broad team of clinical and professional staff, such as pharmacists and social workers, with GPs playing a key role. This will aim to keep social care and support, such as housing, benefits, and social networks, in place especially if a period in hospital is required. We would also like to see more services provided in primary care, with enhanced resources. For example, more tests could be provided in GP surgeries with shared arrangements where they cannot efficiently be sited in all practices. We would also like to see new ways of working, such as specialist cancer nurses working across groups of practices. Joining up NHS and local authority social care is an essential part of the plan. We would like to consider more co-location of teams together, perhaps with joint management and common working practices. We see potential in GP-led clinics, or hub practices, as the obvious base for local multidisciplinary working. We believe that supporting carers is a vital part of this, working closely with voluntary sector support. What is a Neighbourhood Team? A Neighbourhood Team is a multi-disciplinary team, based in the community, which coordinates and delivers tailored care to high risk patients to enable them to live as 6 P a g e
independently as possible. The team typically consists of community-based staff, including: district nurses, social workers, and some therapists. Although the members may be employed by different organisations, the teams will increasingly be managed as a single team with aligned and complementary roles. How does mental health fit in? The Neighbourhood Teams can call on the support of community-based mental health staff. Embedded mental health demands a broader range of skills and capabilities across all staff groups, and a good understanding of mental ill health and mental health services. The specialised mental health clinicians will also continue to be available to support care in community settings. How will patients and local people be involved in implementing the Fit for the Future programme? We will engage on changes with our staff, patients, service users, families, and carers, to shape care and empower healthy behaviours. Our engagement with the public has three key aims: publicising the Fit for the Future programme and setting out our vision for health and care, and the benefits of our proposals for patients and local people co-designing care models, working with health and care users, including those who require the most intensive support, and engaging fully with the public, where services will change. supporting behavioural change and working with the public to promote healthy behaviours and individual responsibility for health and wellbeing. We will involve our patient groups where potential major changes are being considered, using their contributions to inform quality and inequality impact assessments of our proposals and to help us consider the implications of any changes. 7 P a g e
What the Fit for the Future programme means for the different areas in Cambridgeshire and Peterborough Huntingdonshire What are the benefits of a merger of Hinchingbrooke and Peterborough hospitals for Huntingdonshire services? The collaboration between Hinchingbrooke Heath Care NHS Trust and Peterborough and Stamford Hospitals NHS Foundation Trust will help to ensure that services are viable for the longer term, and that many of the workforce challenges that exist in a number of specialties can be addressed. The Trusts will be: clinically stronger by working together organisationally stronger by working together financially stronger by starting to reduce back office costs. What changes are proposed for Hinchingbrooke Hospital A&E? The Sustainability and Transformation Programme has brought our health and care system together to look at how we can ensure that services across Cambridgeshire and Peterborough meet the health needs of our population, deliver good quality services and outcomes, and that we do so within the resources we have available. 24/7 urgent care services will remain on our three main hospital sites: Hinchingbrooke Hospital, Peterborough City Hospital and Addenbrooke s Hospital. The collaboration between Hinchingbrooke Health Care NHS Trust and Peterborough and Stamford Hospitals NHS Foundation Trust will help to ensure that services are viable for the longer term, and that many of the workforce challenges that exist in a number of specialties can be addressed. What changes are proposed for maternity services at Hinchingbrooke Hospital? The Sustainability and Transformation Programme has brought our health and care system together to look at how we can ensure that services across Cambridgeshire and Peterborough meet the health needs of our population, deliver good quality services and outcomes, and that we do so within the resources we have available. We expect that maternity services will remain on our three main sites: Hinchingbrooke Hospital, Peterborough City Hospital and the Rosie Hospital. The collaboration between Hinchingbrooke Health Care NHS Trust and Peterborough and Stamford Hospitals NHS Foundation Trust will help to ensure that services are viable for the longer term, and that many of the workforce challenges that exist in a number of specialties can be addressed. 8 P a g e
