Credit where credit is due! So well done everyone who helped turn round the situation in A&E at the Royal Cornwall Hospital, Treliske (Truro). Now the right lessons must be learned.

— This post can be downloaded as a pdf here. —

‘There have been significant improvements … in ambulance lost time, delayed transfers of care and the provision of timely care within the Emergency Department. GPs have been working alongside their hospital colleagues, community services and social care have provided additional resources to support patients’ discharge and improvements have been made in transport booking to support patients to be in the most appropriate setting for their needs. Many staff made themselves available for extra shifts.’

This is an extract from a report submitted to the Transformation Board which is overseeing work on the Shaping our Future programme for reshaping health and social care services in Cornwall and the Isles of Scilly.[1] It shows that a major turn-round was achieved in A&E at Treliske Hospital (Truro) in March this year. At the time of writing the Royal Cornwall Hospitals Trust has unaccountably failed to highlight this good news story, so I am happy to fill the gap.

The Report
First of all, here is the report itself, as submitted to the Transformation Board:

What we can achieve working as an integrated care system
In March 2018, Cornwall A&E Delivery Board established a Gold Command in response to unprecedented levels of demand on urgent and emergency care services, leading to the Royal Cornwall Hospitals Trust being in a constant state of escalation for many weeks. Patients were experiencing long waits to be seen in the Emergency Department in Truro, some patients were having to be cared for in the corridor and high number of beds were closed due to flu or norovirus. Some planned surgery needed to be cancelled due to the pressures within the hospital. High numbers of patients in acute and community hospitals were being held up in their transfer home or on to another care setting. Also, ambulances had regularly been unable to transfer their patients into ED due to overcrowding with a consequent adverse effect on ambulance responsiveness.

The Gold Command approach brought together Chief Executives, senior clinicians and operational managers from across health and social care twice daily every day to work intensively together at every level, deploying additional resources, in order to return to a position where people had access to safe health and social care.

The achievements of this intensive system approach have been extraordinary. There have been significant improvements for example in ambulance lost time, delayed transfers of care and the provision of timely care within the Emergency Department. GPs have been working alongside their hospital colleagues, community services and social care have provided additional resources to support patients’ discharge and improvements have been made in transport booking to support patients to be in the most appropriate setting for their needs. Many staff made themselves available for extra shifts. In the lead up to Easter, for the first time in recent memory, Cornwall was on the lowest level of operational alert: Operational Pressure Escalation Level 1 (formerly ‘green’). Emergency Department performance has been above the national standard of 95% and local hospitals greatly reduced the number of long stay, medically fit patients. Indeed, performance on the 4 hour Emergency Access Standard was the best for any Trust in the South of England.

The co-ordination and co-operation across our health and social care system has been outstanding, and provides strong demonstration of what can be achieved by a joined up, cohesive system putting patient care before the interests of individual organisations. Working as an Integrated Care System, there is a determination to maintain and build on the progress over recent weeks.

What we can learn from this report?
Besides telling us about what was achieved, this report is giving us two different messages. One message is about hierarchy, the ‘Gold Command approach’ which brought together Chief Executives, senior clinicians and operational managers from across health and social care.

The other message is about ‘pitching in together’: involving GPs, who aren’t part of any hierarchy, for example, and staff making themselves available for extra shifts. These don’t come about as a result of instructions from a ‘Gold Commander’ at the top of the hierarchy. They happen because a ‘team system’ has been created.

In a team, the ‘structure’ of control and communication is relatively flat compared to the pyramid you find in most hierarchical organizations. There will be different levels of seniority, but the lead in a situation will be taken by whoever shows themself best informed and most capable, not necessarily by the most senior person. Communications tend to be ‘lateral’, with your ‘opposite number’, rather than ‘vertical’ (‘data up, decisions down’), so they are more like consultation than command. And the incentives that motivate people – to put in extra hours, for example – stem from a community of interest rather than a contractual relationship.[2]

There is an important lesson to be learned here. At a time when Cornwall Council and health bodies are negotiating to create an integrated, ‘strategic’ health and social care system, it is tempting for their leaders to celebrate the turn-round as a triumph of the ‘Gold Command’ way of doing things. They must not overlook the importance of creating conditions where teams can flourish within that hierarchical structure.

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This post is a slightly revised version of a post originally published on 13 April 2018.


[1] Transformation Board: Agenda paper for meeting 6 April 2018, Item 6.
http://doclibrary-shapingourfuture.cornwall.nhs.uk/DocumentsLibrary/ShapingOurFuture/TransformationBoardMeetings/Minutes/1819/201804/DevelopmentOfAnIntegratedCareSystem.pdf

[2] The distinction between hierarchies and networking teams draws on the classic work by Tom Burns and G.M. Stalker, The Management of Innovation (Tavistock 1961, Oxford University Press 1994). They distinguished between mechanistic and organic structures: the term ‘mechanistic’ is little used these days, while ‘organic’ has acquired a dietary connotation. A summary of the characteristics of the two kinds of structure can be found in Peter Levin, Successful Teamwork (Open University Press 2005), pp.74-76.