There are two versions of this report. This is the SHORT REPORT, which can be downloaded as a pdf here. There is also the FULL REPORT, published simultaneously as a post on this site. That one comes with footnotes, to tell you where I found stuff and show I haven’t made it up, and a number of lessons. That report too can be downloaded as a pdf, here.
What this report is about
Basically, health and social care in Cornwall are run by five bodies. At national level, there is NHS England: it hands money to, and oversees, the local body NHS Kernow, which buys health services on behalf of local people. These services include acute hospital care, which is provided by Royal Cornwall Hospital Trust, and mental health care, provided by Cornwall Partnership Foundation Trust. The fifth body is Cornwall Council, which both pays for and provides social services across Cornwall.
Recently these bodies have been involved in a string of bungles. The cost, in terms of wasted time and effort and distraction from important tasks, not to mention actual money wasted, has been immense. This report highlights six bungles and their consequences.
A little history
In October 2014 NHS England issued a document called Five Year Forward View. It proposed ‘new models of care’, new ways of organizing services, like helping GP surgeries to get together and integrating them with hospitals, and setting up networks for urgent and emergency care. Financial incentives – rewards and penalties – would encourage these.
In December 2015 came another document from NHS England: Delivering the Forward View: NHS planning guidance. This required local health and care bodies to produce Sustainability and Transformation Plans for their area.
Then in March 2017 NHS England issued Next Steps on the NHS Five Year Forward View. Sustainability and Transformation Plans got only one slight mention.
Bungle Number 1 The so-called ‘planning guidance’ on delivering the Five Year Forward View required the production of Sustainability and Transformation Plans but actually gave no guidance on how to produce them. It is clear that both NHS England nor NHS Kernow had little idea how to do that. NHS Kernow had to hire management consultants, at considerable expense – probably around £1.5 million. (Over England as a whole the cost to the NHS must have been more than £60 million.) And then the plans were quietly shelved!
Bungle Number 2 NHS Kernow spent money on management consultants but did not turn a critical eye on their work. The consultants did what consultants do: they wrote their own brief and produced a ‘target operating model’ and a ‘business case’, not a plan. Not producing what NHS England asked for was hardly guaranteed to win funds.
Bungle Number 3 There is a golden rule for winning money from a funding body: ‘In your application speak to the fund-giver in their own language.’ You really do not want the fund-giver to have to decipher or puzzle over your application. Yet just as NHS Kernow submitted a business case when asked to submit a plan, they failed to register that when Five Year Forward View highlighted new models of care, this was a clue that their case/plan should do the same. Instead their Outline Business Case merely said ‘we will have created and embedded a new model of care’: it did not relate this aim to any of the models of interest to NHS England.
Bungle Number 4 NHS Kernow was one of very few local bodies to get a mention in Five Year Forward View: ‘In Cornwall, trained volunteers and health and social care professionals work side-by-side to support patients with long term conditions to meet their own health and life goals.’ This was the Living Well programme, run by Age UK Cornwall. It ended in September 2016, after Age UK Cornwall had asked for a grant of £9.5 million (to be spread over 5 years) to enable it to continue. The request was not supported by a business case, and with NHS Kernow’s financial plan for 2016/17 showing a forecast end-of-year deficit of £38.8 million, it was declined. But no steps were taken to ensure that the learning from the project was not lost, or find other ways of continuing it. So NHS Kernow blew their credit with NHS England.
Bungle Number 5 Bundling together of ‘communications’ and ‘engagement’ is rife all over the NHS, in management positions, teams, strategies etc. But they are two very different things, calling for very different skills. So when communications specialists are entrusted with engagement, they are liable to mess it up.
Communications people often have a journalism background. They are trained to persuade, to ‘put the message out’ and put a positive gloss on it. In contrast, successful engagement requires some of the skills of the social researcher. It calls for the asking of unbiased, non-loaded questions. It requires skills in questionnaire design and in listening rather than selling.
So when we have communications experts attempting engagement, what we often find is that persuasion slips in. In the ‘co-production workshops’ currently being held across Cornwall to engage local people in designing a new model of care, we find ‘information packs’ given out that have a certain ‘slant’: a selection of facts that support a ‘case for change’, and what you might call ‘endorsement by name-dropping’, where close inspection reveals that those whose name is cited have not actually endorsed the view stated. This discredits engagement, and it detracts from any benefit that ‘co-production’ might bring.
Bungle Number 6 Issues around ‘accountable care organizations/ systems’ and ‘integrated strategic commissioning’ have been preoccupying local leaders in the health and care system. Huge amounts of time and energy have been devoted to wrangling about organizational structure. (Or, as those in charge like to put it, ‘governance’.) In all this, the local leaders have been taking their eyes off what has been happening to patients and clients.
But while this has been going on, something remarkable has been happening at the ‘coalface’. In the box below is an extract from a report about recent events in the Emergency Department at the Royal Cornwall Hospital, Treliske. It describes a major turn-round in performance, basically achieved by everyone ‘pitching in together’.
Sadly, people concerned with ‘governance’ see things differently, as one of them has revealed:
Developing a fully functioning Integrated Care System is a complex process and would need to be a multi-stage process, requiring a developmental and incremental approach. With organisations working together in 2018/19, subject to approval, to test the concept, review and refine the model and progressing through a series of phases. Mobilisation, Design, Refine and finally Operational subject to the appropriate approval processes.
So the Treliske experience risks being taken to justify a complex, multi-stage process. It is hard to see that leading to anything other than a complex set-up to oversee it. We are witnessing a failure to learn from this recent experience, to grasp the notion of ‘pitching in together’.
The right lesson is not being drawn from this heartwarming story. Given the support, the resources and the responsibility, there are people at ‘ground level’ – those who actually deliver the service – who are very capable of doing a good job, of responding to emergencies in an agile, enterprising and enthusiastic way, and the last thing they need is a complex system overseeing them. Arguably, too, this kind of approach – bottom-up, not top-down – will do more to attract funding from NHS England than any amount of tinkering with ‘governance’.
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A remarkable turn-round at Treliske
‘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 (ED) 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.’