What changes are proposed for stroke services at Hinchingbrooke Hospital? The STP s Clinical Advisory Group is considering options for stroke services, both hyperacute and inpatient rehabilitation, and it is expected that proposals will follow later in the year. What is the Hinchingbrooke Health Campus? Hinchingbrooke Health Care NHS Trust has already developed an ambitious plan to build a new intergenerational health campus on its site. This will integrate primary, secondary, community, and social care services. Facilities and housing for patients and staff include: a stepdown medihotel for patients who do not need the resource-heavy benefits of an acute hospital bed three hundred staff residences for junior doctors, nurses and support staff accommodation for 70 medical students a pool, gym, and therapy centre. The development will also include around 400 new residential dwellings. These plans would bring in significant revenue and play a key part in reducing the hospital's deficit. The development vehicle the trust has adopted is a publicly-procured strategic estates partnership (SEP) with involvement by private sector partners and brings development investment of more than 100million. Fenland and East Cambridgeshire What changes are proposed for the three Fenland and East Cambridgeshire Minor Injuries Units? The STP s Clinical Advisory Group is considering options for minor injuries and walk-in urgent care services. It is expected that proposals will follow later in the year. All urgent care services will be developed in accordance with recently-updated quality standards in the Keogh Report (Professor Sir Bruce Keogh s comprehensive review of NHS urgent and emergency care system: safer, faster, better). Any proposals for change are expected to include a Health Inequalities Assessment and significant engagement with patients, residents, and other stakeholders. Staff are already being engaged in shaping options for the future. Fenland and Cambridge What is the Community Intermediate Care Review, and what has it concluded? 9 P a g e
An Intermediate Care Review is taking place which is being led by the CCG. The current approach is not sustainable, nor is it always delivering the best outcome for patients. The system has committed to the redesign of local services and pathways around hospital discharge and intermediate care services. The review will identify and map the full stock of health bed-based provision and ensure our local intermediate care services are designed around the needs of our patients. The programme aims to enable people to remain in their own homes for as long as possible, ensuring that admissions to hospital are appropriate and as short as possible. It is anticipated that the review will result in a shift from bed-based services to home-based models of care, with bed-based intermediate care provision remaining available for those patients with the most complex needs. There is a wealth of national evidence that demonstrates better patient outcomes for patients discharged from a hospital setting to their own home to receive intermediate care and therapy to complete their process of healing and rehabilitation. The review conclusions will be considered by the STP s Clinical Advisory Group, and it is expected that proposals will follow later in the year. Cambridge What changes are proposed for stroke services at Addenbrooke s Hospital? The STP s Clinical Advisory Group is considering options for stroke services, both hyperacute and inpatient rehabilitation, and it is expected that proposals will follow later in the year. Peterborough What is the impact of a merger with Hinchingbrooke Hospital? The collaboration between Hinchingbrooke Health Care NHS Trust and Peterborough and Stamford Hospitals NHS Foundation Trust will help to ensure that services are viable for the longer term, and that many of the workforce challenges that exist in a number of specialties can be addressed. The Trusts will be: clinically stronger by working together organisationally stronger by working together financially stronger by starting to reduce back office costs. 10 P a g e
What changes are proposed for stroke services at Peterborough City Hospital? The STP s Clinical Advisory Group is considering options for stroke services, both hyperacute and inpatient rehabilitation, and it is expected that proposals will follow later in the year. What changes are proposed for Peterborough Minor Illness and Injury Unit (MIIU)? All urgent care services will be developed in accordance with recently-updated quality standards in the Keogh Report (Professor Sir Bruce Keogh s comprehensive review of NHS urgent and emergency care system: safer, faster, better). The Clinical Advisory Group is considering options for minor injuries and walk-in urgent care services and it is expected that proposals will follow later in the year. This includes looking at Peterborough s MIIU. What changes are proposed for cardiology services? Options are also being considered for extending cardiology services at Peterborough City Hospital when Papworth Hospital moves to the Cambridge Biomedical Campus. In addition, a task and finish group is reviewing Peterborough City Hospital s cardiology services in the context of workforce issues and future networking. It is expected that proposals will follow later in the year. System-wide services In addition, in some clinical areas, the Clinical Advisory Group (CAG) is looking at services which are provided from hospitals across Peterborough and Cambridgeshire, which include: Considering options for the best configuration of orthopaedic services, and it is expected that proposals will follow later in the year Ear, nose and throat (ENT) services are currently provided from all hospital sites and the CAG is considering the options for these services. It is expected that proposals will follow later in the year. In the establishment of Cancer Alliances, the optimum footprint for configuration of cancer networks covering the population of Cambridgeshire and Peterborough is still under consideration. 11 P a g e
