This Comment, originally published as a letter to the editor in The Cornishman, 4 November 2021, can be downloaded as a pdf file here.

It was heartening to read in The Cornishman that our acute hospital at Treliske has set up a ‘reablement’ ward to help older patients regain their mobility and independence after treatment, while at the same time training healthcare workers in the skills that they need for this purpose. It is a hugely significant development for an acute hospital, because unlike the current official guidance (usually slavishly followed) it appreciates that older patients in particular need a stage of recovery and reablement between their treatment and discharge, and that providing this will release sorely needed beds and thereby allow a speedier flow of patients through the Emergency Department. It’s a good example of joined-up thinking! Congratulations to Frazer Underwood, who is spearheading this development.

There is an important question here for Cornwall’s health and social care managers. Helping patients with recovery and reablement is not a new idea for hospitals, but in the past it has been carried out in community hospitals, with the acute hospitals providing major surgical and medical treatment. Unfortunately NHS Kernow, Cornwall’s clinical commissioning group, has been pigheadedly insisting that we are over-provided with hospital beds, and has been doing its level best to close community hospitals. The Edward Hain hospital in St Ives is the latest to go under, leaving Penwith with none and local residents who are still recovering from treatment discharged from Treliske to a care home or one of the remaining community hospitals up to 70 miles from their home territory. It’s good that the deficiency in recovery and reablement services is being remedied now, but should it have been left to Treliske to do it?

NHS Kernow is currently in the process of being absorbed into Cornwall’s new Integrated Care System. It is to be hoped that a more insightful approach to the role of community hospitals will prevail from now on. A good start would be to integrate all Cornwall’s NHS hospitals, acute and community, under a single management.

 

 

This page can be downloaded as a pdf file here.

Introduction
The question of how many hospital beds we need in England has been a divisive one for some time, especially during the Covid-19 pandemic.

In Cornwall, which has recently had the highest incidence of the disease in England and acute hospital facilities under huge strain, we saw the county’s clinical commissioning group, NHS Kernow, going into the latest wave saying there is evidence of an over reliance on hospital beds. But the Royal Cornwall Hospitals Trust (RCHT), which runs Cornwall’s main acute hospital at Treliske and its two satellites, says more beds are needed. They can’t both be right. But might they both be wrong? This paper examines the two claims and finds both wanting.

The Royal Cornwall Hospitals Trust sees its world in terms of ‘inpatient beds’. In effect it is taking it for granted that the purpose of hospital beds is simply to accommodate patients who are being provided with surgical or medical treatment. Its language shows no concern with what happens to them after their treatment.

NHS Kernow is not specifying any particular type of hospital bed. It has made it its mission to close ‘hospital beds’, and it has been concentrating on closing beds in community hospitals. In the past a proportion of the patients discharged from Treliske have gone to these en route to their homes or to a care home. Now Cornwall has lost the only two community hospitals in Penwith, the westernmost area of the county: two more (in Fowey and Saltash) are on the way. That’s 40 beds gone. Some Penwith residents discharged from Treliske have been sent to the other end of the county, up to 70 miles from home, as a result.

Guidance from above: The ‘Discharge to Assess’ model
Under the impetus of the Covid-19 pandemic, the Department of Health & Social Care (DHSC), having noted that a number of patients who were staying in hospital after treatment were waiting first for an assessment of their fitness to go to accommodation elsewhere and then to be actually moved there, concluded that beds would be freed if those assessments were carried out after rather than before they vacated their hospital bed.

In March 2020 the Department published guidance which directed all hospital trusts in England to implement what it calls the ‘Discharge to Assess’ (D2A) model. This instructed hospitals to assess patients twice a day and judge whether they were ‘medically fit for discharge’. If they were so judged ‘they must be transferred from the ward to a … discharge area or lounge as soon as possible, to leave hospital the same day’.

How to judge whether a patient is ‘Medically fit for discharge’ 
The DHSC’s guidance said that the judgment as to whether a patient is ‘medically fit for discharge’ needed to be based on only a snapshot, a here-and-now view of their current physiological condition: for example, whether they required intravenous fluids or had undergone lower limb surgery within the past 48 hours.

The clinician’s judgment did not have to be based on how the patient was progressing, or whether in normal circumstances they would be kept in for observation, or what their prospects were for successful post-treatment recovery and rehabilitation if they were discharged immediately. It did not have to be based on consideration of the patient’s overall situation – for example, if they had a complex of conditions, or were living with frailty, or approaching the end of their life.

What the ‘medically fit for discharge’ criterion did was to invite the clinician to ask a simple question: ‘Can I do anything more for this patient by way of treatment?’ If the answer was ‘No’ the next step was obvious: schedule them for immediate removal. No further thought was required: the patient’s treatment episode was now finished and he or she was now someone else’s problem.

The route from acute
The original D2A model specified four ‘pathways’ for patients being discharged:

‘Pathway 0: 50% of people simple discharge, no input from health / social care’

‘Pathway 1: 45% of people: support to recover at home; able to return home with support from health and/or social care’

‘Pathway 2: 4% of people: rehabilitation in a bedded setting’

‘Pathway 3: 1% of people: there has been a life-changing event. Home is not an option at point of discharge from acute’

A new version of the guidance from DHSC was published in July 2021. It divides patients into the same four categories as the original but introduces the concept of ‘likelihood’. It says it is ‘likely’ that 50% of patients will be able to simply go home (those on ‘Pathway 0’). It is ‘likely’ that another 45% will be able to return home and recover with support from health and/or social care (these are on ‘Pathway 1’).

On Pathway 2 there is ‘likely to be [a] maximum of 4% of people discharged [for] recovery, rehabilitation, assessment, care planning or short-term intensive support in a 24-hour bed-based setting, ideally before returning home’.

And finally on Pathway 3 there is ‘likely to be a maximum of 1% of people discharged’ who will require bed-based 24-hour care and will need to be discharged to a care home for the first time.

The significance of ‘likelihood’ is that it allows for adjustment of the percentage figures to take account of the age structure of the local population. This will be necessary in Cornwall because there are half as many people again in the over-65 age bracket as in the population of England. Evidently it is now seen that there was previously a risk that clinical commissioning groups and providers would take the percentage figure for each pathway as a target.

Unfortunately, in its calculation of Cornwall’s need for hospital beds, NHS Kernow has done exactly that. So it will have significantly under-estimated the number of people likely to need rehabilitation and recovery in a bed-based setting.

Rehabilitation and recovery
The latest guidance says that a small proportion of the people placed on Pathway 2 ‘will need and benefit from short-term care in a 24-hour bedded facility for the purposes of rehabilitation or recovery where time is given to the assessment and consideration of options for longer term care. This could be in a rehabilitation facility, care home or hospice care’. Local health and care systems must ensure adequate rehabilitation is provided in relevant 24-hour bedded facilities.

In Cornwall we can add something to this latest guidance. ‘Bedded facilities for the purpose of rehabilitation or recovery’ already exist here. They are called community hospitals. But because the beds in them are, not surprisingly, labelled ‘hospital beds’ these are precisely the facilities that for the past seven years NHS Kernow has been set on closing down. 40 beds that used to be available have been lost.

The community hospitals in Cornwall have historically provided a rehab/recovery ‘step-down’ function for patients discharged from Cornwall’s main acute hospital at Treliske and its satellites. The lack of those 40 beds is a significant contribution to the problems that the Royal Cornwall Hospitals Trust is now facing in its struggle to dispatch patients who have been judged medically fit for discharge.

Closing community hospitals has created major problems for the local population, of course. In Penwith, the far western area of Cornwall, two community hospitals have been lost: just recently Edward Hain Community Hospital in St Ives and before that Poltair Hospital in Penzance. Now there is no community hospital in Penwith. In recent years a number of Penwith residents who would previously have been discharged to Edward Hain hospital for rehabilitation and recovery have instead been sent to community hospitals and care homes as far as the other end of the county, up to 70 miles away from their home community.

How NHS Kernow made use of the ‘Medically fit for discharge’ criterion
We can see that NHS Kernow, besides basing its calculations on misinterpreted targets, is resting its argument that there is an over-reliance on hospital beds in Cornwall on two propositions:

1. 1. A clinician’s judgment that a patient is medically fit for discharge can be taken at face value: that patient is ready to leave hospital and there is no need to ask how that judgment was arrived at.
   2. Beds should be occupied only by patients not yet judged medically fit for discharge.

RCHT is adopting the same two propositions. What both organizations are failing to do is to look at hospitals’ roles in the context of the paths that patients need to follow to regain their health.

For once central Government is leading the way in responding to patients’ needs, and indeed identifying those paths with some sensitivity. The latest guidance says some inpatients (especially in acute hospitals) will need to move on to a ‘24-hour bedded facility’ for rehabilitation or recovery before they can go home.

RCHT is manifestly working on the principle that it is not its job to provide rehab/recovery facilities, although it has done so in the past. Such facilities do exist elsewhere in Cornwall but they are in community hospitals (which are run by a different Trust), so the beds are labelled ‘hospital beds’, precisely the ones which NHS Kernow has made it its mission to close.

What is missing and what to do about it (1): Joined-up thinking
What we can see is missing from the calculations of both NHS Kernow and the Royal Cornwall Hospitals Trust is the joined-up thinking that would identify and remove obstacles to the flow of patients needing rehab/recovery facilities from the acute hospital to those facilities elsewhere – in community hospitals, for example. To close down community hospitals and thereby create a blockage in the acute hospitals is not sensible.

NHS Kernow and its successor body should be aware that some urgently needed bedded facilities for the purpose of ‘rehabilitation or recovery’ already exist, and the need for such facilities is recognized by the DHSC. Just because those facilities are called ‘community hospitals’ and the beds in them are consequently known as ‘hospital beds’, that is no reason to close them down. Community hospitals perform a ‘step-down’ function that is crucial to the smooth running of acute hospitals, and should be cherished.

Joined-up thinking is also lacking when clinicians are making ‘medically fit for discharge’ decisions solely on the basis of whether there is more treatment that they themselves could provide for a patient.

Joined-up thinking requires the paths followed by patients through the hospital system to be considered as a whole. Treatments should be considered from beginning to end. It makes no sense to increase the provision for people to go through surgical or medical treatment and not do the same thing with the provision for their subsequent rehabilitation and recovery. There must exist an appropriate ratio between acute beds and rehab/recovery beds and a fact-finding study should be carried out to provide the basis for judging what this should be. Our hospitals badly need joined-up thinking, sadly not greatly in evidence to date, and patients deserve no less.

If a clinician categorizes someone as medically fit for discharge without considering their overall condition or contributing to an assessment of what they still need in terms of rehabilitation or recovery, that is also an example of the failure of joined-up thinking. Indeed, they are abdicating their responsibility towards the patient. It should be their duty to make constructive contributions to patients’ future wellbeing.

What is missing and what to do about it (2): Geographical fairness
Geographical fairness is conspicuously absent from the current distribution of community hospitals in Cornwall. Penwith, shaped like an isosceles triangle with Land’s End at its peak and sea on its two long sides, is the most remote part of Cornwall: it is the last place that should be deprived of its own community hospital. But the recent closure of Edward Hain Community Hospital in St Ives has left it with none.

NHS England’s guidance on planning, assuring and delivering service change for patients reminds commissioners of their duty to reduce health inequalities. Since the closure of inpatient beds at Edward Hain there has been inequality of community hospital provision as between Penwith and other areas in Cornwall. For example, the Camborne-Redruth area has its own community hospital, and the Cornwall Partnership Foundation Trust’s website specifically says: ‘Camborne Redruth Community Hospital provides physical and mental health care … services for people in the local area.’ Penwith has nothing like this.

Penwith is its own local area and deserves at least the same community hospital service as other parts of Cornwall. To reduce health inequalities, the replacement of Edward Hain Community Hospital with a modern rehab/recovery facility, with a full complement of physiotherapists and occupational therapists, must be a priority. Given its likely contribution to the smooth functioning of the acute hospitals, it must be a cost-effective measure.

In conclusion
To return to our question: Do we really have enough hospital beds in Cornwall?

We can see now that this question is unanswerable as it stands, because it does not distinguish between acute hospital inpatient beds and rehab/recovery beds. What we can say with confidence is that there must exist an appropriate balance between the two. If the Covid pandemic has shown us anything it is that such a balance does not exist at the moment, and that NHS Kernow’s ill-advised attack on community hospitals has contributed to this.

As for the total number of beds needed, there is no straightforward answer. A new pandemic against which there is as yet no vaccine could invalidate all previous calculations, and different people will make different judgments about how many beds it would be appropriate to allow for unexpected developments.

Under the Health and Care Bill currently before Parliament, the bodies that will make up the new Integrated Care System are specifically expected to work ‘in the best interest of their immediate service users [and to] have strong engagement with their communities’. Acting to promote joined-up thinking and geographical fairness would show the people of Cornwall that those running the new Integrated Care System do have their best interests at heart.

 

8 September 2023

This paper can be downloaded as a pdf file here.

A recent investigation by Healthwatch England into the Discharge to Assess scheme found that 82% of patients discharged from hospital did not receive a follow-up visit or assessment. This paper suggests that to meet an evident need some community hospitals should be repurposed as ‘recovery centres’ to assess and assist the recovery of discharged patients who have returned home, and accommodate for brief ‘transitional’ stays others who are not quite ready to take that step. The former Edward Hain Hospital in St Ives, Cornwall, would make an excellent trailblazer.

Captain Edward Hain was the only son of Sir Edward and Lady Hain, of St Ives in Cornwall. By all accounts a gifted and popular young man, he lost his life in the Great War, at Gallipoli, on November 11th, 1915, at the age of 28. A memorial fund was set up in his name. After the end of the War it was widely felt that St Ives needed a hospital: a suitable building came on the market, and it was bought with money from the memorial fund and from the Hain family. The Edward Hain Memorial Hospital, often referred to locally as ‘the convalescent hospital’, was opened in 1920 and has been a treasured feature of the town ever since. But in 2016 the inpatient beds were closed and in 2020 NHS Kernow, Cornwall’s clinical commissioning group, finally decided to close the hospital.[1]

Executive Summary

The middle of the Covid-19 pandemic may not seem like an opportune moment to be worrying about the closure of a community hospital. But the issues are connected by the question of how to free up beds in acute hospitals. In the past, patients who no longer needed to be in an acute hospital could ‘step down’ to a community hospital, which served as a ‘staging post’ for them on their journey home. Those hospitals too are now under pressure, but our healthcare system needs those staging posts more than ever.

During the Covid-19 pandemic, the UK Department of Health & Social Care published a ‘rulebook’[2] in which it directed all hospital trusts in England to implement what it calls the ‘Discharge to Assess’ model. This model is unsatisfactory on four counts:

(1) It instructs hospitals to discharge very promptly patients who are judged ‘medically fit for discharge’, but this judgment is to be based only on a ‘snapshot’ view of their current physiological condition, not on indications of how they are progressing;

(2) It fails to distinguish between assessment of a patient’s need for community support and assessment of their need for further treatment;

(3) It fails to take account of the likely impact of speedy discharge on the risk that patients will need to be readmitted as an emergency.

(4) It is inherently based on the assumption that there is an identifiable point in a patient’s recovery after treatment when responsibility for care can, without doing harm, be abruptly switched from the hospital to a completely different system, one which involves the patient either being returned home and supported with a ‘package of care’ and visits from their general practitioner, or being placed in a care home or nursing home.

This paper makes the case that staging posts are indeed still needed but, if Discharge to Assess is to become standard practice, they should take a different form from the community hospitals that we are accustomed to. There needs to be a transitional stage in a patient’s recovery, to take place in a setting where (a) their recovery can continue to be monitored, and (b) they can – with assistance – take their own steps towards resuming an active life. A ‘recovery centre’ could provide such a setting, and an Edward Hain Memorial Recovery Centre in St Ives (in West Cornwall) could serve as a prototype. There are other community hospitals in Cornwall that could be similarly repurposed. This paper proposes eight principles for the design of such a centre. These are shown in the table below.

