An appeal to Simon Stevens: Please intervene in Cornwall’s inadequate planning for integrated health and social care services

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Dear Simon Stevens

As Chief Executive of NHS England, you will know that the Cornwall and Isles of Scilly Sustainability and Transformation Partnership is looking for an Independent Chair to lead it in the next stage of transforming and integrating health and social care services into an Integrated Care System. It has recently published a 16-page Independent Chair Recruitment Pack for the post. The job description gives a disturbing insight into how the Partners are approaching their task.

Our concerns are as follows:

1. The ICS will apparently not employ a Chief Executive, so the Chair will have no full-time counterpart with whom to work. Although the Chair’s role is described in the job advertisement as one of leadership, the recruitment pack says it is to ‘assist the increasingly cohesive Leadership Group’. Assisting is not the same as leading, and the Chair will be in an isolated position.

2. The recruitment pack contains only a one-page case for change (‘Why we want to transform’). It says almost nothing about people’s needs and makes negligible use of national and local data.

3. Much of the recruitment pack presents potential applicants with plans already formulated, which must raise further questions about the role envisaged for the Chair. These plans are expressed merely in brief phrases and sentences that would fit comfortably on a Post-It Note. They are not supported by any data or reasoning.

4. The recruitment pack makes no reference to NHS England’s guidance document Designing integrated care systems (ICSs) in England. Applying this document’s ‘system maturity matrix’, by which we can gauge progress towards an integrated care system, there should exist by now ‘system-wide plans on workforce, estates and digital’. Cornwall’s recruitment pack makes no mention of any such plans.

5. There is no indication that a systematic planning process is being followed. For example, we see no sign of a progression from identified needs to challenges/issues to options to choices. Instead we have planning by brainstorming, with plans that take the form of visionary aspirations that fit on Post-It Notes. This will inevitably serve as a major obstacle to any meaningful form of public engagement in the planning process.

For these reasons, we feel we must question the competence of those who have been in charge of the planning process thus far and of recruiting the Independent Chair. We ask you to suspend the recruitment process until our concerns have been addressed and the situation rectified.

West Cornwall HealthWatch

* * *

The Cornwall and Isles of Scilly Sustainability and Transformation Partnership (STP) says it is looking for ‘an inspirational Chair … who can lead it in the next stage of transforming and integrating health and social care services into an Integrated Care System (ICS). It has published a 16-page
Independent Chair Recruitment Pack for the post.[1] The description of the job gives a disturbing insight into how the leaders of this partnership are approaching their task.

This note compares Cornwall’s approach to planning with that of Kent and Medway’s STP, which has just appointed an independent chair. It draws on information presented in the two recruitment packs.[2]

The current situation in Cornwall
Until now the STP has been led by a ‘self-managed team’, comprising the chief executive officers of Cornwall Council, NHS Kernow (the
Duchy’s single clinical commissioning group), the Royal Cornwall Hospitals Trust (the acute trust) and Cornwall Partnership NHS Foundation Trust (which runs community hospitals and provides a range of mental health and physical health services for children and adults). These four CEOs are the leading members of the Transformation Board, which is overseeing work on the integration project and is currently chaired by the Cornwall Council CEO.

How has the ‘self-managed team’ been operating? If we look at delayed transfers of care, as an example of an issue that cuts across organizational ‘jurisdictions’, we find that the Partnership Trust has assiduously been closing community hospitals while the acute Trust has 20 or so beds continuously occupied by patients who have had their treatment and would be ready to ‘step down’ to community hospitals, where they could receive rehabilitation/re-ablement: however, they cannot do this since there are not enough beds available to accommodate them.[3]

Seen from this viewpoint, each organization has its own ‘turf’ and the ‘self-managed’ system works because, so far as possible, they don’t interfere with one another. It may be ‘self-managed’ but it is not integrated.

The conflicting roles that Cornwall’s Independent Chair will be expected to undertake
The current search is for ‘an independent Chair, [whose] role will assist the increasingly cohesive Leadership Group to give a strong values-based lead to our network of organizations and ensure a culture of trust, honesty and mutual respect’. This is a very unfocused aspiration.

The published advertisement for the post lists seven different ways in which the Chair will be required to support the Integrated Care System. So some of his or her roles are to be ‘leading’, others ‘assisting’ or ‘supportive’. Such conflicting expectations must prove difficult to reconcile.