Finance Is this all about the money? No - there are financial challenges, but even if we had all the money we needed there are still things we should be doing differently to improve our population s health and wellbeing outcomes. This work is allowing the system to step back and refocus on how best to meet our local people's needs, which are changing as people age, technology changes, and more people move in to our area. How much money do you need to save? Our deficit for 2015/16 for NHS care was about 150million (about 9% of our total collective budget). Unless we change the way services are provided this deficit is projected to increase to 250million by 2020/21. We have explored all opportunities for improving the financial position of our system and returning it to financial balance by 2020/21. We fully believe we can make the savings set out in the STP, but we also recognise that the scale of the change required is significant and that delivery will be challenging. We know that we can get better at living within our means by mobilising everyone involved, including our staff, patients, and carers, to redesign services and tackle any waste that can be reduced or eliminated without eroding the quality of care. How does the STP bring the health economy back into balance? We have a clear understanding of the financial challenge facing health and care services in Cambridgeshire and Peterborough now and in the future. We explored every opportunity through working together to develop the STP to identify efficiencies and savings which we could make immediately. The STP has been developed to achieve sustainable organisations across Cambridgeshire and Peterborough. It is based on providing services in different ways, for example with more care provided closer to home in community settings, and patients actively managing their own health. We are also seeking efficiencies through streamlined back office and support services. A wide range of changes are identified to reduce the overspend, including reducing demand through prevention and better self care, improving outcomes through standardisation, and securing better efficiency through smarter use of the time of our most expert staff. The STP describes a potential it will need the involvement of local clinicians and leaders to develop the plans to achieve this. 12 P a g e
What the Fit for the Future programme means for staff What will Fit for the Future mean for GPs? The role of general practitioners (GPs) will be key to making the change. We will make expertise available in the community, through specialist consultants advising and supporting GPs and the wider primary, community, and social care teams. Planning and delivering primary care at greater scale aims to bring: better access to resources through sharing best practice and overheads closer working between GPs and colleagues in hospitals a more resilient service through advice and support for primary care from hospital clinicians. What benefits does this offer to GPs? We need to invest in primary care in the short term to ease operational pressures, and in longer term to provide capacity to keep people well and at home more often. In addition, Fit for the Future brings the potential to reduce the workload. For example, supporting patients to take an active role managing their own health could reduce unnecessary attendances in primary care. Better case management could mean fewer emergency episodes. Closer working in partnership with hospital clinicians could help to streamline the patient s journey, with fewer referrals and repeat appointments to free up GP time. Better information management and technology, coupled with general practice at scale could streamline administrative systems and reduce paperwork. How have GPs led thinking on the new ways of working? GPs have been involved in the STP as members of Clinical Working Groups and via engagement through workshops and events. They have also been kept informed through, and contributing views through, their own locality networks. What benefits does Fit for the Future offer to staff? Fit for the Future offers a range of benefits for staff: Sustainable clinical services the best chance for staff to provide improved patient care. Sustainable employers able to provide job security. Collaborative leadership and one implementation team that will work with and across all organisations to achieve change. A positive, single culture, improved communication and IT, and better use of technology. Better opportunities for specialisation, learning and professional development through networking and being part of a larger system. 13 P a g e
Opportunities for new roles (e.g. nurses in multi-disciplinary Neighbourhood Teams), or to work in a team which covers several hospital sites. Additional staff residences and student accommodation (e.g. Hinchingbrooke Health Campus) Improving patient care with a growing reputation of which we can all be proud Care networks how will this model work? Networking is central and is important to achieving both clinical and financial sustainability. Care networks will improve care for patients by: reducing unwarranted variation setting out standards and expectations encouraging innovation and integration establishing a framework for responsibility and holding each other to account providing clinical advice and leadership to support local decision making. We aim to work as operational networks for planned, unplanned, routine and specialised care. The detail of how this would work will be co-designed with staff, however we expect to see: Some clinicians working across sites within Cambridgeshire and Peterborough Single process management systems across providers Standardised patient pathways Quality and clinical governance shared across Cambridgeshire and Peterborough. For all specialties, including those where physical consolidation does not make sense such as ophthalmology, the service will increasingly be run as one across the acute sites to make the most of the expertise we have in some providers. Networking will address unwarranted variation and we are considering opportunities including: e-referrals, offering GPs direct access to a consultant opinion, streamlining pathways, and the potential for more nurse-led care. How will staff be supported to work differently and what behaviours and skills have been identified within the new system? We want staff to: think differently about the service they provide, as part of a system which focuses on keeping people well rather than simply treating ill health work more closely with a wider range of colleagues, for example in multidisciplinary teams, and in partnership with patients and families strengthening joint work between NHS and care colleagues develop a culture of learning - a shared understanding of our services, priorities, and challenges, and a common approach to finding solutions together. Working with Health Education England, we will develop a long-term system workforce plan, develop a common set of behaviours system-wide, and develop our organisations to support a culture of learning. 14 P a g e