Eight principles for designing a recovery centre Principle 1: The process of recovering after illness or surgery requires the active involvement of the patient. It is more than merely receiving care. Principle 2: Aiding recovery is a multi-disciplinary specialism. It requires people with a range of qualifications to work in teams in a suitably equipped environment. Principle 3: Medical and nursing professionals can and should be part of the recovery team, but it should be run as a co-operative, not a hierarchy. Principle 4: The recovery model needs its own language: it should avoid the language of the medical and nursing professions. Principle 5: Recovery should be thought of as the concluding stage of a patient’s journey through the health care system, not as an afterthought to treatment. It should be joined up to the stages that precede it. Principle 6: A recovery centre would be the appropriate setting for carrying out assessments of patients discharged from an acute hospital and should be made use of for this purpose. Principle 7: Recovery is likely to be more effective and beneficial when carried out in a social context rather than on individual visits to people in their own homes. Principle 8: A recovery centre should have its own premises and include some beds for overnight stays. It should work with hospitals, and could play an extremely valuable part in operating the Discharge to Assess scheme, but it should not be a hospital or care home.

The context: the National Health Service under pressure

This paper is being written ten months into the 2020 Covid-19 pandemic, at a time when sheer numbers of patients are putting the people who work in the NHS under pressure as never before. Doctors, nurses, other health professionals and support staff are chronically stressed. Equipment has been in short supply and much-needed funding held back, while the Government has been criticized for the extent to which it has entrusted some crucial services to the private sector. Waiting lists for elective treatment that is not immediately urgent have grown considerably.

At national level, responsibility for handling this situation falls primarily to the Department of Health and Social Care (DHSC) and NHS England (NHSE), an executive non-departmental public body sponsored by DHSC, which has administrative oversight of the trusts that provide hospital and other health services (such as mental health care) at local level and of the local clinical commissioning group governed by general practitioners which commissions those services from the providers. Social care services, however, are provided by the upper tier of elected local authorities, of which Cornwall Council is one.

The NHS is good at responding to emergencies, when there is a single, well-defined goal to focus on, such as getting the ‘Nightingale’ hospitals built in the early stage of the Covid-19 pandemic. Planning may not be the system’s strongest feature, as witness the remarkably brief life of Sustainability and Transformation Plans. Urged by the centre on the localities, it soon transpired that neither understood what such planning entailed and how to do it. After a mere 15 months, in 2015-2017, those plans were quietly abandoned.[3]

Joined-up thinking may present particular problems, to judge by the way in which ‘protecting the NHS’ was taken to justify the indefinite postponing of hospital treatments that weren’t immediately urgent and the exporting to care homes of elderly patients without providing them or other care home residents or staff with equipment to protect them against catching Covid-19. Failing to appreciate that the Discharge to Assess model would have an impact on emergency readmissions to hospital is another example. The episodic nature of hospital care, discussed below, is yet another.

At the centre, DHSC and NHSE have long wanted to reduce the numbers of patients who were thought to be taking up hospital beds when they were suitable for transfer elsewhere, such as from an acute hospital to a community hospital or from either to a care home. In 2019 Government Mandates to NHS England instructed it to reduce ‘NHS-related delayed transfers of care’ from hospitals. The 2019 NHS Long Term Plan duly set as a goal ‘to achieve and maintain an average Delayed Transfer of Care (DTOC) figure of 4,000 or fewer delays’. NHSE provided hospital trusts with ‘guidance’ for preparing their DTOC figures. This attempted to shoehorn together two very different approaches, one of which did not even offer a procedure to follow.[4]

In practice, it transpired that every trust was free to decide for itself how to measure its DTOC figures, as examples from Cornwall and elsewhere showed. So their figures could not meaningfully be added together. This clearly did not provide a sound basis for planning.

That situation was known about at local level for several years, and concerns were relayed upwards, but nothing was done about it. NHSE said its latest guidance would remove ambiguity, but it did not. It was supposed to emphasize local collaboration, but it removed an injunction to that effect in the previous version. It was claimed that it would offer ‘good practice examples’ from around the country, but it presented none at all. NHSE then forced a ‘comply or explain’ regime on to trusts, but this merely distracted them into playing a game of ‘satisfy the statisticians’.[5] The Covid-19 pandemic has at least had the beneficial consequence that the collection of DTOC data has been suspended.

The defects of Discharge to Assess
The Department of Health & Social Care, having noted that patients are often kept in hospital while waiting for assessments of their fitness to leave and be accommodated elsewhere, has concluded that beds would be freed if those assessments were carried out after rather than before they leave. In the Covid-19 rulebook[6] it directs all hospital trusts in England to implement what it calls the ‘Discharge to Assess’ model. This instructs hospitals to promptly discharge patients who are judged ‘medically fit for discharge’. Patients are to be assessed twice daily. If they are assessed as medically fit for discharge ‘they must be transferred from the ward to a … discharge area or lounge as soon as possible, to leave hospital the same day’.

The rulebook offers four ‘pathways’ for patients judged fit for discharge. They are based on the expectation that 50% of patients will be able to simply go home, with no formal input needed from health or social care: this is ‘Pathway 0’, and it is expected that those patients will be out of the hospital within two hours of leaving the ward. It is expected that another 45% will be able to return home and recover with support from health and/or social care (Pathway 1). It is also expected that 4% of people will need rehabilitation or short-term care in a 24-hour bed-based setting (Pathway 2). Finally it is expected that 1% of people will require ongoing 24-hour nursing care, ‘often in a bedded setting’ (Pathway 3). They are seen as likely to require long-term care.’

Discharge to Assess (D2A) has four major defects:

(1) It fails to take account of the likely impact of speedy discharge on emergency readmission of patients. We know that many patients are discharged from hospital only to be admitted again as an emergency. The Nuffield Trust found that between 2010/11 and 2016/17 the total number of 30-day emergency readmissions to hospital in England rose from nearly 1,158,000 to nearly 1,380,000. The percentage of admissions followed by an emergency readmission within 30 days rose from 7.5% in 2010/11 to 8.0% in 2016/17.[7] While some of those emergency readmissions may have entirely new causes, it is clearly not safe to assume that all patients can be discharged without harm.

Healthwatch England reported in October 2020, on the basis of a survey of patients’ experiences of leaving hospital (sample size more than 500):

approximately one in five people (19%) felt they were not prepared to leave hospital. For those that were discharged at night, 27% felt they were not prepared. People who told us they had a significantly worse experience of leaving hospital than they had had previously, generally felt that it was too soon for them to be discharged.[8]

The Covid-19 rulebook provides no advice on steps to be taken to guard against an increase in 30-day emergency readmissions. And in relation to discharges at night, we should note that ‘out of hours’ is when inexperienced clinicians are likely to be on duty. Consultants will be on call, but their juniors may well be reluctant to disturb them.

(2) Discharge to Assess also fails to distinguish between assessment of a patient’s need after treatment for social care – to help them manage at home, for example – and assessment of their post-treatment need for continuing medical care, e.g. for rehabilitation or reablement. Again, it appears that the prime concern is to get patients off hospital premises as quickly as possible.

(3) The expected percentages of patients likely to use each pathway might well become informal targets, as the Healthwatch England report says.[9] This seems more likely than not. In Cornwall the proportions might well be affected by demography: the proportion of people aged 65 and over in the population is half as much again as the national percentage for England, and in some parts of the county household incomes are among the lowest 10% in the country. But the formula does not allow for such variations to be taken into account in responding to local needs, and hospital staff will know that they may have to justify any departures from the norm.

(4) The judgment as to whether a patient is ‘medically fit for discharge’ is required to be based on only a ‘snapshot’ here-and-now view of their current physiological condition (e.g. whether they require intravenous fluids or have undergone lower limb surgery within 48 hours), not on their progress. None of the criteria are dynamic, to do with how well the patient is progressing or drawing on the consultant’s experience-based judgment of how they might progress.

So the Discharge to Assess system rests on an underlying but unspoken assumption that there is an identifiable point in a patient’s recovery after treatment when responsibility for care can, without doing harm, be abruptly switched from the hospital doctor or surgeon to a completely different system, involving the patient being returned home and supported with a ‘package of care’ and visits from their general practitioner, or being placed in a care home. The acute hospital treatment is but one episode in the patient’s pathway through the healthcare system.

The episodic nature of hospital work
That lack of continuity of care is consistent with the way that NHSE sees the work of doctors, as a series of episodes. (The unit of work done in the NHS is the ‘finished consultant episode’.) When one set of doctors in a hospital finish their shift and hand over to another, they hand over responsibility for the continuing care of their patients to the set taking over: consequently the system discourages doctors from seeing as a single process an ill or injured patient’s journey all the way through the healthcare system, from initial condition to their resumption of normal life. It discourages continuity of care; it discourages doctors from looking ahead to that stage in a patient’s pathway through the healthcare system when they have been discharged from hospital but still need healthcare and/or social care to complete their recovery.

A new recovery model
I conclude that a new post-treatment recovery model is needed, one that will both allow patients to be followed while they are continuing their recovery and, where appropriate, allow hospital clinicians to work with recovery specialists in contributing to that process. No one model will fit all circumstances, but acting on the eight fundamental principles set out here should help.

Principle 1: The process of recovering after illness or surgery requires the active involvement of the patient. It is more than merely receiving care.
Recovering is the process by which a person who has had to spend time in a bed in an acute hospital after an operation or other treatment gets back the skills and confidence, the physical health and the mental health, that they need for resuming normal life. To achieve a successful recovery, the individual must play an active part in the process. He or she must actively want to recover, and should be supported to envisage both that goal and the path by which it can be reached.

Principle 2: Aiding recovery is a multi-disciplinary specialism. It requires people with a range of qualifications to work in teams in a suitably equipped environment.
Aiding recovery is the province of people with different skills, knowledge and qualifications: specialists in rehabilitation medicine,[10] physiotherapists, occupational therapists, expert strength and fitness coaches, dieticians, podiatrists, speech and language therapists, geriatricians, and mental health practitioners such as psychotherapists. These specialists require appropriately equipped places in which to work.

Importantly, they need to work together in teams, where the team is defined by the particular set of needs of the individual person being helped, not by managers or administrators allocating staff to boxes on organization charts. Teamwork also implies getting away from the style of working commonly experienced in NHS hospitals where, although staff talk about teams and often have regular team discussions about patients, they tend to work in ‘silos’, especially when coping with busy work schedules:

The physio does their job, the speech therapist does theirs, the occupational therapist does theirs, the nurse encourages and supports … but rarely do they work with the same patient simultaneously. [Former NHS Trust Medical Director, now retired]

A multi-disciplinary team approach in the setting of a recovery centre also avoids wasted time between therapy visits, time in which the patient, if he or she is not able to self-motivate, will inevitably regress.Importantly, such an approach will get practitioners away from thinking that their role is to ‘deliver packages of care’. That way of thinking is not only episodic: it casts people who are in the process of recovering as mere recipients of a service rather than as active participants in a process, which needs to be the case if recovery is to succeed.

Principle 3: Medical and nursing professionals can and should be part of the recovery team, but it should be run as a co-operative , not a hierarchy.
Doctors are trained from medical school onwards to think of themselves as leaders in any healthcare context: ‘clinical leadership’ is a term we frequently encounter. (Interestingly, few if any medical school syllabuses incorporate any specific training in clinical leadership, let alone in being led.) Among nurses, we see this trait in ‘territorial domination’ behaviour, where the territory – the domain – is the hospital ward. Unless it is made clear that the role of doctors and nurses is to work with their partners in the recovery team, dominating behaviours of these kinds will often hinder team working.

The assiduous application of the ‘medically fit for discharge’ test in hospitals further underlines the message that doctors and nurses should not automatically be in charge of a recovery centre. The pressures on hospital doctors distract them from patients once they are on the road to recovery: not only is there nothing more that they, the doctors, can do for them at that point but patients needing immediate treatment necessarily have a greater claim to priority. And as mentioned earlier, while nurses are in the business of providing care, they may – as some nurses have been found to do[11] – take it for granted that patients will be going to a care home when they leave. A multi-disciplinary recovery centre of the kind suggested here should be run not as a hierarchy but as a co-operative, with respect accorded to the representatives of every discipline.

A centre that is not monopolized by a single profession could and should be flexible, so clients can move gradually from bed-based to on-your-feet provision; from residential provision for someone nervous about spending their first night or two out of hospital alone, to sleeping in their own bed; and from close medical supervision to none at all. The Covid-19 rulebook draws a hard-and-fast distinction between bed-based and home-based care, but recovery requires something altogether more flexible.

Principle 4: The recovery model needs its own language: it should avoid the language of the medical and nursing professions.
In many ways the language of doctors and nurses today reflects a Victorian way of thinking: it is language that Florence Nightingale would have recognised. Essentially, it assigns a dispensing rather than enabling role to staff and a submissive, receptive role to users of the service. Hospitals are institutions that are defined by the number of beds in them. A care home my be designated as offering a certain number of ‘reablement beds’. The beds contain patients and are grouped into wards. Doctors are in charge, and they decide what’s good for you. The wards are staffed by nurses whose role is to provide care for patients.

In the 21st century, we need recovery centres with places for clients. Work should be done in rooms – including seminar rooms, a gym and a kitchen – in a centre staffed by recovery specialists, therapists and trainers whose role it is to re-enable and re-skill clients and help them get physically and emotionally fit and confident so they can resume life at home and in their local community. The ethos of such a centre would be one of movement and dynamics, of development rather than of being – literally – patient. Getting the language right would be an important step towards instilling that ethos.

Principle 5: Recovery should be thought of as the concluding stage of a patient’s journey through the health care system, not as an afterthought to treatment. It should be joined up to the stages that precede it.
As noted earlier, all the criteria set out in the Covid-19 rulebook for judging whether a patient is medically fit for discharge involve taking a ‘snapshot’ view of their physiological condition: none of the criteria are dynamic, to do with how well the patient is progressing or drawing on the consultant’s experience of how they might progress.

Although some hospital doctors, for example those who work with stroke patients, fully appreciate the importance of treating the patient’s journey to recovery as a whole, the ‘medically fit for discharge’/’Discharge to Assess’ scheme is inherently, albeit possibly unconsciously, based on the assumption that the patient’s journey need not be viewed in this way, that there is an identifiable point in a patient’s recovery after treatment when care can, without doing harm, be abruptly switched away from the hospital doctor or surgeon to a completely different system. But we know that in England as many as one patient in seven is discharged from hospital only to be readmitted as an emergency within 30 days. So it is simply not safe to assume that all patients can be discharged without harm.

To be clear: the implicit assumption in the Covid-19 rulebook that no harm will be done by cutting care off and abruptly transferring the patient elsewhere is not well-founded. There needs to be a transitional stage in a patient’s recovery, to take place in a setting where (a) they can continue to be visited by the hospital clinician who has been treating them, and (b) they can – with assistance – take their own steps towards resuming an active life. A recovery centre could provide such a setting, and an Edward Hain Memorial Recovery Centre in St Ives could serve as a prototype.

Importantly, the availability of such a setting would make implementation of Discharge to Assess much more straightforward to deliver while reducing the number of emergency readmissions to acute hospitals, and thereby also reducing the pressure on emergency departments and beds.

Principle 6: A recovery centre would be the appropriate setting for carrying out assessments of patients discharged from an acute hospital and should be made use of for this purpose.
The Healthwatch England investigation into hospital discharge during the Covid-19 pandemic found that a remarkable 82% of discharged patients ‘did not receive a follow-up visit or assessment’. It appears that acute hospitals are – understandably – giving priority to the actual treatment of patients, with little thought about what happens to them afterwards. This finding echoes that of another investigation made in 2019 of delayed discharges in 14 systems covering more than 10,000 discharges. This found that up to 54% of those who were delayed were discharged to a setting where the levels of care were not well-matched to their needs. Of these, in 92% of cases the setting was providing a more intense level of care than would have maximized the individual’s independence.[12]

Ideally a patient’s destination on discharge would be borne in mind from the day that they entered hospital but, as the Covid-19 rulebook demonstrates, mainstream thinking in the NHS is that hospital doctors should not concern themselves with what happens to a patient once discharged from their immediate care.

The consequences of the lack of care given to patients on discharge have been uncovered by earlier investigations:

Discharge planning to maximise independence would save money and improve outcomes. For nearly a quarter of people (24%) who were discharged from hospital with a care package, a preferable pathway was identifiable that could have delivered better outcomes at lower cost. [A] significant subset of these pathways results in costly long-term residential placements … [Practitioners] estimated that 59% of long-term residential placements resulting from an acute hospital admission could be delayed or avoided.[13]

There is clearly a need for assessment to be put on a systematic and rigorous basis. A purpose-designed recovery centre would be the obvious and natural place for it. Patients who have been discharged home would be referred to it for assessment, while those who feel unable to leave hospital safely could be transferred to it for a short stay. The arrangements for assessment specified under Discharge to Assess would work as they were intended to, and smoothly.