They do things differently elsewhere
In the Kent and Medway area, there is a Sustainability and Transformation Partnership (STP) that is seeking to deliver integrated health and social care, just like Cornwall’s ICS. An Independent Chair has just been appointed. The Kent and Medway approach to the Chair’s appointment could not be more different.

In Kent and Medway there is already a chief executive officer who will be the Chair’s counterpart: the Chair will be working with him and alongside him, within an established organizational structure. In Cornwall there is no CEO, nor is there any plan to have one.

Also in Kent and Medway, the Chair will lead a group of Non-Executives which will oversee the delivery of the STP plan and any necessary refresh of the STP strategy. In Cornwall, we are told, ‘the Leadership Group is focusing on an emerging governance system in which the role of Non-Executive Directors is seen as crucial’. From which we can only infer that there is as yet no commitment to anything.

Differences in the case for change
When we compare the case for change in Cornwall with that in Kent and Medway very striking differences emerge. In Kent and Medway a detailed study of health and social care needs and current provision has been carried out, with wide participation from across the area, especially healthcare providers. It was updated in March 2018 and its findings have been published in an 88-page report, Case for Change.[4] It contains 205 references to data sources etc. There is a link to it in their recruitment pack. It identifies the needs of the area, and then issues that are faced in responding to those needs. So it is a serious, reasoned document.

In Cornwall’s recruitment pack, there is just a single page on the case for change (see the final page of this note). There is no reference to a study or investigation or data sources. Headed ‘Why we want to transform’ and enlivened with half-a-dozen pictograms, it amounts to nothing more than a little collection of statements that could each be written on a Post-It Note:

► ‘47% is the expected increase in the number of people aged 75-84 between 2015 and 2025’.  
Comment: We are not told what the significance is of this figure, nor why that particular age group has been singled out.

► ‘A sense of scale (1): 545,351 Population: 300,000 population increase in summer. [Area] 3,559 square kilometres. 2+ hours to travel from Land’s End to the [River] Tamar.’
Comment: We aren’t told the date of the very precise census figure, or what the summer increase in population implies. The significance of the land area of Cornwall and the duration of a hypothetical end-to-end journey across the Duchy is not explained.

► ‘A sense of scale (2): 140,000 people live with a long-term condition; 68,600 live in the 20% most ‘deprived’ communities in England; 20% of people are under 18 [years old]; 25% are over 65 [years of age].
Comment: We are not told to what date these figures refer; nor whether they are increasing or decreasing and, if so, at what rate; nor how they compare with other parts of the country. So they convey no information whatever from which a need for action might be inferred.

► ‘35% of community hospital bed days are being used by people who are fit to leave.’
Comment: This is a statement that could be used to justify closing community hospital beds. The judgment ‘fit to leave’ really means ‘for whom we think we have done all we can’. On this criterion people may be judged fit to leave when they are not actually fit to be accommodated elsewhere – in their own home, for example. This statement ignores
the basic fact that every journey through the healthcare system has a destination as well as a point of departure. 

► ‘Around 60 people each day are staying in an acute hospital bed in Cornwall and don’t need to be there.’
Comment: The same narrowly-focused argument is provided here as for community hospital beds. In fact, we know that a sizeable proportion of the patients ‘stuck’ in acute hospital beds are there because they can’t be accommodated in the community hospitals, three of which in Cornwall have been closed in the past three years.

► ‘Older people can lose 5% of their muscle strength per day of treatment in a hospital bed.’
Comment: We aren’t told whether ‘older’ people necessarily do lose muscle strength at this rate, or whether adequate physiotherapy can prevent this: nor are we told whether people confined to bed at home lose muscle strength at the same rate. So this statement on its own provides no basis for planning hospital bed provision.

► ‘83% of admissions to community hospitals are from acute services, compared to 42% nationally.’
Comment: This is of course a striking difference, but we aren’t told whether it reflects well or badly on Cornwall. So as it stands it offers no basis for planning anything.

► ‘600+ care worker vacancies across Cornwall and the Isles of Scilly.’
Comment: This is the only statement in this list that unambiguously denotes a need. Among the others, there is not a single one that relates to people’s experiences.

Plans on Post-It Notes
Half of Cornwall’s recruitment pack lists ‘plans’ that appear to have been already formulated, under the heading of ‘key workstreams’: ‘Prevention, Children and Young People; Integrated Community Services (including Mental Health and Primary Care); Planned Care; Urgent and Emergency Care. They are without exception visionary aspirations, seemingly the outcome of brainstorming exercises, and they are expressed merely in brief phrases and sentences that would fit comfortably on a Post-It Note. They are not supported by any data or reasoning.