The system workforce plan will: identify the skills mix we need for the future develop the skills of existing staff develop routes into our organisations which will enable us to grow our own new staff attract the best staff to join us in the new system. We also want all staff to contribute to the plans for organisational and individual development which will be needed to support them in new ways of working. What do we mean by a single set of system behaviours? We know that patients are not attached exclusively to a single NHS organisation or service. As we move to work more closely together as a system, resources will increasingly be shared along with the responsibility for delivery and outcomes. So we want staff to see themselves as part of the Cambridgeshire and Peterborough system, not just the organisation that employs them or their clinical specialism or role. Developing a single organisation culture will be supported by: strong leadership teams, both managerial and clinical, across the system, backed up by the System Delivery Unit. clinical leaders across the system will continue to be encouraged and supported to work collaboratively across organisational boundaries and hold each other to account. we will move as quickly as possible to align employment practices (recruitment, training and reward) both to bring efficiencies and improved outcomes through standardising on the best approach. we will increasingly refer to providers as part of the Cambridgeshire and Peterborough system, though we want to build on the worldwide reputation of our hospitals and share in their collective achievements. How will we engage staff with the proposals? Co-design and co-development will be essential for the next stage of detailed service redesign, involving staff and their colleagues doing similar work in other parts of the system to reflect the approach of the Clinical Working Groups. An important focus on the next phase of engagement will be how to develop solutions which ensure the best health outcomes across service networks. So far, more than 200 senior clinicians have been involved and we want staff from Board to ward to participate in designing the solutions. There will be events, workshops, and a range of opportunities for staff to contribute ideas and find out more. These will be across all sites and for those working in primary care, community-based services, and social care. 15 P a g e
How will the Fit for the Future programme support clinical leadership and clinical leaders? The STP is about a collective approach to improving patient outcomes and population health Clinical leadership and collaboration across specialties and hospital, mental health, primary care, and adult social care will be essential. It has been clinically-led from the outset and clinicians will co-design new models of care and detailed service plans. Workforce development is a key part of the STP. Opportunities will be provided to develop the skills and capabilities we need, and provide opportunities to develop careers across specialisms. Leadership and structure How is the Fit for the Future programme being led? A Health and Care Executive leads development and implementation of the STP and oversees the work of the Clinical Advisory Group. The members of the Health and Care Executive are the chief executives of the NHS organisations in Cambridgeshire and Peterborough, and the joint Chief Executive of Cambridgeshire County and Peterborough City councils. Additionally, the programme is supported by national bodies, in particular NHS England and NHS Improvement. These make sure the transformation programme is on track, and encourage the programme to take a system-wide view, rather than the perspective of individual organisations. What about clinical leadership? Clinical leadership is provided by Clinical Working Groups. Each of these has a formally appointed clinical chair and involves a range of clinicians, including consultants, nurses, and midwives, as well as patient representatives, public health representatives, and social care representatives. The chair of each of the Clinical Working Groups also serves as a member of the programme s Clinical Advisory Group, made up of: Chair Dr Alex Gimson (CUHFT) Sustainable Primary Care (with a focus on services led by GPs) Dr David Roberts (retired GP) Elective Care Dr Sarah Clarke (Papworth Hospital) Children and Young People Dr Melanie Clements (NHS England) Proactive and Preventative Care Dr Martin Stefan (CPFT) and Dr Mark Brookes (GP) Urgent and Emergency Care Dr Andrew Anderson (GP) and Dr Callum Gardner (PSHFT) Maternity and Neo-natal working Deirdre Fowler (HHCT) Dr Gerry Hackett (CUHFT) Patient representatives Healthwatch, patient representatives and mental health service user representatives 16 P a g e
The Clinical Advisory Group s role is to recommend a sustainable clinical vision for health and care, including the transformation required to deliver it, and to provide clinical assurance for the work of the programme as it progresses. This includes recommending ways to improve the effectiveness and efficiency of care in the short term, as well as longer term options for the system as a whole. 17 P a g e