Importantly, by taking advantage of such a setting the number of emergency readmissions to acute hospitals would be reduced, as would the pressure on emergency departments and acute beds. It would also reduce the need for expedients such as placing patients in care homes intended primarily for long-term residents and, in seaside areas like Cornwall, in a hotel room. These environments are neither designed for nor suited to a recovery programme.

A recovery centre would be the setting for the penultimate stage in a patient’s journey back from hospital to their home and normality. Its staff would constitute a group to whom hospital doctors and surgeons could refer patients on discharge and would provide a service that general practitioners in the local area could take advantage of (a ‘step-up’ function). There would be the possibility, to put it no higher, of developing team-like relationships between members of the medical and nursing professions and the recovery specialists.

Principle 7: Recovery is likely to be more effective and beneficial when carried out in a social context rather than on individual visits to people in their own homes.
The value of this principle has been impressively demonstrated by an initiative in West Cornwall, where community nurses employed by the Cornwall Partnership Foundation Trust set up the Centipede Club, a community hub for older people with leg ulcers.[14] After an initial assessment, patients referred to the leg ulcer service are invited to attend weekly group meetings in a relaxed café-style setting in a community location. No appointments are required.

Patients are treated while they sit together, with a separate room for those wishing to be seen privately. People continue to be seen even when their legs are healed. Tissue viability specialist nurses attend the group, updating the knowledge and skills of all the staff involved and the therapy services on offer. Patients have testified to the relaxed and friendly nature of the group meetings, compared with more formal clinical encounters. Staff say they love working at the group and are more confident in the work they do.

The Club clearly makes a highly effective use of staff time, not least by eliminating the time taken for nurses to drive between appointments at the homes of individual patients. It operates as an unofficial professional development organization too. Importantly, it demonstrates that recovery can usefully be envisaged as a social process, not just an individual one.

At the present time there is a great deal of emphasis within the NHS on getting people back to their own homes. In West Cornwall, Penzance STEPS (Short Term Enablement and Planning Service), part of Cormac Solutions Ltd, provides personal care to people in their own homes. The aim of the service is to re-enable people to maximise and regain their independence, within their own home, after a period of illness and/or hospital stay. It helps people for up to six weeks with daily activities such as washing, dressing, showering, getting up and going to bed; toileting; preparing meals; doing exercises and mobility practice; and identifying local community services to support them in the long term.[15] [16] It implies no criticism of the service to point out that there is no collective, social, out-of-the-house component to it, such as there is with the Centipede Club. Mutual support, shared enthusiasm and learning from one another are not available in one’s own home.

Principle 8: A recovery centre should have its own premises and include some beds for overnight stays: it should work with hospitals, and could play an extremely valuable part in operating the Discharge to Assess scheme, but it should not be a hospital or care home.

A recovery centre that has its own premises in a settled location can provide a much wider range of services than a ‘flying visits’ service. Ideally it will have a dedicated gymnasium with installed equipment for developing strength and fitness, and a kitchen in which to demonstrate and teach cookery skills and dietary knowledge. It should have rooms for discussion and teaching, a room suitable for clubs like the Centipede Club, and one or more rooms with basic equipment and store cupboards that regular clinics can use. It would be advantageous for it to have a small number of ‘sleepover’ rooms for people who are literally half-way home: who have just been discharged from hospital and are understandably nervous about spending the night on their own

The recovery centre would of course provide a base for the specialists who practise there. So it should have office accommodation, together with a staff room and seminar rooms, as well as consultation rooms. Doctors and nurses have institutional and physical bases in hospitals, clinics and GP surgeries. Specialists in recovery need exactly the same if they are to be effective. And if the recovery service extended to supporting people in their own homes, staff who travel around the area would have a base to work out of and return to.

The Edward Hain Recovery Centre: A prototype in West Cornwall
For a recovery centre to serve its purpose, it would be vital that it complement and work closely with the hospitals in its vicinity, and not compete with them. How would this work? We can consider two distinct cases: the centre vis-à-vis West Cornwall Hospital (sub-acute) in Penzance, and second, the centre vis-à-vis the Royal Cornwall Hospital (acute) at Treliske.

Consider the case of West Cornwall Hospital. Presumably because today the priority of NHS Kernow and the Royal Cornwall Hospitals NHS Trust is to develop West Cornwall Hospital as a centre of healthcare excellence, recovery in that hospital seems to be inevitably taking second place to surgical and medical treatment. There is no re-enablement gym, the physiotherapy and occupational therapy services are ward-based, and therapy staff are so stretched at the moment that there is no cover at weekends: evidently recovery services are accorded low priority when it comes to funding. A patient may see a physiotherapist just once or twice a week for only 15 to 20 minutes, and be expected to do their exercises in bed on their own. Nurses may be expected to ‘walk’ them, but in practice not have time to do so.

However, a specialist recovery centre in nearby St Ives, especially if it were equipped with a small number of beds for clients staying overnight, could work closely with West Cornwall Hospital and could provide the recovery services that the latter cannot or will not provide. For example, when patients are being discharged from the acute hospital at Treliske, those in need of continuing medical or nursing care could go to West Cornwall Hospital, while those ready to start on a recovery programme could go to the Edward Hain Memorial Recovery Centre. So there is a complementary role for a recovery centre in St Ives.

As an acute hospital, the Royal Cornwall Hospital at Treliske is under pressure to operate the Discharge to Assess scheme. The Governing Body of NHS Kernow was told at its meeting on December 1st, 2020:

[We] have received confirmation that a purpose built new care home will be open to receive its first residents in Penzance in January 2021. This is the first time a new care home has been built in Cornwall for over a decade. This will provide 28 beds and these have been commissioned as discharge to assess beds which by their nature have a focus on reablement. The intended length of stay for individuals will be up to 6 weeks … Some beds will be for people with dementia and complex care needs. This will increase bedded reablement capacity in the west of Cornwall …[17]

A subsequent Freedom of Information request elicited the information in mid-January 2021 that the ‘new care home’ would not be ‘purpose built’ but a conversion of a former nursery school, that planning permission had not yet been granted, and that the beds would not be available until March 2021 at the earliest. There appears to be nothing to prevent a CCG’s officers from relaying hopelessly optimistic ‘assurances’ to its Governing Body.

More importantly, it is difficult to comprehend the thinking here. If ‘Discharge to Assess’ is to be taken at face value, assessing should take a matter of days, certainly much less than six weeks. The notion that ‘discharge to assess beds … by their nature have a focus on reablement’ is very much open to question. No explanation is provided of how the care home is to provide simultaneously for two very different classes of resident: those in transit undergoing ‘reablement’ and residents in for the long term ‘with dementia and complex care needs’.

The point needs to be made forcefully that a care home of the kind widely found in the UK is very different from a centre for recovery. As the above quotation itself demonstrates, it is defined in terms of beds; some of those beds will be used for people who are not capable of being re-enabled; and as for six-week stays, once you have been in a care home for that length of time, that is where you are likely to end your days, as various case studies illustrate.[18] Far from being a place of recovery, a care home will disable those who find themselves there.

The closing of Edward Hain Community Hospital offers an opportunity to rethink in its entirety the journey of a sick or injured patient through the healthcare system. The resources freed should be used to create a recovery centre that completes the path from hospital bed to bed at home. The Discharge to Assess scheme as it stands seems destined to end in the abandonment of discharged patients on a large scale, a mushrooming of care homes, and a mish-mash of care packages delivered in flying visits to people’s homes. A recovery centre would provide the final link in a patient’s journey that has hitherto been missing.

Doctors and nurses have institutional and physical bases in hospitals, clinics and GP surgeries. Specialists in recovery need exactly the same if they are to be effective. The NHS and Cornwall Council should do some joined-up thinking and provide buildings and organizational structures for them. It would be good to see the Edward Hain Recovery Centre lead the way in this.

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Acknowledgments: I am very grateful to colleagues, friends and family for their comments on earlier drafts of this paper, and I salute the workers on the NHS frontline, with deepest respect. They deserve to be working in a system which treats them with appreciation and understanding.

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Notes and references (All websites last accessed 18 January 2021)

[1] ‘Lost Heir to the Hain Dynasty in Hospital’s Naming’,
http://s513102927.websitehome.co.uk/files/News/CommunicationsNews/Lost_Heir_to_the_Hain_Dynasty_in_Hospitals_Naming-1.pdf

[2] ‘Hospital discharge service: policy and operating model’, 21 August 2020

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/912199/Hospital_Discharge_Policy_1.pdf

[3] Peter Levin, ‘Six bungles and no funeral: the short life, unmourned death and high cost of Cornwall’s Sustainability and Transformation Plan for the NHS’, 9 April 2018
https://spr4cornwall.net/six-bungles-and-no-funeral-the-short-life-unmourned-death-and-high-cost-of-cornwalls-sustainability-and-transformation-plan-for-the-nhs-full-report/

[4] Peter Levin, ‘Delayed Transfers of Care: problems of definition, measurement and governance’, 3 August 2020

https://spr4cornwall.net/delayed-transfers-of-care-problems-of-definition-measurement-and-governance/

[5] As [4]

[6] As [2]

[7] Jessica Morris (Nuffield Trust), ‘Emergency readmissions: Trends in emergency readmissions to hospital in England’, 1 June 2018 
https://www.nuffieldtrust.org.uk/news-item/emergency-readmissions-trends-in-emergency-readmissions-to-hospital-in-england-1#references

[8] Healthwatch England, ‘590 people’s stories of leaving hospital during COVID-19’, October 2020

https://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20201026%20Peoples%20experiences%20of%20leaving%20hospital%20during%20COVID-19_0.pdf

[9] As [8]

[10] British Society of Rehabilitation Medicine (BSRM), ‘Rehabilitation in the wake of Covid-19 – -A phoenix from the ashes’,
https://www.bsrm.org.uk/downloads/covid-19bsrmissue2-11-5-2020-forweb11-5-20.pdf

[11] Local Government Association, ‘Efficiency opportunities through health and social care integration’, June 2016

https://local.gov.uk/sites/default/files/documents/lga-efficiency-opportunit-b9c.pdf

[12] Better Care Support Programme, ‘People first, manage what matters’, 2019 
https://reducingdtoc.com/People-first-manage-what-matters.pdf

[13] Local Government Association & Association of Directors of Adult Social Care, ‘Community health and care discharge and crisis care model’, July 2020
https://www.local.gov.uk/sites/default/files/documents/LGA-ADASS%20Statement%20on%20Community%20Care%20and%20Health%20Discharge%20new.pdf

[14] NHS England, ‘The Centipede Club, a community hub for older people with leg ulcers’, 20 November 2018

https://www.england.nhs.uk/atlas_case_study/the-centipede-club-a-community-hub-for-older-people-with-leg-ulcers/

[15] Care & Support in Cornwall, ‘Penzance STEPS’,
https://www.supportincornwall.org.uk/kb5/cornwall/directory/service.page?id=JNjTvOsV2-g

[16] Care Quality Commission, ‘Penzance STEPS’, Inspection report, 7 January 2019

https://api.cqc.org.uk/public/v1/reports/efca134a-61b3-4102-b1bd-9362d71d17e8?20190206130000

[17] Kernow CCG, Community Hospital Engagement Report, for meeting on 1 December 2020

https://doclibrary-kccg.cornwall.nhs.uk/DocumentsLibrary/KernowCCG/OurOrganisation/GoverningBodyMeetings/2021/202012/GB2021071CommunityHospitalEngagementReport.pdf

[18] Peter Levin, ‘How to look after yourself in hospital’, 23 September 2020
https://spr4cornwall.net/wp-content/uploads/HOW-TO-LOOK-AFTER-YOURSELF-IN-HOSPITAL.pdf

Social Policy Research for Cornwall

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

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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!

 

Social Policy Research for Cornwall

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(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
https://spr4cornwall.net/wp-content/uploads/Embrace-Care-political-purposes.pd

 

This report can be downloaded as a pdf file here.

In the midst of the stress and turmoil caused by the Covid-19 pandemic, work on integrating Cornwall’s health and social care system goes on. Little has been heard of the Embrace Care project since before Christmas, so it’s time to take a closer look at it.

The context to the project was set by NHS England, which wants to see better use made of hospital beds. It also expects all hospitals with a major emergency department to provide an acute frailty service and carry out a clinical frailty assessment of a patient within 30 minutes of their arrival. [1]

The Embrace Care project in Cornwall was set up in May 2019 ‘to focus on improving the outcomes for older people’. It was run by a team from consultants Newton Europe, who reviewed the cases of 54 patients over 65 years old, in a workshop with participants drawn from a range of hospital and care roles.[2]

For each patient, participants were asked: ‘Should this person have been admitted?’ They concluded that more than half of the most frail patients were admitted inappropriately, whereas not a single one of the least frail was.

Of course, the most frail are most likely to have complex needs, such as multiple long-term conditions and mental health vulnerability, so it’s bound to be more difficult and time-consuming to reach a confident diagnosis for them, especially for junior doctors working on their own. Keeping patients in for observation will always be the safest thing to do.

The Royal Cornwall Hospitals Trust says on its website that it provides a frailty assessment service in the Emergency Department and Medical Admissions Unit,[3] but how well does this work? In 2019 its main acute hospital at Treliske was inspected by the Care Quality Commission. The CQC’s report said:

People could not always access [it] when they needed it and did not always receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.[4]

So here was a situation which Newton Europe’s bright sparks could have investigated, aiming to improve access and waiting times for frail patients, as has been achieved elsewhere. But they didn’t.

Last November, a short report, Embrace – An Introduction to the Design Phase, appeared.[5] This proposed ‘a new way of working’, with Community Teams.

The Community Team would provide support for an older person so they wouldn’t have to go into hospital following a fall or other mishap. It would identify their needs, such as adaptations to their home and therapy to improve mobility. It would help inpatients to return home, and ensure that appropriate care was organized. And it would establish contact with their GP and their carers, and with local organizations that might be able to help re-establish them in their community. There would also be a local bed-based rehabilitation centre, to which the Team could refer patients.

While we might applaud these proposals, there is nothing at all in them to help someone who’s just had a fall and needs a smooth pathway to a hospital bed.

So where did the community team ideas come from? None of the Newton Europe work generated a question to which community teams are the obvious answer. 

They are, however, an obvious answer to a political question. The proposal for community teams looks like a bid from Cornwall Council, which would run them, to take control of the health and social care system. It doesn’t follow from the Embrace Care project.

The Newton Europe team appears to be being used, under the pretext of solving a technical problem, to achieve a political objective. 

– – –

This report was published as an article under the title ‘Project has been used to fulfil political objectives’ in The Cornishman, 18 June 2020.

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Notes and references (Checked 16/07/2020)

[1] NHS England, The NHS Long Term Plan, January 2019
https://longtermplan.nhs.uk

[2] NHS Kernow et al, Embrace Care, A Summary of the Diagnostic Findings, July 2019
https://spr4cornwall.net/wp-content/uploads/Embrace-Care-Diagnostic-Review-abridged.pdf

[3] Royal Cornwall Hospitals Trust, Older People’s Services
https://www.royalcornwall.nhs.uk/services/older-peoples-services/

[4] Care Quality Commission, Royal Cornwall Hospitals NHS Trust, Inspection Report, 26 February 2020
https://www.cqc.org.uk/sites/default/files/new_reports/AAAJ7508.pdf

[5] Embrace – An Introduction to the Design Phase was a paper prepared for a Transformation Board meeting scheduled for November 2019. This meeting was cancelled owing to the calling of a General Election for the following month, and the paper is no longer available on any website.

EIGHT CHALLENGES THAT THE NHS LEADERSHIP MUST RISE TO

This post can be downloaded as a pdf here.

Before health and social care services can be successfully integrated the NHS needs to get its own house in order. This report, produced for West Cornwall HealthWatch, sets out eight challenges revealed by the Embrace Care project in Cornwall and suggests how the NHS leadership must rise to them to provide better value for the money that we spend on the NHS: a better service for patients and a better working environment for staff.

