An Accountable Care System for Cornwall: Is ‘Shaping our Future’ now an exercise in empire-building?

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

The latest report on the ‘Shaping our Future’ (SoF) project for health and social care in Cornwall, to be placed before Cornwall Council’s Health and Wellbeing Board on January 25th, 2018,[1] shows that ‘Moving to an Accountable Care System’ is now part of the SoF project. This raises an important question: Is the purpose of the project really to meet the needs of the people of Cornwall, or has it become primarily an exercise in empire-building? This note addresses that question. 

Findings

  • The approach being taken by the project is very much a ‘top-down’ one, starting from questions about ‘leadership’ and ‘strategy’, and who should be in charge of commissioning. It seems directed towards creating a health and social care ’empire’. It does not start from ‘grass roots’, from the needs of patients and communities.
  • The report treats components of the so-called ‘system’, such as Urgent Treatment Centres, in isolation, rather than treating the system as a whole, as a ‘systems approach’ requires.
  • The report is written in ‘management-speak’ – using terms such as ‘model of care’, ‘single place based budget’, ‘areas that require further focus’ – and in a very ‘high-level’ way, so councillors can’t see how their constituents, people living in their ‘patch’, will be affected.
  • There are few commitments to public consultation over the future shape of the health and social care system. There is to be formal public consultation over options for location of Urgent Treatment Centres, but there is no mention of consultation over the future of Minor Injury Units or community hospitals.
  • The report shows the project is relying heavily on ‘co-production workshops’, but these seem to be taking place in an entirely different world. For example, the report says: ‘[The] future model for re-ablement, rehabilitation and recovery [is] subject to the co-production process …’, but Section 5 of the report, which is about those workshops, doesn’t even mention re-ablement, rehabilitation and recovery. Workshops have taken the form of brainstorming sessions, but participants have not been provided with information in advance, and information provided on the day has been grossly inadequate.[2]
Comment and recommendations

A grass-roots versus top-down approach

Chris Ham, Chief Executive of the King’s Fund, has drawn attention to ‘new care models’ currently being adopted:

Two of these care models, primary and acute care systems (PACS) and multispecialty community providers (MCPs), seek to integrate care and improve population health. In PACS hospitals often take the lead in joining up acute services with GP, community, mental health and social care services [whereas the] emphasis in MCPs is on GPs working … to forge closer links with community, mental health and social care services.

An advanced example of an MCP is Encompass in east Kent where 13 general practices are collaborating to improve care for a population of 170,000. The MCP has five community hubs bringing together multidisciplinary teams of GPs, community nurses, social care workers, mental health professionals, pharmacists, health and social care co-ordinators and others. These teams manage the care of individuals who have been identified as being at high risk of hospital admission. Other initiatives include a database of voluntary and community services, a social prescribing service and drop-in dementia clinics. Early evidence suggests that these changes have led to year-on-year reductions in emergency admissions to hospitals.[3]

An approach that starts from ‘grass roots’, from the needs of patients and communities, and builds upon the work of GPs and others, including the voluntary and community sectors, seems to be perfectly suited to the situation of Cornwall, with its small towns and scattered population. A ratio of five community hubs to 170,000 people would allow for 16 such hubs across Cornwall. This approach should be investigated without delay.

A systems approach

A diagram in Section 3 of the report (p.7) shows a ‘revised critical path for development of the model of care’. This refers options for the location of Urgent Treatment Centres but there is no mention of other places for receiving urgent treatment, such as hospital Emergency Departments and Minor Injury Units. Evidently a systems approach is not being adopted here. And we can only conclude that Minor Injury Units and similar facilities (including a GP surgery in St Ives) are deliberately being abandoned.

The SoF team should adopt a genuine systems approach, in the first instance to understand how the existing health and social care system – as a whole – works well and where it does not. This would facilitate a transition to a grass-roots, community-hub based system. Such an approach is also essential to carry the workforce along with decisions that are taken.

Avoiding ‘management-speak’

As we have seen, the report is full of terms with which people working on the project will be familiar – ‘model of care’, ‘single place based budget’, ‘building on the concept of “place”‘, ‘business case’ (is that the same as a plan?), ‘areas that require further focus’ – but this language will not be familiar to most councillors. It should be incumbent on officers to present a report that councillors can understand, and that will enable them to get a sense of how their constituents will be affected.

The report should be rewritten in plain English and examples given of how people living in different parts of Cornwall will be affected by its proposals. At the very least, a glossary of terms should be included.