If the self-managed System Leadership Group has authorised this, the role of the newly-appointed Chair will be merely to ratify and progress these ‘plans’. And scope for the public to engage in the planning process would also be very limited. We find neither prospect encouraging.

In June 2019 NHS England published a guidance document Designing integrated care systems (ICSs) in England.[5] Applying this document’s ‘system maturity matrix’, by which we can gauge progress towards an integrated care system, there should exist by now ‘system-wide plans on workforce, estates and digital’. Cornwall’s recruitment pack makes no mention of such plans.

We have been here before
There has already been one experiment with having an independent chair for Cornwall’s
Sustainability and Transformation Plan. In June 2016 Joyce Redfearn, described as an experienced health and social care leader, was appointed as the Chair of the Cornwall and Isles of Scilly Transformation Board and Convener of the STP. She left that post just five months later, in November 2016, to be succeeded as Chair by Cornwall Council’s Chief Executive. It would be helpful to know what lessons have been learned from that experience.

Notes and references

1. Shaping our Future, Independent Chair Recruitment Pack, July 2019.
s at (fixed term contract/ secondment until March 31, 2022, minimum 8 days per month) and (secondment only).

2. The Kent and Medway information pack is entitled Candidate Briefing Document.

3. For fuller details, see Peter Levin, ‘Inpatient beds that Edward Hain hospital provided are still needed’, The Cornishman, July 4, 2019

4. Kent and Medway, Case for change, March 2018

5. NHS England, Designing integrated care systems (ICSs) in England, June 2019

Inpatient beds that Edward Hain hospital provided are still needed

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Reprinted from The Cornishman, July 4, 2019

The new set-up at the Edward Hain hospital building in St Ives is receiving plaudits for its work as a day centre. Plans are being developed for a ‘community-based model of care’. But the loss of inpatient beds is being glossed over.

Inpatient beds at Edward Hain community hospital were ‘temporarily’ closed to new admissions in February 2016.

They are still closed.

Those beds had been used intensively – on an average night 93% of them were occupied – and they were much used by Penwith residents: in the 12 months before they closed they held 174 patients, almost two-thirds of whom lived in Penwith.

Mostly they had been treated at Treliske, the acute hospital, and were now recovering. They were well enough to leave Treliske but not yet well enough to go home: they were still in need of rehabilitation. With the former Poltair community hospital closed and sold off there is now no community hospital with inpatient beds in Penwith.

The latest performance report to the Royal Cornwall Hospitals Trust – the acute trust – tells us that in April 2019 nearly 600 bed days were lost on account of delayed transfers of care caused by patients waiting for further non-acute NHS care, following completion of their acute treatment.

The report says: ‘These will be patients waiting for onward care, including community hospitals, for rehabilitation.’

Losing 600 bed days in one month is equivalent to having a ward of 20 acute beds continually unavailable for that month!

So what’s being done in Penwith to help Treliske out?

The new day centre being trialled in the Edward Hain hospital building is not receiving any referrals from Treliske, so clearly this service is not compensating for the loss of inpatient beds at Edward Hain.

Many patients benefit from the rehabilitation provided by the community hospitals, which are run by the Cornwall Partnership Trust, but for the past three years the Trust has shown no interest in providing community hospital beds in Penwith.

If the admittedly-elderly Edward Hain building is unsuitable for present-day needs, it is time to consider replacing it with a modern community hospital hub with inpatient beds.

We hear a lot about developing community-based models of care, but what is being done in the here and now, as well as in planning the future, to relieve Treliske of the patients waiting for onward non-acute NHS care for rehabilitation, and still needing beds?

Last month NHS England published an ‘implementation framework’ for its Long Term Plan.

This requires the NHS in local areas to make plans that will give priority to ‘actions that will help improve access to care for their local populations, with a focus on reducing local health inequalities and unwarranted variation.’

It is precisely such an inequality in Cornwall that in Penwith we now have no local access at all to inpatient beds in community hospitals. Our residents are losing out, and the acute hospital at Treliske is consequently short of a ward too.

At West Cornwall HealthWatch we are asking: How are local plans for the NHS being drawn up, and by whom?

Are we going to learn what they are at a point when there’s no time to change anything?

Will these plans provide for the badly-needed inpatient beds in a community hospital setting?

Is any thought being given to integrating the management of acute and community hospitals in Cornwall, to enable the smooth progression of patients from acute care to rehabilitation that is so badly needed?