Contents 

Background: The Embrace Care project

Challenge No 1:
To find out how the hospital system works 

Challenge No 2:
To explain why there are inappropriate admissions to hospital 

Challenge No 3:
To uncover the causes of delayed transfers of care 

Challenge No 4:
To explain variations in the effectiveness of community hospitals 

Challenge No 5:
To discover why elderly people decline quickly in hospitals

Challenge No 6:
To re-imagine the role of community hospitals 

Challenge No 7:
To make best use of therapists’ time

Challenge No 8:
To establish and encourage teamwork in hospitals and community services

Final thoughts

Notes and references 

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Background: The Embrace Care project

This report draws mainly on findings from the Embrace Care project, which was set up in May 2019 ‘to focus on improving the health outcomes for older people’ across Cornwall and the Isles of Scilly. The following month, ‘the diagnostic part of the project started to build an evidence base around what opportunities there are to achieve this’.[1]

This work was entrusted to Newton Europe Ltd, a firm of consultants.[2] In early August 2019 they presented their findings in the form of a ‘diagnostic review’ to two audiences of Kernow Clinical Commissioning Group (KCCG) and Cornwall Council (CC) staff and health and social care professionals. A printout of their slideshow has been more widely circulated, under the title Detailed Findings from the Embrace Care Diagnostic Review.

At the time of writing, the Detailed Findings document has not been published. In our judgement, as a document funded by public money, it ought to be, and so it is being made available here.[3] We are referring to it as ‘the Diagnostic Review’. A summary of it was presented to the Shaping our Future Transformation Board in August 2019, this is available on the web.[4]

West Cornwall HealthWatch[5] sent committee members’ comments on the Diagnostic Review to KCCG, and met with KCCG and Newton Europe (NE) staff and others on January 27th, 2020 to discuss it.[6] This report draws mainly on information contained in the Diagnostic Review. We feel that the NE team could have done more to draw attention to the challenges that they identified and to steps that could be taken to meet those challenges, so we are offering suggestions of our own in this report.

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Challenge No 1: To find out how the hospital system works
Those in charge of the Embrace Care project tell us that their proposals are ‘evidence-based’ and ‘data-driven’. But evidence and data on their own rarely tell us much about how things actually work. They tend to portray only what can be seen on the surface of a system and are straightforward to measure. And as students of government know very well, quantitative data – especially in the hands of economists – can all too easily trump qualitative.

To improve a system we need first of all to understand how it’s working at the moment. And that means digging below the surface to identify the processes, the mechanisms, at work.

Here’s an example. The Diagnostic Review tells us, on the basis of workshops with 131 practitioners, that 7% of cases where someone was not getting an ideal outcome[7] from the hospital system ‘were due to the patient, family or carer’s choice to take an alternative pathway’.[8] And we read: ‘family choice [was] a significant driver for non-ideal outcomes at every stage …’[9] The implication is that family members were acting in their own interests and against the best interest of the patient, an argument which would justify overriding family choice.

But if we look at a close-up study of delayed transfers of care carried out by Healthwatch Cornwall during July 2019[10], and ask what was actually going on, we learn that families may be well aware – correctly – that community hospitals are under a great deal of pressure and that unless they hold out for a place near home patients may be placed far away. Families may also have noticed that the condition of their elderly relative is getting worse, probably mentally as well as physically, and worry that they won’t be able to cope if the decline continues.

Here the process at work – i.e. the reasoning of family members – appears perfectly rational and understandable. It follows that proposals for a change in policy should address the concerns that families have rather than seek to override them.

Uncovering processes within complex organizations requires expertise in a number of social science disciplines, notably operational research, social psychology and organizational analysis.[11] Since management is taught in the UK largely as a craft rather than the application of careful observation, cross-checking and other elements of scientific method, people who attain management positions in health and social care are unlikely to possess relevant analytical skills unless they have acquired them intuitively or have worked alongside someone who already possesses them. In recent years we have seen the Department of Health implicitly recognising this by urging clinical commissioning groups to employ management consultants to draw up Sustainability and Transformation Plans. The fact that many of these plans have since been abandoned testifies to the inadequacy of this arrangement.

SUGGESTION
As a collective, the health and social care leadership in Cornwall, as personified in the membership of the Shaping our Future Transformation Board, does not possess analytical skills or a questioning, analytical mindset. It would be sensible for the leadership to inaugurate and develop an in-house multi-disciplinary team that does possess these attributes, charged with inquiring into how systems work within health and social care, and with using their findings to formulate and evaluate policies and plans.

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Challenge No 2: To explain why there are inappropriate admissions to hospital
The Diagnostic Review tells us that a case review workshop of 54 people from across Cornwall admitted to hospital found that in 22 cases (41%) the reviewers answered ‘no’ to the question ‘Should the patient have been admitted’?’ In effect, they were said to have been admitted inappropriately.[12] In six cases, the reason attributed was ‘Risk aversion’; in four cases ‘Lack of time to make correct decision’; and in three cases ‘Lack of a multi-disciplinary team approach’.

Unfortunately we are not told what the risks were to which decision-makers were averse, but if the risk was that the patient would come to harm if not admitted it can be questioned whether the decision to admit was indeed inappropriate. ‘Lack of time to make correct decision’, presumably denoting pressure of time – pressure to make a snap decision, perhaps – does not tell us what could have been done differently if more time had been available. Like ‘Lack of a multi-disciplinary team approach’, this looks like a judgement made with the benefit of hindsight.

It was also found that level of frailty was a significant factor.[13] At the highest levels of frailty, more than half of people admitted were judged to have been admitted inappropriately, whereas at the lowest levels none were.

Some comments from workshop attendees[14] shed light on these findings:

Inexperienced clinicians at the front door at out-of-hours times, of course decision making is going to be affected! – Geriatric consultant

It’s much harder to discharge someone from the Emergency Department into community services later in the day … admitting them is the easiest option. – Discharge coordinator

SUGGESTIONS
(1) There is a case for entrusting out-of-hours admissions to an experienced clinician. At the very least, specific training in making decisions on admission should be given to those new to the task.
(2) There is clearly an issue around people with a level of frailty. Consideration should be given to designing a separate pathway for them. Such a pathway could perhaps involve a one-night stay, allowing observation free of time pressure, followed by moving out to a community hospital.
Value for money These measures would allow the Emergency Department to work in a calmer, more orderly way and should be achievable with little extra expense.

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Challenge No 3: To uncover the causes of delayed transfers of care
The Diagnostic Review found that of the acute hospital beds available at Treliske (as the main RCHT hospital is locally known) and Derriford (Plymouth, used by many residents of East Cornwall), some 22% were occupied by patients who were recorded as having no medical need to remain: Medically Fit for Discharge 15%, Delayed Transfer of Care 5% or Could be treated elsewhere 2%. Of the available beds in community hospitals in Cornwall, an extraordinary 67% were occupied by patients in these categories.[15]

In the period January-March 2019 bed occupancy at Treliske at midnight averaged 91%, significantly above the England standard of 85%.[16] In January 2020 RCHT was under considerable pressure. It was reduced to making provisional bookings in local hotels ‘to facilitate social discharges or [the discharge of patients with] low social needs’.[17]

While ‘extra escalation beds’ were made available at three community hospitals, the fact that around 67% of community hospital beds were occupied by patients who had no medical need to be there – this equates to between 160 and 180 beds – leads us to ask: Is the Cornwall Partnership Foundation Trust (CPFT), which runs those hospitals, playing its proper role as part of the hospital system? There is no indication that CPFT was following the example of RCHT in energetically seeking and taking innovative measures.

The latest integrated performance report from RCHT tells us: ‘The top reason for delayed transfers of care remains waits for further non-acute NHS care … . These will be patients waiting for onward care, largely those awaiting a community hospitals bed.’ (my italics)[18]

The Diagnostic Review does not say anything about how beds are currently utilized in the community hospitals, but for May 2015 there are figures showing that the community hospitals in Cornwall then in use were running at an average overnight bed occupancy rate of 90% or more, with several registering more than 95% and in one case a staggering 99.4%.[19] Three of those hospitals have since been closed. Statistics published by NHS England for the period July-September 2019 show that of 235 available beds in community hospitals in Cornwall, no fewer than 214 were occupied overnight on average, an occupancy rate of 91%,[20] well above the England standard of 85%. To put it another way, the ‘margin’ – the leeway for responding to emergencies or a build-up of demand in the system – is only 9% as opposed to the recommended standard of 15%.

So the scepticism of patients’ families that they can rely on their relative being moved out of Treliske to a community hospital near their home can certainly be understood.

SUGGESTIONS
(1) There needs to be an investigation, covering both admission and discharge procedures, into why there are currently a massive 67% of patients in community hospitals who on medical grounds do not need to be there.
(2) On the face of it, there is a case for amalgamating the two hospital trusts, RCHT and CPFT, to unify their management and thereby facilitate the freeing-up of Treliske to concentrate on acute and emergency treatment. The feasibility of doing this should be investigated urgently.
Value for money Amalgamating the two hospital trusts should save money by eliminating the duplication of organizational structures, and having a unified management should facilitate the transfer of patients from the acute hospital to community hospitals.

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Challenge No 4: To explain variations in the effectiveness of community hospitals
As part of the Diagnostic Review, daily ‘delay conference calls’ were examined for two community hospitals ‘using our improvement cycle analysis framework … Staff attitudes, and actions and accountability from those meetings dramatically differ… Effective meeting and review enables Community Hospital 1 to have a much higher visibility of delays during discussion, allowing for more effective planning and problem solving.’[21]

It was also observed that while reasons for delayed discharge of ‘fit-to-discharge’ patients were recorded for 62% of patients in Community Hospital 1, they were recorded for only 38% of those in Community Hospital 2.

The Diagnostic Review also contains a flow chart contrasting discharge procedures in the two community hospitals. In Community Hospital 1 they appeared to work smoothly while in Community Hospital 2 it was noted that there were ‘dysfunctional relationships between social services and nursing teams, [and] debates over to whom delays should be attributed’. In the latter case, the Progress Coordinator, when asked to explain the objective of the morning patient flow conference call, gave a one-word reply: ‘Blame’.[22]

We do not know for how long the disparity between the two community hospitals has existed, but it points to a failure of management at Trust level that it has not been addressed.

SUGGESTION
The existence of a number of community hospitals within a single Trust and with much the same brief offers an opportunity, as the Diagnostic Review demonstrates, for the Trust management to discover where there is best practice and for the weaker hospital managements to learn from this. Full advantage should be taken of this opportunity.
Value for money There can be no dispute that bringing the management of weaker hospitals up to the standard of the best would improve their performance at little if any extra cost.

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Challenge No 5: To discover why elderly people decline quickly in hospitals

An acute hospital shouldn’t be seen as a place of safety … protracted length of stay can do significant harm to a patient. – Consultant Geriatrician[23]

There is a considerable amount of anecdotal evidence of how elderly patients decline in acute hospitals. The report on a study carried out in July 2019 by Healthwatch Cornwall contains a distressing account of two visits to a patient at Treliske.[24] On the first visit the patient – let’s call her A – is engaging and engaged:

[A says] I have good and bad days. It feels like I’ve been in hospital a long time – too long. … I have no idea when I’m leaving. The doctors haven’t spoken to me about leaving here yet. I’m worried about money. It’s not always possible to get what you want. I’m from a large family and wish I could be with them now. But I’m quite happy here on the ward. The food is good and I’m well looked after.

[The visitor says] We visited A again seven days later. It was like visiting a different patient. Last week she was engaging and although [she] clearly had a level of cognitive impairment, she had a degree of understanding and seemed happy and talkative. Today she seemed unhappy and distressed and kept repeating that she wanted to go home.

– – –

Another example of decline, this time in a community setting, is provided by the Embrace Care project:[25]

Day 0: J, an elderly woman with a history of falls, has a fall at home. After a very short stay in the acute hospital, she is discharged to a community hospital.

Day 1: At this point J is able to use the commode, is washing herself (with some support to reach her feet),cleaning her teeth, brushing her hair, and is moving around. She says she wants to return home when she is discharged from hospital. A search begins for support at home to enable her to do this.

Day 60: After many attempts to source a support package in the community have failed, J is told she will have to be moved into an intermediate care setting while a long term support package is found. She spends the following two days in bed.

Day 62: J starts to require full support to wash herself.

Day 74: A support package has been found to allow J to return home. However, her needs have increased and her physiotherapist suggests that the support package is now not sufficient, and it is refused.

Day 78: A checklist is completed and J again expresses her desire to return home.

Day 89: J is moved into a temporary bed in a care home.

Day 185: Still in the temporary bed in the care home, J dies.

– – –

There are several lessons to be learned from these two stories.

First, in both there is a very evident decline in the patient’s mental health. Mental health gets only a single mention in the Healthwatch Cornwall study and no mention at all in in the Diagnostic Review. But it is clear that both A and J had been abruptly plucked from familiar surroundings and were now being deprived of stimulus, of control over their own daily pattern of life, and of any opportunity to discover from those in positions of power what the future might hold for them. These deprivations cannot possibly have helped them to maintain a good level of mental health. What we see in action here is inherently a process that, irrespective of their physical health, disables people by inducing in them a state of despair.

Second, physical decline can be very rapid, from the outset. As we see, J’s two days in bed severely reduced her ability to look after herself unaided.

Third, what we seem to be witnessing in J’s case is an instance of a patient being ‘parked’. She was held in a ‘temporary’ bed for more than three months, a period that ended only when she died. We have to ask: Did ‘out of sight’ mean ‘out of mind’? No doubt parking her in this way allowed staff to turn their attention to the pressing needs of other patients.

The mental and physical decline that patients suffer may go some way to explaining why some family members shy away from taking their elderly relatives home. Witnessing it must inevitably lead them to ask ‘Where is this heading?’ and whether they will be able to cope.

SUGGESTIONS
(1) There is a need for mental health nurses and therapists, as well as physiotherapists, to be involved in a patient’s care, and from the moment a patient enters a community hospital.
(2) It would be worth investigating how the discharge process works in practice. The existence of the discharge co-ordinator role shows that this process is taken seriously, but some simple questions should be asked about how the system works. Are discharge co-ordinators involved early enough in a patient’s stay? Exactly what do they co-ordinate? Who do they talk to? Is it perhaps the case that they talk to everyone except patients?
Value for money Supporting the mental health of patients will clearly enable them to leave hospital sooner, and will thus offset much if not all of the cost entailed. But, no less important, it is a humanitarian service, and should be part of what the NHS provides, just as physical health care is. A patient’s physical and mental health are as indivisible as body and mind: they cannot be successfully treated in isolation from one another.

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Challenge No 6: To re-imagine the role of community hospitals
It is very easy to fall into thinking of community hospitals as nothing more than places to which patients can be moved after they have been treated at the acute hospital. Conceiving of their provision in terms of ‘beds’ does nothing to dispel this way of thinking. It is all too easy to slip into regarding them as parking places for patients for whom no other place can be found. This essentially ‘static’ view inevitably leads to decline, not improvement, in a patient’s condition.

Alternative views are possible. We can take a ‘dynamic’ view, seeing patients as being on a pathway, or ‘trajectory’, with one or more intermediate stops between acute hospital and home. For example, we could re-imagine community hospitals as ‘half-way homes’. Instead of being consigned to a bed in a ward, where they are effectively trapped for much of the day as well as at night, people staying there overnight could, during the day, be actively being reskilled, re-enabled to function, physically and socially, in their homes and communities. Indeed, they could progress to spending some nights at home. They would be literally half-way to home. It follows that staff, and those who employ them, would have to think of their roles as much wider than the traditional one of seeing to patients’ bodily needs.

Half-way homes could also be made use of as ‘activity centres’ along the lines of the Edward Hain Centre, run by Age UK Cornwall during 2019 in the Edward Hain hospital building as a ‘hub’ attended during the day by local people for rehabilitation and therapy, and greatly appreciated by its users.

This service has got me out of the house and to meet folk, many in similar situations to me. – User of the Edward Hain Activity Centre[26]

Another alternative to the community hospital, suitable for patients who require daily treatment but are able to return home or to a safe place at night, is the ‘day hospital’. This is an outpatient facility that can provide not only professional health care services but social care as well, adding up to both physical and mental support.

It has become something of an article of faith on the part of the health and social care leadership in Cornwall that as many patients as possible should be cared for at home. There is danger in treating this as dogma: it can encourage hospitals to resist admitting a patient and to send patients home before they are ready. Moreover, patients confined to their home find themselves spending their days waiting for a carer to call, for what may turn out to be a disappointingly brief visit. They become isolated; they lose social confidence. Their mental health suffers. So this dogma needs to be challenged.