Public consultation

As noted above, there are few references in the report to public consultation over how the health and social care system is to be reshaped. While there is to be a short list of locations for Urgent Treatment Centres to take to formal public consultation, there is no mention of consultation over the future of Minor Injury Units or community hospitals, for example. And references to developing just one ‘new integrated model of care’ imply that the public will have no opportunity to choose between alternative models.

The public should be fully informed at an early stage about options for all elements of the system, and provision should be made for open discussion of potential impacts, including any which are not immediately obvious. Only then will members of the public be able to contribute effectively to ‘co-production’ and make informed choices.

Co-production workshops

As we have seen, the ‘co-production workshops’ seem to be taking place in an entirely different world. The workshops have essentially taken the form of brainstorming sessions, and we wait to see what sense is made of the many comments received, which included such gems as: ‘Locations of UTCs on arterial routes is probably a good approach’ and ‘Have 4 super hubs along the spine of the county’.[4]

As an example of the inadequacy of information provided to workshop participants, they were asked ‘What if we replace Minor Injury Units with fewer strategically placed Urgent Treatment Centres – will it allow more people to receive the care they need without going to an acute hospital?’ but were given no information whatever about the current usage of Minor Injury Units![5]

Participants in the co-production workshops, most of whom work in the community and have good local knowledge, should be properly briefed beforehand and able to circulate their own evidence in advance. They should be involved in the process of formulating and resolving issues. This would enable a much richer, broader and more genuine public debate about what type of health and social care system the people of Cornwall need and aspire to.

* * *

Overview: The failings of organizational empires

The report to the Health and Wellbeing Board is itself a demonstration of how organizational empires operate: the overriding concern with ‘leadership’ and ‘strategy’, the inability to take a ‘whole system’ approach despite paying lip-service to it, the use of management-speak, the failure to connect with the community.

In the recent past, the Cornwall Council empire has reacted to the untidy plethora of community groups by searching for a single body to represent them. In other words, it has sought to impose tidiness rather than find ways of coping with and utilizing untidiness, which often brings with it alertness, energy and spontaneity. And NHS Kernow, the Clinical Commissioning Group, could not reach agreement with another empire, Age UK Cornwall, resulting in the closure of the Living Well project, under which local GPs in Penwith had worked closely with community groups, developed supportive communities, and brought together front-line practitioners across health and social care networks. Our experience of organizational empires is not a happy one. Lessons should be learned from it.[6]

Notes and references

(All websites last accessed on 21 January, 2018)

[1] https://democracy.cornwall.gov.uk/documents/s106878/Shaping%20our%20Future.pdf

[2] http://spr4cornwall.net/community-hospitals-under-threat-are-decisions-being-taken-on-scrappy-information-and-limited-understanding/

[3] https://www.kingsfund.org.uk/publications/making-sense-accountable-care

[4] As 1, page 11.

[5] https://www.shapingourfuture.info/wp-content/uploads/2017/10/West-LAW.pdf

[6] http://policies.kernowccg.nhs.uk/DocumentsLibrary/KernowCCG/OurOrganisation/GoverningBodyMeetings/1617/201605/GB2016017LetterFromGPMembersReLivingWell.pdf

 

Minor Injury Units: “Absolutely no decisions have been made …” Which means what, exactly?

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

Probably we all think we know what a decision is? But not everyone knows that the word ‘decision’ means one thing to the man and woman in the street and quite another to a bureaucrat? Read on to learn what consequences this can have.

My last report on this website, entitled NHS in Cornwall poised to close Minor Injury Units, drew a stern response from the chief officer of NHS Kernow, the Clinical Commissioning Group. She said:

Absolutely no decisions have been made about the number and future locations of urgent treatment centres … and any other community alternatives to the emergency department. … No decision will be made before [the public consultation] process has ended and the evidence collected during any consultation has been examined.

So here’s a question:

What exactly does she mean by a ‘decision’?

We should be aware that the word ‘decision’ is used in one way in ordinary life and in a quite different way in British bureaucracies.

In ordinary life, a decision is a choice. When we decide what to buy for dinner or what to watch on TV, we are making a choice, a choice between alternatives.

But in British bureaucracies, like the NHS, a decision is a formal step in a policy-making or administrative process. Once the decision is taken, the body concerned has permission to go on to the next step in the process.

Moreover, it is the usual thing in British bureaucracies that, when a public consultation stage is reached, only one proposal is put forward. There is no choice offered. The public are not offered alternatives to choose between.

