Backroom visionaries or frontline practitioners: who should shape Cornwall’s integrated health and care system?

Social Policy Research for Cornwall

This is a post on behalf of West Cornwall HealthWatch. It can be downloaded as a pdf file here.

Last week we saw for the first time evidence of behind-the-scenes rivalry over how to decide what the shape of Cornwall’s new integrated health and care system should be.

Thanks to a report called System Objectives submitted to the ‘Partnership Senate’, which is overseeing developments, we can now see exactly what’s going on.

On one side, we have the backroom utopian visionaries who obviously wrote the report and want the Senate to endorse it. On the other are the frontline practitioners, currently busy coping with the coronavirus pandemic.

The System Objectives report set out some ‘high-level objectives’ and ‘game-changing aspirations’. It painted a glowing picture:

Our vision: A Health and Care partnership working for a better quality of life in a thriving Cornwall & IoS, with every resident making informed choices, in a strengthened, integrated and more efficient health and care system, where ‘place’, community and people are at the heart of our thinking.

This is said to mean things like

  • We enjoy an inclusive economy, which promotes skills development and access to good work for all.
  • Everyone has access to a safe home, community assets and built environment that supports wellbeing.
  • We live sustainably and value the health benefits of our natural environment.
  • Ensuring the development of positive social networks.
  • We create healthy and sustainable places and communities to live, learn, work and age.
  • Our children are lifted out of poverty and protected from adverse childhood experiences.
  • Every young person is equipped to be successful in the next stage of their life.

What on earth, we wonder, are aspirations like these doing in a document on health and care when there is hardly anything that the NHS and Cornwall Council can do to bring them about.

On the other side from the visionaries are the practitioners working on the front line. They don’t see the problem in terms of a vision: they are all too aware of issues, i.e. ‘what shall we do about X?’ questions. For example, they were quick to identify an issue around making best use of the available hospital beds and treatment facilities, and it was heartening to discover last week that the chief executives of Cornwall’s two NHS hospital trusts are in talks about a merger to address this issue. (This is something we were advocating back in March.)

The differences between visionaries and realists are highlighted by one simple fact: the visionaries’ report is so ‘head in air’, so utopian, that it overlooks what is happening on the ground. It makes no mention whatever of the coronavirus pandemic!

Evidently the visionaries have learned nothing from the pandemic. By contrast, the realists have learned, and continue to learn, a great deal.

What is very clear now is that the way forward is to address issues. Here is our first shot at a list:

Issue: How to integrate care homes and domiciliary care into the system. Freeing up NHS hospital beds by off-loading patients into care homes without a test for the virus has been a scandal, as has been the failure to provide homes and carers with the personal protective equipment (PPE) they needed.

Issue: How to enable people to die with dignity, with their loved ones around them. This is badly needed both for the sake of those departing and those they leave behind.

Issue: How to ensure that people who have to self-isolate, on their own or with their children or frail elderly relatives, are given support for their mental health.

Issue: How to maintain ‘normal’ services, especially for planned and emergency acute care, during abnormal times.

Issue: How to ensure that, with a new combined NHS hospitals trust, (a) services for the elderly and chronic sick, necessarily provided both by hospitals and in the community, are truly and seamlessly joined up; and (b) there are sufficient beds available in community hospitals to accommodate patients who require rehabilitation close to home after acute treatment.

Successfully addressing these issues would go a long way towards creating an integrated health and care system. We don’t need utopian visions.

Here in Cornwall we’ve seen what ‘high level’ visionary thinking leads to, in the 2016 Sustainability and Transformation Plan. This ill-thought-out plan, now jettisoned, was devoid of input from the public, and presented in jargon-laden language and with incomprehensible diagrams – the usual management-consultant guff. Our message to the Partnership Senate is a simple one: please don’t let them pull that trick again!


A new health and care system – but where are the voices of care homes and patients?

Social Policy Research for Cornwall

(Published as a letter to the editor in The Cornishman, 2 July 2020)

This comment can be viewed as a pdf file here.

On June 18th The Cornishman hit the streets with an article of mine* pointing out that bulletins on the Embrace Care project, set up to improve the NHS’s care for older people, had been suspended in March to allow work to concentrate on dealing with the Covid-19 pandemic, and that the public had heard nothing since.

Lo and behold! Within 12 hours, a brand new Embrace Care bulletin was being circulated. We learn that, under the pressure of Covid-19 and facilitated by a shower of cash in March from central government, a whole new health and care system has been developing.

The new system for Cornwall is based on fourteen primary care networks (PCNs), comprising groups of GP practices. These are at the centre of neighbourhood teams, made up of GPs and practice staff plus clinical pharmacists, community and district nurses, community geriatricians, dementia workers, and allied health professionals such as physiotherapists and podiatrists, along with social care staff and people from the voluntary sector.

The PCNs are themselves grouped into three Integrated Care Areas, and there is a Community Coordination Centre in each of them ‘to coordinate community based resources’.

There is also a new Single Electronic Referral System (SERS), long overdue, which enables all referrals for community health and care services including bedded care to be prioritised and allocated by a single team, led by staff from Cornwall Partnership Foundation Trust, NHS Kernow and Cornwall Council. It’s not apparent whether the Royal Cornwall Hospitals Trust, with its responsibilities for our acute hospitals, is involved.

Another new development is the Discharge to Assess Bed Bureau, set up to coordinate all bedded care across the county. ‘Led by experienced health and care colleagues they have been able to ensure that, wherever possible, people referred for bedded care could go home if it was the best outcome for them. This has allowed for more appropriate rehabilitation-oriented use of fewer community hospital beds’. This sounds like a justification for reducing the number of such beds.

Mostly these developments are encouraging to see. For the moment enthusiasm and money are available, which will lubricate power-sharing between the NHS and local government. We have to hope this continues.

Missing, though, are two voices: the voice of care homes and the voice of patients.

We have seen in the Covid-19 pandemic how, ‘to protect the NHS’, patients carrying the virus were moved out of acute hospitals into unprotected care homes. Many elderly and frail residents have died. Care homes complained but they weren’t heeded.

And despite the good intentions behind the Embrace Care project, the ethos of the ‘deferential patient’ persists. Patients are expected to be grateful for the care they get. They have no say in planning, although many are savvy consumers.

The remodellers must find new ways of involving the fragmented care home sector and the public in the design and running of the health and care system. Putting a single representative on a committee doesn’t cut the mustard these days.

* Has the Embrace Care project been employed for political purposes? Cornwall’s frail older folk deserve better, 18 June 2020