The manager of West Cornwall Hospital, part of the RCHT group, recently told West Cornwall HealthWatch of his observation that patients whose homes are in the local area are able to leave sooner than those who live some distance away. It could be that local patients are visited more regularly by relatives and friends, maintaining their sense of membership of the local community: maybe they simply don’t have a sense of having been torn away from familiar surroundings. Whatever the cause or causes, this is a significant observation by an authoritative source.

On January 23rd, 2020, it was announced that investment would be made available to Cornwall and the Isles of Scilly (one of seven areas across the country) to enable community teams to respond quickly to peoples’ needs and prevent unnecessary hospital admissions. ‘[It is intended that] the additional investment will see urgent requests responded to within two hours. In addition, support to help people regain their ability to perform their usual activities like cooking meals, washing and getting about will be provided within two days. The quicker response times should help people to remain well, in their own homes and independent 365 days a year.[27]

While the additional resources can only be welcomed, it is to be hoped that the effort going into making a success of this bright and shiny new initiative will not distract attention from the pressing problems existing now in community hospitals.

SUGGESTIONS
(1) The role of community hospitals needs to be completely rethought. Currently, they are being treated as mere providers of ‘beds’, as ‘parking places’ for people who aren’t fit to be discharged home or to a safe place. They should be reassessed for their suitability as ‘half-way homes’ or ‘day hospitals’, and fresh thought should be given to the role and skills of the staff needed and to the facilities provided.
(2) Given that local patients get home sooner, thought should urgently be given to the geographical distribution of facilities. It is striking that since the closure of Poltair (Penzance) and Edward Hain (St Ives) community hospitals, there is no community hospital west of Helston, more than an hour away by bus from both Penzance and St Ives. The far south-west of Cornwall, Penwith, has a strong claim to a half-way home, providing in-patient beds as well as re-ablement facilities for an increasingly elderly population: already one in four are over the age of 65.[27]
Value for money Again, the underlying argument here is for the provision of a humanitarian service, treating mental health as well as physical and what we might call social health. And again, there will be a payoff in terms of enabling patients to leave bed-based hospital provision and thereby release scarce resources sooner.

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Challenge No 7: To make best use of therapists’ time
The Diagnostic Review team asked whether services are being used effectively. It was found that only 29% of ‘therapist time [was] spent directly in contact with people, carers or families, for example on individual assessments or reviews’. 20% of therapist time was spent on travelling between visits and meetings.[28]

The Diagnostic Review team also reviewed 106 therapy visits with senior therapists (Bands 6 and 70 to understand how patient-facing time was being spent. They found that 23% of the visits were not using therapist time effectively. ‘Most of these unnecessary visits were covering for patients with mental health needs, not therapy needs. This takes up 370 visits each month.’ [29]

Further, the Diagnostic Review also reveals that ‘community therapy teams are struggling to meet patient needs due to job dissatisfaction and limited resources … leading to staff shortages and delays in patient care. One Band 6 occupational therapist has to spend 40% of her time conducting personal care visits, which are usually done by Band 3 support workers.’[30]

‘Older people in need of rehabilitation don’t only have to contend with [long] wait times for short-term therapy. The care that they receive once their treatment begins varies significantly between teams. In one area, patients receive one visit every 10 days and take twice as long to rehabilitate as those in another area, where patients are visited every five days.’[31] (The difference is typically nine weeks as opposed to four and a half.)

SUGGESTIONS
(1) Wide local differences in team behaviour and job satisfaction clearly point to a problem for and within management. Those in charge at the Cornwall Partnership Foundation Trust, which provides these services, and in individual hospitals, should be held accountable by the Kernow Clinical Commissioning Group.
(2) As already noted, it has become something of an article of faith on the part of the health and social care leadership in Cornwall that as many patients as possible should be cared for at home. It does seem that the impact of this on the time that therapists spend travelling has not been fully thought through, as it needs to be. Given Cornwall’s notoriously poor road network, which becomes heavily congested from May to September, and the proportion of unproductive visits found by the Diagnostic Review team, it is nonsensical, wasteful and frustrating for therapists to have to spend so much time driving themselves around. An alternative way of delivering their services needs to be found.
Setting up local hubs for rehabilitation, for therapy work, along the lines of the temporary activity centre run by Age UK Cornwall during 2019 in the Edward Hain hospital building, or the half-way homes or day hospitals suggested above as replacements for community hospitals, should be seriously considered.
Value for money Levels of job satisfaction for therapists in some parts of Cornwall are outstandingly poor. Reorganizing their work to address this can only increase the benefit that the therapy services provide and make it easier to recruit more and more-motivated staff.

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Challenge No 8: To establish and encourage teamwork in hospitals and community services
There are some references in the Diagnostic Review to failures of teamwork, notably to ‘dysfunctional relationships between social services and nursing teams, [and] debates over to whom delays should be attributed’ and to ‘community therapy teams … struggling to meet patient needs due to job dissatisfaction and limited resources … leading to staff shortages and delays in patient care’.[22,29] At Treliske, a lack of teamwork has been identified as a contributory cause of the death in 2017 of a six-year-old child with autism.[32]

Fostering of teamwork expertise in the NHS is long overdue. Tellingly, while the NHS has a Leadership Academy this organization has paid little attention to teamwork, and where it has done so its approach has been to view teams as if they were competing on a sports field, with an inherently competitive ethos of ‘us against them’ and defining boundaries rather than being open and permeable to questions and ideas from any source. Real life issues like those that have arisen in Cornwall – in getting social services and nursing teams to work together, for example, and establishing constructive working relationships between young doctors and experienced nurses – are not being addressed.

SUGGESTIONS
The Embrace Care Project has identified a damaging absence of teamwork within health providers on the ground in Cornwall. At the same time, the leaders of the health and social care system in Cornwall and the Isles of Scilly have committed themselves to ‘culture change’, albeit without specifying what form this should take.[33] Given that our health and social care system requires members of different professions and with different levels of experience to work together, and will increasingly do so, the leadership should commit to developing a culture that prioritizes teamwork behaviours, skills and ways of thinking in their staff across the system.
Value for money Embedding an ethos of teamwork within the health and social care system in Cornwall will provide the staff with a structure of supportive relationships within which to work, confidence to ask if they don’t know the answer to a question, and job satisfaction. We are not talking massive expenditure here, simply growing a culture that works purposefully and with good humour towards attaining brilliant results.

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Final thoughts
The eight challenges revealed by the Embrace Care project vary widely. The suggestions put forward here are similarly varied. To go down the paths suggested will call for an open mindedness and flexibility of thinking that health and social care leaders have yet to show. Some observers will find it laughable that NHS leaders can call for integration of health with social care and at the same time overlook the lack of integration within the NHS itself.

If the suggestions put forward in this report are implemented, will we be getting better value for money from Cornwall’s NHS hospitals? They add up not only to a claim for more resources, but also to be allowed to make better use of those that are available. If the NHS in Cornwall can show that it makes good use of the resources that it already has, that it understands the needs of its population and can respond sensitively to them, that it appreciates those who work for it and will support and encourage them to develop their skills and work as teams, it will be able to make a strong case for more resources when they become available.

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Notes and references (Web sources last checked 9 February 2020)

1. Embrace Care: A Summary of the Diagnostic Findings, July 2019, p.4 http://bit.ly/EmbCare02
The Shaping our Future Transformation Board is made up of all the leaders of the major health and care organisations in Cornwall, including Healthwatch Cornwall.

2. https://www.newtoneurope.com

3. Detailed Findings from the Embrace Care Diagnostic Review, July 2019 http://bit.ly/EmbCare01
To respect the privacy of individuals who were the subject of short case studies, pages 8 and 9 have been removed from the original.

4. As Note 1.

5. West Cornwall HealthWatch is a voluntary, independent campaigning health watchdog that has been serving West Cornwall since 1997. It monitors developments and campaigns to safeguard and improve services provided in West Cornwall by the National Health Service. See http://westcornwallhealthwatch.com/

6. The meeting was originally arranged for November 2019. It was delayed by two months on account of the state of ‘purdah’ leading up to the December 2019 general election.

7. ‘Ideal outcome’ is used in the Diagnostic Review to denote the ideal path to be followed by the patient, not successful treatment of the patient’s condition.

8. As Note 3, p.11.

9. As Note 3, p.42

10. Healthwatch Cornwall is one of 152 local Healthwatch bodies set up under the Health and Social Care Act 2012. They work with the national body, Healthwatch England. ‘Our sole purpose is to understand the needs, experiences and concerns of people who use health and social care services and to speak out on their behalf.’ See https://www.healthwatch.co.uk/our-history-and-functions

11. The seminal study here is that of Tom Burns and G.M. Stalker, described in their book The Management of Innovation (Tavistock 1961).

12. As Note 3, p.23. ‘There were 36 workshop attendees from acute Emergency Departments, inpatient wards and health onward care team, adult social care, therapy, home-based reablement and GPs.’

13. As Note 3, p.25

14. As Note 3, p.25

15. As Note 3, pp.34-36

16. As Note 3, p.16

17. Richard Whitehouse, Royal Cornwall Hospital put patients in hotels during ‘black alert’ crisis,  16 January 2020
https://www.cornwalllive.com/news/cornwall-news/royal-cornwall-hospital-put-patients-3746083

18. Royal Cornwall Hospitals Trust, Summary Integrated Performance Report, December 2019, p.41  http://bit.ly/RCHTBoard01

19. Peter Levin, Community hospitals under threat: Are decisions being taken on scrappy information and limited understanding? http://bit.ly/spr4c01

20. NHS England, Bed Availability and Occupancy Data – Overnight, 2019-20 http://bit.ly/NHSEbeds01

21. As Note 3, p.38

22. As Note 3, p.38

23. As Note 3, p.5

24. On Healthwatch Cornwall, see Note 10

25. As Note 1, p.7

26. Age UK Cornwall & Edward Hain, Learning Report 2019, Age UK Cornwall, 2019

27. Cornwall and Isles of Scilly to fast track plans to help older people stay well and avoid hospital admissions, 23 January 2020  http://bit.ly/CIoSPress01

28. As Note 3, pp.57-59. No distinction is made between therapist specialisms, e.g. between physiotherapists and occupational therapists.

29. As Note 3, pp.60-61

30. As Note 3, p.60

31. As Note 3, p.62

32. Peter Levin, How a lack of teamwork at the Royal Cornwall Hospital contributed to the death of a child with autism, December 2019 https://bit.ly/TeamworkRCHT

33. As Note 1, p.12

This post can be downloaded as a pdf here.

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

* * *

Introduction
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. http://bit.ly/AAtSS01
Advertisements at http://bit.ly/AAtSS02 (fixed term contract/ secondment until March 31, 2022, minimum 8 days per month) and http://bit.ly/AAtSS03 (secondment only).

2. The Kent and Medway information pack is entitled Candidate Briefing Document.
http://bit.ly/AAtSS04

3. For fuller details, see Peter Levin, ‘Inpatient beds that Edward Hain hospital provided are still needed’, The Cornishman, July 4, 2019 http://bit.ly/AAtSS05

4. Kent and Medway, Case for change, March 2018 http://bit.ly/AAtSS06

5. NHS England, Designing integrated care systems (ICSs) in England, June 2019
http://bit.ly/AAtSS07

This post can be downloaded as a pdf here.

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?

This post can be downloaded as a pdf here.

Implementing the NHS Long Term Plan, embodying as it does another switch from down-to-earth planning to the visionary kind, poses many problems. In Cornwall we’re finding that a utopian vision, a planning process shrouded in mystery, and a ‘shopping list’ attitude to public engagement are of little help in planning for a local area. A new approach holds promise, but the problem of delayed transfers of care reveals the organizational obstacles that it faces.

CONTENTS

1. The recent history of NHS planning
   
2. Health and social care planning in Cornwall: what is being done?
   
3. A utopian vision, with help from management consultants
   
4. Bad language: ‘system’ and ‘strategic’
   
5. A planning process shrouded in mystery
   
6. A ‘shopping list’ on a PowerPoint slide: is this all that public engagement produces?
   
7. Why the planning process needs to be transparent
   
8. A case study: community hospital beds for West Cornwall
   
9. The NHS needs internal integration, not only integration with social care
   
10. A new approach: outsourcing public engagement and research
    
11. The tests that a new approach must meet

1. The recent history of NHS planning
Over the past five years NHS England has issued four edicts prescribing the shape and form of the NHS. In October 2014 it published Five Year Forward View[1] in which it argued that the NHS needed to change and listed a range of new models of care that it would support. These included:

• • The Multispecialty Community Provider (MCP), which would permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care.

  • Primary and Acute Care Systems (PACS), where hospital care and primary care are integrated, so ‘combining for the first time general practice and hospital services’.

  • Urgent and emergency care services redesigned ‘to integrate between A&E departments, GP out- of- hours services, urgent care centres, NHS 111, and ambulance services’.

  • Help for smaller hospitals to remain viable.

As we see, the language used was ‘down-to-earth’: it made it clear what each of these models of care actually entailed.

In December 2015, Sustainability and Transformation Plans (STPs) came on the scene. They were announced in Delivering the Forward View: NHS planning guidance: 2016/17 – 2020/21.[2] Every health and care system – comprising clinical commissioning groups, provider trusts and local authorities – was asked ‘to come together, to create its own ambitious local blueprint’, an area-based five–year STP.

But how was the plan to be created? The ‘planning guidance’ did not provide any kind of manual: there was no step-by-step set of instructions. All it had to say on the subject was this:

Producing an STP … involves five things: (1) local leaders coming together as a team; (2) developing a shared vision with the local community, which also involves local government as appropriate; (3) programming a coherent set of activities to make it happen; (4) execution against plan; and (5) learning and adapting.

Success also depends on having an open, engaging, and iterative process that harnesses the energies of clinicians, patients, carers, citizens, and local community partners …

Essentially, then, the STPs were to be ‘vision-driven’, in contrast to the down-to-earth models of care previously advocated: ‘The best plans will have a clear and powerful vision …’[3]

In March 2017 NHS England published another policy document, Next Steps on the NHS Five Year Forward View.[4] It described itself as ‘this plan’, but primarily it amounted merely to a list of actions that NHS England was committing itself to take in the next two years. Prominent among these was taking new models of care forward, especially those that had been developed in fifty localities (as part of the ‘Vanguard’ programme). So practical developments, notably Multispecialty Community Providers and Primary and Acute Care Systems, were once again at the forefront of NHS England’s thinking. 15 months after their launch, the vision-driven Sustainability and Transformation Plans were quietly dropped. Thinking had swung once again, from visionary back to down-to-earth.

But this was not to last. In January 2019 The NHS Long Term Plan was published.[5] Among other things, this document says:

• • We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health services.

  • The NHS will reduce pressure on emergency hospital services.

  • People will get more control over their own health and more personalised care when they need it.

  • Local NHS organisations will increasingly focus on population health – moving to Integrated Care Systems everywhere.[6]

This is essentially a vision of the world as those running NHS England would like it to be. What we see here is the resurrection of visionary thinking. It is hard to see what qualifies it as a ‘plan’. It is not a blueprint for action so much as a list of aspirations and intentions, some of them of the unassailable ‘motherhood and apple pie’ variety.

Some user groups – such as patient participation groups, leagues of friends of hospitals, and groups campaigning against hospital closures – will have their suspicions raised by these ambitions. Will ‘boosting’ out-of-hospital care be used to justify closing hospital wards and beds? Will giving patients more control over their own health and care be taken by health and social care professionals to justify leaving them to take care of themselves? And importantly, we know that money is tight – indeed, providers are to return to ‘financial balance’[7] – and change always incurs costs: so will cuts be made to find the money to pay for these changes?

2. Health and social care planning in Cornwall: what is being done?
Health and social care planning in Cornwall is overseen by a ‘Transformation Board’. It is not of itself a decision-making body, but currently its leading members – described as ‘system leaders’ – are the four chief (executive) officers of Cornwall Council, NHS Kernow (the Clinical Commissioning Group for Cornwall), the Royal Cornwall Hospitals NHS Trust and Cornwall Partnership NHS Foundation Trust,[8] so they have decision-taking roles in their own spheres and they are publicly committed to working together as partners. Their joint ambition is to be endorsed as an Integrated Care System by 2020.[9]

In order to implement the Long Term Plan at local level, NHS England has asked local health and social care bodies to plan the changes required, but it has provided no guidance for them on how to do this. It does say that local health systems ‘will be expected to engage with their local communities … in developing plans’,[10] but makes no suggestions as to how to do this either.