And this is precisely what we can expect from NHS Kernow. Their Outline Business Case for the Cornwall & Isles of Scilly Sustainability and Transformation Plan (STP), said:

We propose to replace the current Minor Injury Units with a new model of strategically located Urgent Care Centres across the spine of Cornwall. The Centres will provide enhanced, consistent and resilient clinical cover to meet the urgent care needs of all residents and visitors.

As we see, there is no mention here of alternative models – like the one adopted in Devon, for example.

And just over a month ago, NHS Kernow’s chief officer reminded her governing body:

Cornwall’s Shaping our Future STP plans include a commitment to replace Minor Injury Units with fewer strategically placed Urgent Treatment Centres.

If we take these statements at face value it is crystal clear that no work is being done to explore ways of upgrading or modifying Minor Injury Units. Consequently we can be absolutely certain that at the public consultation stage such a possibility will not voluntarily be put forward as an alternative for the public to choose.

Just like concrete steps, failure to do something can close off alternatives. Pursuing one course of action to the exclusion of others creates a fait accompli before a formal consultation stage is ever reached. As a former Head of the Civil Service put it:

The experience of anyone who has worked in Whitehall is that there is an early stage in any project when things are fluid; when, if you are in touch with those concerned and get hold of the facts it is fairly easy to influence decisions. But after a scheme has been worked on for weeks and months, and has hardened into a particular shape, and come up for formal decisions, then it is often very difficult to do anything except either approve it or throw it overboard.

He might have added that there is invariably a considerable penalty attached to throwing it overboard at that point.

There is of course one thing that NHS Kernow’s chief officer could do to reassure the public. She could give an undertaking that when the public consultation stage is reached there will be more than one possible plan up for discussion. The alternatives should be genuine and should include one that involves keeping on Minor Injury Units in one form or another, so the public can make a choice and say which of the alternatives they prefer.

Will she give that undertaking?

 

[For references, please see posts dated September 12, 2017 and January 3, 2018]

 

NHS in Cornwall poised to close Minor Injury Units

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

In a week when Treliske hospital has been on black alert and ambulances have been queuing outside waiting to discharge patients instead of answering emergency calls, Kernow Clinical Commissioning Group continues to pursue a policy of closing Cornwall’s NHS Minor Injury Units, while insisting that nothing has yet been decided.

This report shows

  • How failure to make the most of the Minor Injury Units (MIUs) only increases the burden on Treliske’s Emergency Department.
  • How the decision to close the MIUs has become ‘pre-empted’, so it has become increasingly difficult for those in charge to change their minds.
  • How Kernow Clinical Commissioning Group (Kernow CCG) unnecessarily tries too hard to get itself into NHS England’s good books.

Where are Minor Injury Units and what services do they provide?
Most MIUs in Cornwall are run by Cornwall Partnership NHS Foundation Trust (CPFT). They are located in eleven community hospitals, which the Trust also runs: Bodmin, Camborne and Redruth, Falmouth, Fowey (currently ‘temporarily closed), Helston, Launceston, Liskeard, Newquay, St Austell, Saltash (also ‘temporarily closed’), and Stratton, near Bude. They treat sprains and strains, broken bones, traumatic wound infections (not surgical wounds), minor burns and scalds, head injuries (where the person has not been unconscious), insect and animal bites and stings, minor eye injuries, and cuts, bruising and grazes. [1] They are open 7 days a week, mostly from 8am to 8 or 10pm. All but one are equipped with X-ray facilities, although these are not available during all the open hours. All the MIUs offer free car parking.

The eleven MIUs listed above, which are listed on the CPFT website [1], are not the only ones in Cornwall. There is one at Treliske run by the Royal Cornwall Hospital Trust (RCHT) and another at the West Cornwall Hospital in Penzance, also run by RCHT. These are shown in a list of MIUs on the RCHT website [2] but they are not shown on the CPFT list, nor are they shown on a third list, on the Kernow CCG website [3]. There is yet one more MIU which is run by the doctors at the Stennack Surgery in St Ives: this appears on the Kernow CCG list of MIUs  but not on either of the other two. (The three lists can be seen  here.) At the present time it appears that call handlers on the NHS 111 telephone inquiry line are equipped only with the CPFT list: if you live at Land’s End you are liable to be referred for treatment to Camborne!

