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

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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]