So how is the Transformation Board setting about its task? Literally, how is planning being done? And what form is engagement with local communities taking in Cornwall?

Three reports to the May 2019 meeting of the Transformation Board help us to piece together answers to these questions. We have an Operational Plan Executive Summary,[11] Development of the Long Term Plan,[12] and Healthwatch Cornwall – Health & Social Care Public Engagement.[13]

3. A utopian vision, with help from management consultants
The Operational Plan Executive Summary[11] shows that, like NHS England with the Long Term Plan, the Board’s members have a vision, and strategic objectives too. These are reproduced in Box 1. Like those of NHS England, they take the form of utopian aspirations.

Box 1. ‘Our vision and strategic objectives’ Our vision ♦  We will work together to ensure the people of Cornwall and the Isles of Scilly stay as healthy as possible for as long as possible. ♦  We will support people to help themselves and each other so they stay independent and well in their community. ♦  We will provide services that everyone can be proud of and reduce the cost overall.’ Our strategic objectives are derived from the quadruple aim to ♦  Improve health and wellbeing. ♦  Improve people’s experience of care. ♦  Reduce the cost of care per capita as a consequence of people using services less frequently and needing less expensive help. ♦  Improve people’s experience at work.

As we see, these are again all very much of the ‘motherhood and apple pie’ variety. They are not presented as the conclusions of a research project or having been reached through political consensus. There is no indication that they arose out of discussions with local communities – groups of local residents or service-users, or campaigning groups – drawing on day-to-day experience. We get no sense of the decisions that have to be made in real life about allocating resources between competing needs. The vision and objectives are what one might expect to be the outcome of a brain-storming exercise conducted by management consultants with senior executives who don’t have daily contact with patients or social care clients.

4. Bad language: ‘system’ and ‘strategic’
Evidence as to the involvement of management consultants is provided by the inclusion in the Operational Plan Executive Summary of a diagram (untitled) reproduced below showing ‘System strategic objectives’ that ‘create the underpinning infrastructure and capabilities that are critical to delivering high quality care and support’. This presentation and language, like the ‘target operating model’ featured in Box 2 below, are straight out of the management consultants’ playbook, as was much of Cornwall’s Sustainability and Transformation Plan of 2016.[14]

The words ‘strategy’ and ‘strategic’ are also being used in a very loose way. The utopian objectives to which they relate offer us no way of telling when they have been realised. Nor do we get any sense of coherence, of how the various elements of the strategy will fit together and combine to realise the objectives.

The term ‘system strategic objectives’ sounds impressive, but on closer inspection we can see that it denotes nothing more than abstract, utopian aspirations.

5. A planning process shrouded in mystery
As to the process of planning, a useful source document should be, to judge by its title, Development of the Long Term Plan.[12] It contains two lists, reproduced below: ‘Box 2. Our approach to long term planning locally’ and ‘Box 3. What we need to do’.

Box 2. ‘Our approach to long term planning locally’ ♦  Welcoming the opportunity to refresh our local ambitions for improving health and wellbeing, and demonstrate how we plan to make the required shifts to more place-based care with a greater focus on prevention; ♦  Using 2019-20 as a platform from which to deliver transformation; ♦  Aligned plans between the NHS and councils; ♦  Shaped by a new Health and Wellbeing Strategy, which will identify local priorities for improving the health and wellbeing of our population, based on local health and care needs; ♦  A two-way relationship with the placed based (bottom up) local Integrated Care Area plans and local operating models; ♦   Working with HealthWatch on engagement; ♦   System transformation programmes for prevention and population health, integrated care in the community, planned care, urgent and emergency care, and care and support for children and young people will contribute to development of the plan; ♦  System enabling plans will develop the resources needed for the target operating model and ensure the workforce, IT, estates and finance are available as needed to underpin the transformation programmes; ♦  Operational plans will identify what each organisation will contribute.

As we see, in Box 2 there is nothing in the ‘approach to long term planning locally’ that can be seen as a progression over time, or as a step or stage in a planning process. No role for public engagement is identified. ‘System transformation programmes’ and ‘system enabling plans’, whatever these are, by their very language exclude those who aren’t members of or working for the Transformation Board.

Likewise, there is nothing in this approach which can visibly be seen as playing a part in realising the vision, in translating it into practice.

The activities listed in Box 3, below, under the heading ‘What we need to do’, are similarly not helpful in gaining an understanding of the planning process. They are a strange mixture: visionary (‘Make a positive difference’), visionary/descriptive (‘Describe how our system will be operating in five years’ time’), self-evident (‘Have a timescale, plan and resources’) or simply unspecific (‘Build on our engagement and co-production to date’). There is no sequence, there is no programme of work. Notably, none of the activities listed offers an invitation or opportunity for outsiders – members of the public, or a group of service users – to get involved, or stipulates a point in time by which contributions need to be received.

Box 3. ‘What we need to do’ ♦  Make a positive difference for our local populations: –  Expand our evidence base used for the 2019-20 Operating Plan to cover five to ten years and to have a good understanding of trends in population health – this will be informed by the Joint Strategic Needs Assessment; –  Increase our understanding of how different groups of people use our health and care services as needs change and society and technology develops and our capacity to respond over the next five to ten years, which will require expanding our modelling work; ♦  Describe how our system will be operating in five years time, what will be different to what we have now and what improvements in outcomes for people, the quality of care and in system performance the changes will deliver – this will include delivery of the commitments in the NHS Long Term Plan; ♦  Describe how delivery of new ways of working will be shaped in integrated care areas and by primary care networks and have a strategy within the plan for how integrated care areas, out of hospital care and primary care networks will develop over the five years; ♦  Have an implementation timescale, plan and resources identified for delivery of the changes; ♦  Build on our engagement and co-production to date.

Given the varied nature of these bullet points, and especially the fact that they are not presented in any discernible sequence, it is difficult to resist the conclusion that, despite the much-vaunted ‘systems’ approach, the process of producing the local plan is not a logical, clearly structured one. The picture presented in this report to the Transformation Board is one of confusion. The process of translating visions into reality may be a difficult one, but it has not been disclosed to the Board. Moreover, as long as this situation prevails the course that the process takes will be entirely hidden from view: there will be zero transparency of the process.

6. A ‘shopping list’ on a PowerPoint slide: is this all that public engagement produces?
NHS Kernow, Cornwall’s Clinical Commissioning Group, tends to publish what it learns from its consultations as slides in PowerPoint presentations, such as that shown in Box 4.[15]

Box 4. ‘What have people told us is important?’ ♦  Focus on prevention and proactive care ♦  Personalising care and support to help people achieve what matters to them ♦  Coordinating care and support locally ♦  Developing the role of local communities in providing support ♦  Improving care home quality and resilience ♦  Improving dementia care ♦  Improving support for carers

This list tells us a number of things:

1. It is simply a list of aspirations.

2. Given the sheer improbability that any individual told NHS Kernow ‘I think you should focus on prevention and proactive care’ or ‘You should be developing the role of local communities in providing support’, the list of aspirations must have been compiled by somebody – we don’t know who – interpreting individual, ‘raw’ responses and aggregating them as he or she or they saw fit. We don’t know either whether the order of the seven items in the list is significant, or – if so – how the order was determined.

3. We aren’t told how many people mentioned each of the seven aspirations in the list, or how the sample of ‘people’ was drawn up. A list like this leaves it entirely to the organization to place them in an order of priority and determine how resources, necessarily limited, should be allocated among them. The reader has no way of contributing to that element of the process.

4. It is striking that whatever survey was carried out treated respondents as sources of information about their needs, but, so far as we can see, it ignored the crucial fact that service users are also sources of information about how systems work. Such information can’t be elicited by asking someone to jot down on a Post-It Note what their top concern is.

5. It is very surprising that, according to the list in Box 4, nobody mentioned what we know to be a major cause of concern in Cornwall, the long-lasting ‘temporary’ closure of inpatient beds in three of the county’s community hospitals.

This example demonstrates the limitations of the ‘shopping list’ approach to public engagement. It will require careful investigation by researchers trained in social enquiry and survey methods to ensure that a statistically valid sample of respondents has been identified, to elicit respondents’ stories, to explore how they feel about their experiences, and make sure those experiences have been properly understood and recorded, and valid lessons drawn from them. There is no evidence that any of this has been done.

7. Why the planning process needs to be transparent
We have seen that the local NHS planning process in Cornwall is extremely difficult to uncover. Undoubtedly things are happening, as they are during all public planning processes, to narrow down the range of options that will be available when choices are made at the end of the process. NHS England expects ‘local health systems’ (sic) to engage with their local communities in developing plans[16] but if that engagement comes only at the end of the planning process, some options which would find favour among the public may already have been ruled out. There are a number of behind-the-scenes mechanisms through which this can come about:

1. Assumptions and constraints get built in to the process. At the very start, terms of reference for the decision-making process are decided, especially in the form of assumptions and constraints that are to be taken as read. For example, it may be assumed that alternative provision to community hospital inpatient treatment will be made available, allowing a hospital to be closed and the buildings and land sold off, whereupon the planning team works on that assumption. So even if the alternative provision does not actually come into being and is not there when needed, the hospital may be closed and sold off regardless.

2. Time and staff resources get used up. Once a deadline has been set, as is often the case, there is simply not the time and manpower available to permit going back to square one and starting again. If certain alternatives have not been investigated and considered, there is no time now to investigate and consider them: the phenomenon of ‘running down the clock’. Even if alternatives have been considered, these will have been reduced to a shortlist, and it won’t be possible to resurrect any that did not make it on to that shortlist.

3. The staff working on the plan become psychologically committed. They take decisions about the kind of plan they want to see, and about working methods, i.e. how they are going to produce the plan: to go back on these decisions, and write off some of the work that has been done, will generate stress and involve loss of face. Similarly, people make assumptions and become wedded to these: even if evidence turns up that shows that their assumptions were unrealistic or – like budgetary limitations – could have harmful consequences, they may disbelieve and deny that evidence (the phenomenon of cognitive dissonance).

And the staff working on the plan will have their own motivations. They will have personal ambitions, such as advancing their careers, and typically will want to produce something distinctive and striking. Such ambitions too generate commitment.

4. The in-house planning team may have a budget to employ outside consultants to research and develop a plan, and will agree a contract with them to do this work. The contract will set out terms of reference for the work, and a deadline for submitting a final proposal. However, as the deadline approaches it may become apparent that the terms of reference have been drawn too narrowly, and that if they had been relaxed another, better, plan. could have been produced. But by then the budget has all been used up, and there is no money to develop the superior option. So that option gets ruled out by default, long before a point of formal decision is reached.

5. Some people, particularly members of entrenched interest groups, will have ‘preferential’ access to the planning process, easier access than others. For example, in the NHS and local government senior managers may get together privately to find and agree a bundle of courses of action that has something for all of them. Once that agreement has been reached, it will be very difficult for others – such as local patient groups – to get it reviewed and altered.

6. The situation on the ground changes. A facility may be closed for repairs, and it happens that staff drift away, local people at first protest and then find ways of coping, the building gets starved of maintenance and begins to decay, so the option of restoring it to use becomes increasingly expensive and consequently difficult to justify (the ‘planning blight’ syndrome). Or a service that up to now has been provided at local level gets abruptly withdrawn, to be replaced on grounds of economy by centralized provision: staff then leave the district, making it difficult to restore the service, and of course costs are placed on patients who have more travelling to do.

– – –

The effect of these mechanisms should not be underestimated. By closing off options they pre-empt formal decisions. As a former very senior civil servant has 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.[17]

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

We have to be alert to the fact that managers who are familiar with these mechanisms can deliberately take advantage of them. Thus they can limit the number of staff working on the plan and impose unrealistic deadlines, they can impose stringent budget limitations, they can reach deals with the more powerful interest groups, and they can change the situation on the ground. Indeed, they may have reached their present positions in their organizations precisely because they are skilled in using strategies like these.

So while managers may say, perfectly correctly, that no formal decisions will be taken before the public are consulted, they may have a host of strategies at their disposal, all aided by zero transparency, to guarantee that they get the result they want. We have seen that the mysterious planning process in Cornwall is the very opposite of transparent. Patients and the public, indeed everyone who benefits from NHS services, have every reason to be concerned.

8. A case study: community hospital beds for West Cornwall
In West Cornwall we have had an example of some of these processes at work in the treatment of Edward Hain community hospital in St Ives, located in the Penwith district in the far South-West. Inpatient beds at this hospital were ‘temporarily’ closed to new admissions in February 2016 due to fire safety concerns: more than three years later they are still closed, despite the required remedial works having been carried out by NHS Property Services, the owners of the building. Cornwall Partnership Foundation NHS Trust, which leases the building, is now stipulating that further conditions must be met before it will reinstate beds.[18] Meanwhile the medical and nursing staff and allied health professionals have of necessity moved on.

The hospital stands on highly valuable land and it is widely felt that the intention is to sell the building and site to realise its value, as was done in 2014 with Poltair hospital, near Penzance. Cornwall now has an estates strategy which NHS England says is ‘Good’ and meets ‘the expected national requirement to release capital’,[19] so it will clearly involve selling off some real estate, but no details have been made public. Understandably, there are fears that Edward Hain hospital has been earmarked for this purpose. Meanwhile, there is no functioning community hospital with inpatient beds in Penwith.

The inpatient beds at Edward Hain hospital had been used intensively. In the 12 months before they closed, on an average night 93% of them were occupied. In those 12 months 174 patients were accommodated in inpatient beds: 64% of them (111) were Penwith residents.[20] Those beds were used mainly to accommodate patients who had been treated at Cornwall’s main acute hospital, the Royal Cornwall Hospital at Treliske, near Truro, and were well enough to leave Treliske but not well enough to go home. At present some patients are sent to other community hospitals in Cornwall. The nearest is at Helston, some 18 miles from St Ives and 24 miles from St Just, the most westerly town in Penwith.

The latest Integrated Performance Report to the Royal Cornwall Hospitals Trust shows that in April 2019 nearly 600 bed days were lost on account of delayed transfers of care caused by waits for further non-acute NHS care. ‘These will be patients waiting for onward care, including community hospitals, for rehabilitation.’[21] It appears that the desirability of selling off Edward Hain hospital is taking precedence over the need to make best use of acute beds at Treliske and the wish of recovering patients to recuperate close to home.

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

How could this situation have been avoided? To answer this question we need to take a (genuine) systems view of a patient’s entire ‘trajectory’ through his or her episode of ill-health. What we see when we do that is that it can be divided into four linked stages: (1) admission and observation; (2) treatment; (3) recovery from treatment; and (4) re-ablement.[22] On a systems view, this trajectory needs to be treated as a whole.

But that is not how the NHS works in Cornwall. The hospital at Treliske – organization, facilities, staffing and ancillary functions, buildings – is designed to provide for the first three of these stages, but the fourth requires the facilities of a community hospital, and in Cornwall these come under a completely separate organization, the Cornwall Partnership Trust. This body has its own goals and incentives, which appear to motivate it to sell off the land and buildings of its community hospitals and make a name for itself as a source of funds for the NHS.

9. The NHS needs internal integration, not only integration with social care
What, if anything, is being done in Penwith to help ease the situation at Treliske?

Currently a new wellbeing/re-ablement day service is being trialled in the Edward Hain hospital building. These activities are led by Age UK and various community and voluntary groups. Preliminary findings from this trial were that no referrals were coming from the acute hospital at Treliske and that many people who had been discharged from hospital were too unwell to attend. An unmet and unanticipated need for physiotherapy provision was also identified. (It was apparent too that the services being provided were very similar to those already being offered at day centres in Penzance and Hayle.) It is clear that this service does not compensate for the loss of community hospital inpatient beds at Edward Hain hospital.

NHS Kernow has a web page dedicated to ‘integrated community services’ and Edward Hain community hospital.[23] What does the material on this webpage tell us?

• • It offers a slide show ‘Edward Hain community hospital – Case for change’ but this doesn’t consider the consequences of closing the inpatient beds. Nor, indeed, does it actually set out any kind of case for change!

  • In another set of slides produced for an Edward Hain workshop, we find a diagram of ‘An integrated team’ which includes GPs, community nurses, social workers and five other groups, but does not include anyone from the acute sector.

  • A ‘countywide evaluation group’ is being set up to evaluate proposals for community care: the acute trust is not represented on that group.