How MIUs assist main Emergency Departments
On May 31st, 2016 a team from Healthwatch Cornwall spent 12 hours in the Emergency Department of the Royal Cornwall Hospital at Treliske, interviewing people who were waiting for treatment. They found that 62 out of 78 respondents were not able to receive full treatment from another service even though they made an effort to access that/those service(s) and consequently ended up at the Emergency Department. [4] [5]

Commenting on these findings, the ‎Senior Commissioning Manager at Kernow CCG said:

Notwithstanding the limitations of the survey, the findings in the report echo other sources of feedback that many patients try hard to seek out alternatives but often find that “all roads lead to the Emergency Department”. [Other steps being taken included creating greater resilience at MIUs.] From the data, MIUs play a significant part in the treatment of patients seeking emergency care and substantially reduced the pressure on RCH Emergency Department. [My italics]

So here’s a question. If MIUs play a significant part in the treatment of patients seeking emergency care and substantially reduce the pressure on RCH Emergency Department, and indeed could do more to reduce that pressure, why are they being scrapped?

Plans to scrap the Minor Injury Units
Plans to scrap the MIUs first surfaced in the Outline Business Case for the Cornwall & Isles of Scilly Sustainability and Transformation Plan (STP), published in October 2016. As the (anonymous) authors put it:

We propose to replace the current Minor Injury Units with a new model of strategically located Urgent Care Centres across the spine of Cornwall. The Centres will provide enhanced, consistent and resilient clinical cover to meet the urgent care needs of all residents and visitors.[6]

September 2017 saw the holding of a series of six ‘co-production workshops’ across Cornwall. On the agenda for each was the question: ‘How would an urgent treatment centre compare to a minor injury unit?’ Participants were told:

The current issue is that our workforce is not sufficient to support the number of minor injury units and opening hours are inconsistent. [7]

Participants were given no facts and figures to support this flimsy judgment, which would in any case come down to a question of funding; they were given no information about the existing array of MIUs and the use being made of them; nor were they given any information about the extent to which they helped to relieve pressure on the Emergency department at Treliske. It is difficult to resist the conclusion that there was a built-in bias against MIUs at work.

The proposal to scrap MIUs has recently been reiterated. In a Director’s Update sent out on December 5, 2017, the Director of Kernow CCG told its Governing Body:

Cornwall’s Shaping our Future STP plans include a commitment to replace Minor Injury Units with fewer strategically placed Urgent Treatment Centres.

Following discussion with A&E Delivery Board system partners, we have confirmed that West Cornwall Urgent Care Centre [at West Cornwall Hospital, in Penzance] currently meets the standards of the national specification (with some improvement required around digital capabilities) and as such, it will be designated as a UTC. The term “designation” refers to the process of assuring that facilities meet the national standard for UTCs. It should be noted that designation of facilities reflects those services that currently meet the national standards. Therefore, designation of sites should not be seen as an indicator of the future location of UTCs as it is accepted that these may change on conclusion of the strategic review currently underway. [8]

Three further sites (Camborne Redruth Community Hospital Primary Care Walk-in Centre, the Minors Department at the Treliske Emergency Department, and Liskeard MIU) had been identified as the next closest to a match, but fell some way short. Notwithstanding which,

[following] discussion with the Chief Executives of Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospital Trust, who own the sites, we have agreed that these sites can be classified as ‘fast followers’ with an expectation of designation in March 2018. [However, this agreement] should in no way be seen as pre-determining our future model of Urgent Treatment Centre locations. [9]

It is a common experience that agreements and synchronized expectations pre-empt formal decisions. Indeed, formal decisions usually ratify – set the seal on – agreements and expectations. And given that the possibility is being entertained of four designated sites for UTCs, there is clearly no prospect of funding being made available to permit Cornwall’s Minor Injury Units to continue to exist in their present form. Whatever funding is available will be going into UTCs.

In short, assurances that no decision has been taken about the future of Cornwall’s MIUs are not consistent with the commitment already created to going ahead with UTCs, the persistent efforts to portray the scrapping of MIUs as something to be taken for granted, and the consonant pre-empting of funds.