What we see is that ‘integration’ is being treated as spanning a variety of community services but excluding care in the acute hospital. In effect, what happens in Penwith is being regarded as none of the business of the Royal Cornwall Hospitals Trust. In practice, as we see from the figures on delayed transfers of care, it has a considerable bearing on that trust’s situation.

Much is heard these days of the need to integrate health care services provided by the NHS with social care services provided by local authorities. What the situation in Cornwall vividly demonstrates is a need for the NHS to integrate its own services. There is clearly a strong case that responsibility for community hospitals with inpatient beds should be transferred from the Cornwall Partnership Trust to the Royal Cornwall Hospitals Trust.

But why, we may reasonably ask, is the Transformation Board not already seized of this problem and taking steps to deal with it. On this evidence, for all their protestations of integrated and cooperative working, its leading members are working in the time-honoured way of carving up the territory and vigorously defending their own patch.

11. A new approach: outsourcing public engagement and research
The third relevant paper submitted to the Transformation Board at its May 2019 meeting was Healthwatch Cornwall – Health & Social Care Public Engagement.[13] This was written by the Chief Executive Officer of Healthwatch Cornwall. It makes it clear that the leading members of the Transformation Board have effectively outsourced their responsibility for engaging the public to that organization.

The generally understood role of the local Healthwatch organizations across England is essentially to promote and support the involvement of local people in the commissioning, provision and scrutiny of local care services. They do this chiefly by providing information for local people about local care services and standards of provision, and obtaining the views of local people about their needs for, and experiences of, local services and making those views known. They can also recommend that special reviews or investigations be carried out, and recommend that their parent body, Healthwatch England, publish reports on particular issues.[24]

How does Healthwatch Cornwall see its role? According to the Healthwatch paper, the organization ‘has a remit to ensure health and social care services in Cornwall are the best they can be for people in the county’. This is not entirely correct. That remit is of course the remit of the commissioners and providers of services. But Healthwatch Cornwall, which has a seat on the Transformation Board, is explicitly positioning itself as a partner to commissioners and providers:

Healthwatch Cornwall seeks to work in partnership with commissioners and providers across the system to complement and enhance public engagement undertaken by them. To model best practice in public engagement, to support colleagues and to act as a critical friend highlighting positive performance and holding organisations to account where public and patient views have not been sufficiently considered.[13]

The language here is carefully non-confrontational. It employs no quasi-military metaphors to do with campaigning or defending the interests of service users. The reference to holding organizations to account is balanced by references to supporting colleagues and highlighting positive performance. So Healthwatch Cornwall has been willingly co-opted into the institutional structure, alongside its ‘partners’ on the Transformation Board.

Healthwatch Cornwall’s recent annual reports show that the issues it has taken up have hitherto stemmed primarily from individual patients’ experiences with services. On major contentious issues, such as the proposal in Cornwall’s Sustainability and Transformation Plan ‘to replace the current Minor Injury Units with a new model of strategically located Urgent Care Centres across the spine of Cornwall’[25] and the total absence of community hospital beds in Penwith since the ‘temporary’ closure of Edward Hain Hospital more then three years ago, Healthwatch Cornwall has been noticeably uninvolved.

However, we read in the Healthwatch Cornwall paper to the May 2019 Transformation Board that as part of its existing work plan for 2019/20, it will

• • Develop and launch a new systemwide engagement tool (a Virtual Citizens Panel)

  • Deliver part of NHS England’s NHS Long Term Plan engagement

  • Deliver an Appreciative Inquiry into Mental Health Services

  • Deliver a conference for Mental Health professionals

  • Carry out research into the needs of End of Life Carers

  • Carry out research with mental health service users

  • Facilitate Cornwall Council partnership boards to contribute to system engagement

  • Advise on engagement plans for Community Hospitals and Public Health 10 year priorities.

It’s early days, but at first sight the approach being adopted by Healthwatch Cornwall has some very promising aspects. It is positioning itself as an interlocutor between patients/clients and the providers of services, which could enable it to perform a very valuable function. And the Transformation Board badly needs to be able to draw on the services of qualified and capable researchers.

11. The tests that a new approach must meet
How will we be able to assess how well Healthwatch Cornwall is fulfilling the brief set out above? Here are some tests that we can apply. They take the form of questions which need to be answered in the affirmative for the test to be passed.

1. When Healthwatch Cornwall is advising on ‘engagement plans for community hospitals’, will it be able to present the public with a clear picture of the steps and stages in the process? Will it be able to identify commitments to closing hospitals that have already been created, e.g. in assumptions made about alternative provision, and will it be in a position to insist that such commitments should be held in abeyance while alternatives are being explored?

2. Will Healthwatch Cornwall employ specialists in engagement, not ‘communications experts’ but people who are able to identify issues through dialogue with local people. (An issue can be defined as a ‘What should be done about X?’ question.) Issues are subjective – they exist in the eye of the beholder – so identifying them necessitates not only in-depth surveys of the population, as opposed to ‘tick-box’ questionnaires, but also discussions with local people who have some insight into issues.

Engagement specialists need to be knowledgeable about planning processes and prepared to explain to local people how positions harden and options get shut off. Only through being honest about these will they earn the public’s co-operation. It follows that they need to act as interlocutors, facilitators of dialogue, not as public relations officers for public bodies.

3. When faced with a controversial issue, such as the future of inpatient beds in community hospitals, will Healthwatch Cornwall be prepared to engage with it while being able to avoid taking sides, in particular to resist being ‘nobbled’ by its ‘partner’ organizations?

4. When Healthwatch Cornwall has reached a judgment as to whether ‘public and patient views have [or have not] been sufficiently considered’, will it tell the public what its judgment is and what criteria it has used in reaching it? Will it publicize what it can actually do by way of ‘holding organisations to account’?

5. When Healthwatch Cornwall has formulated research proposals, will it publish these and invite comment on them? Will it enquire into how the system works as well as merely asking people what they want? Will it publish ‘proper’ research reports (to be distinguished from PowerPoint slideshows) and invite comment on them from local people? Will it call on and take advantage of the research experience that can be found among Cornwall’s population and of course its health and social care workforce? Will it have the resources to call on outside specialists when needed?

Research is everyone’s business: the research mindset involves nothing more complex than paying attention to what is going on and trying to make sense of it. For example, there needs to be a much more sophisticated understanding of patients’ trajectories through the healthcare system than we have at present: the issue of how to reduce delayed transfers of care will not be resolved until the gulf between decision-makers’ perspectives and criteria on either side of the transfer is addressed.[22]

6. Healthwatch Cornwall will be well positioned to monitor edicts emanating from NHS England. To judge by the policy switches already noted, from visionary to down-to-earth and back, it would be prudent to treat NHS England as an unreliable and somewhat capricious paymaster, harbouring crude and unsophisticated ideas about what planning entails. Will Healthwatch Cornwall treat NHS England as a subject for research, and carefully examine its publications and behaviour? It could perform a valuable service by

• • Studying instructions that NHS England issues, and asking if they are derived from appropriate objectives and methodology, and whether such justification as is put forward for them is free of ambiguities and unwarranted assumptions.

  • Analysing funding pronouncements, identifying the criteria on which funds are being allocated, looking for underlying assumptions and any contradictions between allocations and stated aims, and asking if those aims might be achievable by other means.

  • Suggesting strategies that local bodies can employ for negotiating with NHS England rather than simply accepting what they are given and doing what they are told.

If Healthwatch Cornwall can answer ‘yes’ to these questions it will deserve support and encouragement from everyone across Cornwall.

---

Notes and references (All websites were last visited on 31 May 2019. Bit.ly has been used to shorten website addresses where these have run over two or more lines.)

1. NHS England, Five Year Forward View, October 2014
https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
No author stated, but the Foreword says: ‘It represents the shared view of the NHS’ national leadership, and reflects an emerging consensus amongst patient groups, clinicians, local communities and frontline NHS leaders.’

2. NHS England et al, Delivering the Forward View: NHS planning guidance: 2016/17 – 2020/21, Dec. 2015
http://bit.ly/NHS-DFV 

3. Delivering the Forward View …, Para 13

4. NHS England, Next Steps on the NHS Five Year Forward View, March 2017

5. NHS England, The NHS Long Term Plan, January 2019
https://www.longtermplan.nhs.uk/

6. The NHS Long term Plan, P.3

7. The NHS Long term Plan, Para 6.3

8. Shaping our Future, System leaders
https://www.shapingourfuture.info/about/whos-who/system-leaders/

9. Shaping our Future, An integrated care system for Cornwall and the Isles of Scilly
http://bit.ly/SOFTB02

10. The NHS Long term Plan, Para 7.3

11. Shaping our Future, Cornwall and Isles of Scilly Operational Plan Executive Summary 2019/20
http://bit.ly/SOFTB03

12. Shaping our Future, Cornwall & Isles of Scilly Health & Care System, Development of the Long Term Plan, Report to Transformation Board, 9 May 2019
http://bit.ly/SOFTB01

13. Amanda Stratford, Healthwatch Cornwall – Health & Social Care Public Engagement
http://bit.ly/SOFTB04

14. Cornwall and the Isles of Scilly: Sustainability and Transformation Plan: Draft Outline Business Case
http://bit.ly/CIoSSTP01
See also Peter Levin, Six bungles and no funeral: The short life, unmourned death and high cost of Cornwall’s Sustainability and Transformation Plan for the NHS
http://bit.ly/SPR4CAA01

15. Shaping our Future, Integrated Community Services Review, WorkshopSlidePack.pdf, via
http://bit.ly/WCHW1AA

16. The NHS Long term Plan, Para 7.3

17. Lord Bridges (Cabinet Secretary 1938-46, Permanent Secretary to the Treasury and Head of the Home Civil Service 1946-56), ‘Whitehall and Beyond’, The Listener, 25 June 1964. Cited in Peter Levin, Making Social Policy, Open University Press 1997 (p.44) and in Peter Levin, ‘Opening up the Planning Process’, in Stephen Hatch (ed), Towards Participation in Local Services, Fabian Tract 419, 1973
https://digital.library.lse.ac.uk/objects/lse:hol622dav?page=2

18. Peter Levin, Five kinds of nonsense are keeping a community hospital closed
http://bit.ly/SPR4C02

19. Jackie Pendleton and Karl Simkins, CIoS System Strategic Estates Group Briefing
http://bit.ly/SOFTB05

20. Shaping our Future, Edward Hain community hospital: Case for change
http://bit.ly/SOFTB06

21. Royal Cornwall Hospitals Trust, Integrated Performance Report, 6 June 2019 , p.42
http://bit.ly/XRCHT01

22. Peter Levin, Don’t close community hospitals: use them as re-ablement centres, 24 January 2019
http://bit.ly/SPR4C03

23. NHS Kernow, Edward Hain Community Hospital, St Ives
http://bit.ly/XKCCG01

24. A useful list of the statutory duties of Healthwatch organizations can be found in Healthwatch Leicester and Leicestershire, How we work
http://healthwatchll.com/how-we-work/

25. As Note 15, Draft outline business case, p.47

This report can be downloaded in pdf format here.

This report shows how limited and poor-quality information is being used to justify a policy of ‘freeing up’ hospital beds, in effect allowing wards and hospitals to be closed. In Cornwall three community hospitals are currently facing closure. Unfortunately, policy makers seem not to understand that patients stay in hospital not only to recover from their treatment but to go through a process of ‘re-ablement’ so they can regain the skills of daily living and a place in their community. Re-ablement is difficult to achieve in acute hospitals, where patients are more likely to become institutionalized: it calls for specialized re-ablement centres. Local community hospitals should be utilized for this purpose. Staffed by teams of physiotherapists, counsellors and social workers, and providing a base for occupational therapists working in the community, re-ablement centres would take patients who have gone through their acute treatment and would thereby free up beds in acute hospitals.

‘Freeing up hospital beds’: a policy based on inadequate information
NHS England has become very careful lately to avoid suggesting that it is seeking closures of hospital beds and, by implication, hospitals. But we currently see numerous references to ‘freeing up’ hospital beds, as in the recently published NHS Long Term Plan.[1]

In Cornwall we keep being told: ‘Older people can lose 5% of their muscle strength per day of treatment in a hospital bed.’[2] Interestingly, we are never told how much exercise, if any, those ‘older people’ were given. Nor are we told how much muscle strength people lose if confined to bed in their own home. Without this information, that figure of 5% is utterly worthless as a basis for policy making. And the cost of having physiotherapists spending time driving around (with limited equipment) instead of treating patients throughout the day is another factor that policy makers show no sign of taking into account.

We are also told that ‘Around 60 people each day are staying in an acute hospital bed in Cornwall and don’t need to be there’, and that ‘35% of community hospital bed days are being used by people who are fit to leave’. We aren’t told, though, who is making these judgments and what they are taking for granted about a patient’s ability to cope after leaving.

It seems all too likely that these judgments are being made by hospital consultants who consider that there is nothing more that they can do for the patient and are not taking any account of the patient’s housing opportunities or indeed of their need for ‘re-ablement’.

At the present time occupational therapists working in the community are noticing that people are being discharged from hospital despite being very unwell. Evidently, under the pressure to free up beds, too little attention is being paid to the capabilities of patients who are in line for discharge.

The pressures
In NHS hospitals today there is a chronic shortage of funding and of staff. Many staff are overworked, they go home exhausted, and their morale is understandably low. Most of them know what patients need and are frustrated because they don’t have time to provide it. Medical procedures, administering medication and changing dressings have to take priority over encouraging and supporting patients. And pressure of time limits the attention that can be given to the particular needs of an individual.

In some wards, especially geriatric wards, patients who struggle to feed themselves become undernourished because ward staff don’t have time to feed them. Patients who need to be helped to drink become dehydrated. Patients who need but don’t get help with toileting, either using a bedpan or going to the bathroom, may soil themselves and be left in that state for some time.

Imprisoned in hospital
Hospital in-patients, just like the inmates of prisons, are confined. Indeed, they may be confined more tightly, if they are in a bed from which they can’t escape. The lives of both patients and prisoners are governed by a discipline, decisions and a daily timetable over which they have no control. If there are disruptive fellow-inmates in close proximity, patients suffer from a lack of privacy and access to their possessions, and very probably from sleep deprivation too.

Subjected to these conditions, many elderly patients become resigned to their fate, especially if they have been living on their own and have had an accident, been taken to hospital, and then not only found themselves confined in a hospital bed but faced with the fact that they will never see their home again. Many give up. Their mental health, like their physical health, gets worse and worse. They are conditioned to become dependent. They become, in a word, institutionalized.

Reducing reliance on bed-based care
We are currently being told in Cornwall that ‘reducing reliance on bed-based care’ and instead having people ‘supported at home and kept as independent as possible, whenever possible … provides a better experience of care for individuals’. The subtext here is of course that with less reliance on (hospital) bed-based care there will be less need for hospital beds.

What this argument leaves out is any comprehension of the last of the four processes that constitute a patient’s ‘trajectory’ through a hospital: (1) admission and observation; (2) treatment; (3) recovery from treatment; and (4) re-ablement.

Processes 1-3 need no explanation. But note that preparing patients to leave hospital requires more than just recovery from treatment. They have to be equipped to regain their autonomy (the ability to take decisions for themselves), their self-confidence and the physical and mental skills they need for daily living, so they move from a passive state to an active one. This fourth process is known as ‘re-ablement’.[3]

Shockingly, we are told that ‘older people admitted to hospital spend a significant amount of time not being physically active (83-95%)’. What this tells us is that far too little is being done to prepare patients for leaving hospital. Far too little attention is being paid by hospital managers to re-ablement, and consequently far too little by way of resources is being devoted to it.

The re-ablement model and the role of the physiotherapist
Who is best placed to help patients and guide them through the re-ablement process? Ideally it will be someone who can form an ‘alliance’ with the patient. Historically this has never formed part of a nurse’s role. Nurses care for patients during their recovery, and good ones have excellent ‘people skills’, but they are not taught and trained to work with patients, to form an alliance with them.

However, there is one professional group who are taught that it is their responsibility to work with patients in the re-ablement process: they are the hospital’s physiotherapists, members of an ‘allied health profession’. It is their responsibility to ‘mobilize’ patients and restore their fitness.

It is time to rethink the role of physiotherapists. Although they are conventionally viewed as playing an ancillary role in acute hospitals, they don’t just do exercises with people. They take a 3-year training course, during which they learn anatomy (nearly to the same level as doctors), as well as physiology and pathology. They are vital members of teams which carry out transplants, and they work in intensive care and medical wards.