How Kernow CCG unnecessarily tries too hard to get into NHS England’s good books
In her December update referred to above, the Director of Kernow CCG said:

NHS England published a national specification for an Urgent Treatment Centre (UTC) earlier this summer. There is a national expectation that a number of UTCs will be created across the county (sic) to relieve pressure on acute hospitals. A national commitment was made that there will be around 150 sites meeting the national UTC standards by the end of March 2018. [10]

However, what NHS England actually said is subtly different. A ‘key deliverable’ will be

Roll-out of standardised new ‘Urgent Treatment Centres’ which will open 12 hours a day, seven days a week, integrated with local urgent care services. … We anticipate around 150 designated UTCs, offering appointments that are bookable through 111 as well as GP referral, will be treating patients by Spring 2018. [11]

Note that the 150 designated UTCs, across England, are anticipated, not a commitment.

Moreover, NHS England also said:

We know that there will be some exceptions where there will be justification for offering a service that does not meet [our] standards, most likely in more rural or sparsely populated areas. These exceptions should be agreed on a case by case basis working with NHS England and NHS Improvement regional teams. [12]

Clearly, given the prevalence of ‘more rural or sparsely populated areas’ in Cornwall, where there are no cities and the largest built-up area (Camborne-Pool-Redruth) has a population of only around 41,000, it would be perfectly open to Kernow CCG to make a case for a different kind or level of provision. Since Cornwall’s resident population (around 550,000) is 1 per cent of that of England, which would give a pro rata entitlement to 1½ Urgent Care Centres, some departure from the ‘commitment’ will in any case be necessary.

Fortunately a hopeful example of how to do this is close at hand, across the Tamar. NHS Northern, Eastern and Western Devon Clinical Commissioning Group points out:

National guidance has suggested the development of Urgent Care Centres to replace Minor Injury Units.  This new model of much bigger units suits large urban settings, but will not be viable either clinically or financially in many rural areas including our Devon market towns and communities. [13]

Exactly the same is surely true of Cornwall, and it seems to be appreciated by NHS England. So in Devon today we find a range of providers of MIUs, especially healthcare trusts and general practices. In Cornwall we have just a single MIU based at a GP practice, at Stennack Surgery in St Ives. Astonishingly, although this MIU appears on the list of MIUs on the Kernow CCG website it does not appear on the lists of MIUs on the CPFT and RCHT websites.

The guiding principle in Devon is meeting local needs, not standardization and consistency. Kernow CCG should follow suit. There is evidently not the slightest need for it to try to second-guess NHS England on this matter.

– –––––––––––––

Sources (All last accessed January 1st, 2018)

[1] Cornwall Partnership NHS Foundation Trust, Community Hospitals. http://www.cornwallft.nhs.uk/services/minor-injury-units/

[2] Royal Cornwall Hospital, Waiting Times for Urgent Care.
https://www.royalcornwall.nhs.uk/services/urgent-emergency-care/minor-injury-wait-times/ 

[3] Kernow Clinical Commissioning Group, Minor Injury Units.
https://www.kernowccg.nhs.uk/get-info/choose-well/minor-injury-units/?platform=hootsuite

[4] Healthwatch Cornwall, You said, we did – 2016, https://www.healthwatchcornwall.co.uk/our-work/you-said-we-did-2/

[5] Healthwatch Cornwall, 12 hours in Royal Cornwall Hospital Treliske’s Emergency Dept.
https://www.healthwatchcornwall.co.uk/news/12-hours-in-royal-cornwall-hospital-treliskes-emergency-dept/

[6] Cornwall and the Isles of Scilly: Sustainability and Transformation Plan: Draft Outline Business Case, 21st October 2016
https://www.cornwall.gov.uk/media/22984634/cornwall-ios-stp-draft-outline-business-case.pdf

[7] Slides 24 & 25, https://www.shapingourfuture.info/wp-content/uploads/2017/10/West-LAW.pdf . There has been a change in terminology from ‘Urgent Care Centres’ to ‘Urgent Treatment Centres’: this need not concern us here.

[8] Extract from the Director’s Update to the meeting of the Governing Body, Kernow Clinical Commissioning Group, 5 December 2017 (Paper GB1718/097] https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/KernowCCG/OurOrganisation/GoverningBodyMeetings/1718/201712/GB1718097DirectorsUpdate.pdf

[9] As 7.

[10] As 7.

[11] NHS England, Next Steps on the NHS Five Year Forward View, https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf (p.16)

[12] NHS England, Urgent Treatment Centres – Principles and Standards, July 2017 https://www.england.nhs.uk/wp-content/uploads/2017/07/urgent-treatment-centres%E2%80%93principles-standards.pdf

[13] NEW Devon CCG, Minor injuries service in Sidmouth.  https://www.newdevonccg.nhs.uk/2016-news-archive/minor-injuries-service-in-sidmouth-101975