Physiotherapists are equipped to play a key role in the re-ablement process. It is they more than any other professionals who can assist patients to regain their autonomy, self-confidence and physical and mental skills, and leave hospital to resume their place in their community.

The skills of physiotherapists put them in an excellent position to add ‘personal trainer’ to their portfolio of skills. They know very well that working with patients involves treating them as allies. They appreciate the importance of helping patients to set goals and providing feedback on their progress. With continuing professional development, as the recently-published NHS Long-Term Plan says, they would also be well placed to help patients suffering from anxiety and depression.[4]

A re-ablement service needs to be properly staffed and financed. If it is not, patients will be competing for resources: inevitably younger patients, with jobs and family responsibilities, will be given priority. Older people will be at the back of the queue: they won’t get enough exercise, they will continue to lose muscle strength that they will never regain, and they will stay in hospital longer than necessary. But if enough resources are devoted to re-ablement, the number of people staying in a hospital bed in Cornwall who ‘don’t need to be there’ will certainly be reduced.

Re-ablement centres: a use for community hospitals
Hospitals are commonly known by the services they provide. For example, Cornwall’s main hospital at Treliske, near Truro, is described as the provider of acute care services for the county. Cornwall also has a number of so-called ‘community hospitals’, three of which are currently closed to in-patients and at risk of being closed completely and the buildings and land sold off.

Taking a ‘process view’ of hospital provision in Cornwall, one thing stands out. To date, consultants and managers have not shown much if any interest in the re-ablement process. Consultants appear to be no longer interested in patients once recovery from treatment is under way, while managers seem most sensitive to beds being ‘blocked’ (‘delayed transfers of care’). It would suit both groups to have patients moved out of the acute care hospitals after they have received treatment, and if re-ablement centres can be established at the community hospitals, these are the obvious places to move patients to. They would also be closer to home.

Recommendations
Cornwall’s Clinical Commissioning Group should commission ‘physiotherapy-plus’ re-ablement centres for patients, to be based in community hospitals that might otherwise be sold off. Providers would be paid not to supply ‘warehouse space’ to accommodate patients while they regain their autonomy after their incarceration in the acute hospital but to employ teams of physiotherapists, counsellors and social workers in properly-adapted accommodation to create a stimulating mental and physical environment for them.

These centres should also serve as bases for occupational therapists who provide a service to people in their own homes, so there can be continuity of care for former in-patients. And the NHS should affirm the status of therapists as being central, not peripheral, to the process of helping patients to leave care fit and well and raring to go. Finally, policy makers should be reminded that if more resources are provided for re-ablement, this will undoubtedly reduce the number of people staying in an acute hospital bed in Cornwall who ‘don’t need to be there’.

---

Notes and references (Websites last visited on 22 January 2019)

1. The NHS Long Term Plan, January 2019, pp.7, 14, 18, 21
   www.longtermplan.nhs.uk
2. These figures have been supplied in the course of a consultation currently taking place in West Cornwall. See also Peter Levin, ‘Community hospitals under threat: Are decisions being taken on scrappy information and limited understanding?’, 7 August 2017
   https://spr4cornwall.net/wp-content/uploads/Community-hospitals-under-threat.pdf
3. ‘Re-ablement: The active process of regaining skills, confidence and independence after a traumatic or ischaemic injury.’
   https://medical-dictionary.thefreedictionary.com/re-ablement
   See also Karen Johnson, Recognizing and treating depression in hospital patients’, 24 October 2017
   https://blog.medstarwashington.org/2017/10/24/recognizing-and-treating-depression-in-hospital-patients/
4. As Note 1, p.11

Further reading
Peter Levin, ‘Five kinds of nonsense keeping a community hospital closed’, 4 October 2017
https://spr4cornwall.net/five-kinds-of-nonsense-keeping-a-community-hospital-closed/

 

On January 15th interviews will be held for the post of Chief Executive of the Royal Cornwall Hospitals NHS Trust.

The Trust is now looking for its seventh Chief Executive (including acting CEs) in eight years: interviewing panels for this post evidently do not have a great track record!

Who will be on this year’s interviewing panel? One member will obviously be the Acting Chair of the Trust; another will certainly be from NHS Improvement, the regulating body for NHS trusts. A third is likely to be a Chair or Chief Executive from another Trust. In these jobs not one of them is likely to be having daily contact with wards or clinics, of course.

What sort of person will these high-ups be looking for? In the past the emphasis has been on delivering the Trust’s strategic plan and gaining Foundation Trust status. When in 2015 Kathy Byrne was parachuted in from Australia, it was to play a ‘system leadership’ role. In the current job description the Acting Chair of the Trust writes that they are seeking a ‘strong and charismatic’ Chief Executive: a ‘brilliant’ leader who can provide ‘outstanding and inspirational leadership’ is required.

All this seems a world away from reality. The reality is that the Trust is an organization with deep-seated problems. The 2017 Staff Survey asked staff whether they thought the Trust’s procedures for reporting near misses, errors and incidents were ‘fair and effective’, and whether they felt ‘confidence and security’ when reporting unsafe clinical practice: on both counts the Trust came in the bottom 20 per cent in their category of trusts. And more workers than in comparable trusts said they had experienced harassment, bullying or abuse from other staff.

There’s more: a recent study of events leading up to the tragic death of six-year-old Coco Bradford in 2017 exposed a shambles in the organization for which no-one has been brought to account.

One thing is crystal clear. What the Trust does not need at its head is a prima donna, a chief executive whose charisma and brilliance will inevitably attract a coterie of self-promoting sycophants. It needs someone who can manage the organization without bullying or harassing people, who listens to staff and patients rather than just giving orders, who can weld the organization into a team, in which communications run bottom-up as well as top-down. In a nutshell, we need someone who can give genuine meaning to the Trust’s motto: ‘one and all, we care’.

This report can be downloaded in pdf format here.

The Acting Chair of the Royal Cornwall Hospitals NHS Trust says it needs ‘culture change’ but there are very different views of what that means and how to bring it about. The National Guardian’s Office has found deeply entrenched problems which the Trust is in danger of perpetuating.

Towards the end of 2018 the Royal Cornwall Hospitals NHS Trust began recruiting for a number of senior posts: a Chief Executive, along with Clinical Directors, Heads of Nursing etc, and General Managers, who are to head – as triumvirates – seven new ‘care groups’.[1,2,3,4]

The job descriptions and person requirements for the three categories of care group heads all refer to the importance of ‘culture’ and encouraging teamworking and good working relationships. This looks like an imaginative and positive response to a report recently published by the National Guardian’s Office (NGO) following a review of the Trust: this found that ‘workers described a culture that was highly unsupportive’[5] and that ‘relations between staff in several parts of the Trust were poor and were characterized by a grievance culture’.[6]

One worker told us that staff where they worked ‘got into trouble’ for raising concerns. Another, working in a different service, said: ‘If you do speak up middle management will block you.’ Two workers from one service commented: ‘Nobody has acknowledged our difficulty or concerns, and we won’t speak up again.[7]

Several staff from different services also commented that there was a culture of managers telling workers not to raise and record issues using the Trust’s electronic incident reporting system. These staff members said they believed this culture created risks to patient safety.[8]

A highly unsupportive culture like this is clearly detrimental to patients. An emphasis on teamworking, which was exposed as sadly lacking in a recent case that led to the death of a six-year-old child,[9] would be a way of developing a supportive culture and – importantly – foster good communication among staff.

The job description for the new Chief Executive is a strikingly different document. The Acting Chair of the Trust has provided an introduction in which she writes ‘We have a significant culture change to make’, but does not spell out what she means by that, and says her colleagues (i.e. the staff) ‘deserve a strong and charismatic Chief Executive to lead them on their journey’. We also read in the document that the appointee is expected to show ‘outstanding and inspirational leadership’, and that the role requires ‘a brilliant and capable leader’.[10]

One would not want to deny that capability and flair are valuable assets in a leader, but the dazzle of brilliance and charisma should not distract us from the fact that there is work to be done. What is the Chief Executive expected to do?

When we look at the job description for the Chief Executive we find no fewer than 54 bullet-pointed tasks. Several of them begin with ‘ensure’ or ‘ensuring’.

So an applicant for the post needs to ask, for example: How, exactly, will I be able to ensure ‘that the quality of patient care is central to the functioning of the Trust’?

We also see from the job description that he or she is to ‘champion a culture of innovation, continuous improvement and trust’ and ‘champion an open and inclusive culture and management style that is receptive to staff involvement, being effective in working relationships and communications with colleagues so they feel motivated, developed, supported and respective (sic)’. All well and good, but the applicant needs to ask: How, exactly, will I be able to do this ‘championing’?

Which raises the question: What resources will be available to the successful applicant for the purposes of ensuring and championing?

On this the Chief Executive’s job description is silent, unfortunately.

However, it does provide a rudimentary organization chart. This shows a hierarchy, with the Chief Executive perched on top of a row of six directors, one of whom is the Chief Operating Officer, who will be similarly perched atop the seven care groups. Anyone applying for the Chief Executive position should ask whether they would be dependent on the Chief Operating Officer for information from within a care group. That person may well have an incentive not to pass upwards information about a problematic situation in a care group if, for example, that would reveal negligence on his or her part. Hierarchies can be hugely dysfunctional for this reason.

The NGO review mentioned above found several instances of the Trust failing to act to address issues raised when staff spoke up. Their report said these were in breach of the Trust’s speaking up policy that states that the trust is committed to ‘listening to our staff, learning lessons and improving patient care’.[11] (Italics in original)

Workers are the eyes and ears of an organisation and are often first to identify actual or latent issues that could impact on an organisation’s ability to deliver its objectives.[12]

The instances described in the NGO report highlight the need for the Trust to ensure that it responds appropriately to its workers who speak up.

The Trust’s policy on speaking up states: ‘In accordance with our duty of candour, our senior leaders and entire board are committed to an open and honest culture. We will look into what you say and you will always have access to the support you need.’[13]

How can this obligation be fulfilled? How can the Chief Executive connect himself or herself with the eyes and ears of the Trust’s workers? Will they, for example, be able to set up their own unit of open-minded ‘roving inspectors’ who are not bound by the restrictions of hierarchy but free to talk to any Trust employee who is involved in patient care?

What the Chief Executive does receive at present is formal reports. At the foot of Page 4 of the Chief Executive Recruitment Information Pack, you will find a link to ‘the Trust Improvement Programme’, a page on the Trust’s website.[14] At the foot of that page is a further link to ‘Trust Improvement Plan – October 2018 update’. That update (the latest) consists of a four-page report to the Trust Board entitled Quality Improvement Programme update.[15] On Page 3 of that report is an Executive Summary, where we can see half a dozen points under the heading ‘Culture and Leadership’.

While these points may go some way towards building a more cohesive workforce – e.g. ‘Increasing local activity seen throughout social media on informal events for staff to come together to build better working relationships which will improve patient care’ – they fall a long way short of exploring and learning from case-studies of actual patient care and of staff speaking up. They also leave unanswered the question of whether workers who carry out ‘hotel’ functions that have been outsourced to Mitie are treated as ‘staff’. So here are more matters which you may wish to explore if you are called for interview.

Importantly, the NGO report noted that there may be cultural issues specific to Cornwall:

Staff comments often referred to a historic poor speaking-up culture across the trust. One senior leader told us: ‘There’s a long and dark history to this Trust, and to Cornwall generally. Getting through to people is labour intensive. Getting through to them to believe that they will really be listened to and taken seriously has been the most difficult of anywhere I have seen.’[16]

Workers highlighted the geographical location of the Trust as a factor in poor staff relations, stating that because of the Trust’s relative isolation staff often stayed in their roles for many years, and where they remained so did the poor relations between them. One senior leader commented: ‘Many [staff] have a long length of service … Their views become entrenched.’[17]

If you are applying for the Chief Executive position you may wish to think about these comments in advance of being interviewed, and also ask the interviewing board for their views on them.

My own conclusions from this brief survey are two-fold and they are stark. First, the culture of the Trust badly needs a shake-up. It is ossified and it needs a revolution. Second, the notion that what the Trust needs is a brilliant, charismatic leader sitting at the top of a hierarchy is utterly misconceived: there is no way in which this can produce beneficial cultural change.

What is needed is a combination of old hands and young minds: old hands to keep the ship steady, and fresh young minds to ask questions, talk to everyone irrespective of their official position, and bring the energy of startup enterprises to the 70-year-old NHS.

And who knows: perhaps we can look forward to the appearance of the Royal Cornwall Hospitals Teamwork Manual. That really would be something!

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Notes and references [All websites last accessed 31.12.2018]

1. Royal Cornwall Hospitals NHS Trust, Chief Executive Recruitment Information Pack, December 2018
   https://spr4cornwall.net/wp-content/uploads/CEO-Recruitment-Information-Pack-RCHT-Dec-2018.pdf
2. Royal Cornwall Hospitals NHS Trust, Clinical Director, November 2018
   https://spr4cornwall.net/wp-content/uploads/Job-description-RCHT-Clinical-Director-Nov-2018.pdf
3. Royal Cornwall Hospitals NHS Trust, Head of Nursing/Allied Health Professionals, December 2018
   https://spr4cornwall.net/wp-content/uploads/Job_description-RCHT-Head-of-Nursing_AHP-Dec-2018.pdf
4. Royal Cornwall Hospitals NHS Trust, Care Group General Manager, December 2018
   https://spr4cornwall.net/wp-content/uploads/Job_description-RCHT-Care-Group-General-Manager-Dec-2018.pdf
5. National Guardian’s Office (NGO), A Review by the National Guardian of speaking up in an NHS Trust, December 2018, p.12
   https://www.cqc.org.uk/sites/default/files/20181219%20-%20Royal%20Cornwall%20NHS%20Trust%20-%20A%20review%20of%20the%20handling%20of%20speaking%20up%20cases%20.pdf
   OR https://spr4cornwall.net/wp-content/uploads/NGO-20181219-RCHT-Review-by-National-Guardian-of-speaking-up-in-an-NHS-trust.pdf
6. NGO (as Note 5), p.4
7. NGO (as Note 5), p.12
8. NGO (as Note 5), p.12
9. Peter Levin, How a lack of teamwork at the Royal Cornwall Hospital contributed to the death of a child with autism, 19 December 2018
   https://spr4cornwall.net/wp-content/uploads/Lack-of-teamwork-at-the-Royal-Cornwall-Hospital.pdf
10. Royal Cornwall Hospitals NHS Trust (as 1)
11. NGO (as Note 5), p.19
12. NGO (as Note 5), p.19
13. NGO (as Note 5), p.12
14. Royal Cornwall Hospitals NHS Trust, Trust Improvement Programme,
    https://www.royalcornwall.nhs.uk/our-organisation/about/trust-improvement-programme/
15. Royal Cornwall Hospitals NHS Trust, Quality Improvement Programme update,
    https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/TrustBoard/Minutes/1819/201810/App09TrustQualityImprovementProgrammeUpdate.pdf
    OR https://spr4cornwall.net/wp-content/uploads/RCHT-Quality-Improvement-Programme-update-4.10.2018.pdf
16. NGO (as Note 5), p.12
17. NGO (as Note 5), p.11

by Dr Peter Levin and Dr Kath Maguire, published in the West Cornwall HealthWatch column in The Cornishman, December 6th, 2018

This article can be downloaded in pdf format here.

* * *

It is important to recognise the many health care professionals who provide an excellent service. Yet, when things don’t go well, it is vital to learn and avoid repeating the same mistakes.

Sometimes patients feel reluctant to give negative feedback. They might not like complaining, fear giving offence or think that they can’t make a difference.

We would like to tell you about a patient story that did make a difference and share some ways you can get your voice heard.

Last year we heard about Mrs P, an elderly patient who was left feeling anxious and confused. The different nurses visiting each week to dress her leg ulcer often did not know what had been done before and gave contradictory advice.

Our efforts to raise Mrs P’s concerns have been described in detail by
Dr Peter Levin (https://bit.ly/2KN6rTX). This October we met with members of the Community Nursing Team to discuss learning from Mrs P’s story.

This was really encouraging. We heard that Mrs P’s and other patient stories have been discussed at team meetings and used to improve both the training and management of Community Nursing in Cornwall.

Teams have been reorganised to make sure patients are seen by the same nurses as often as possible and that there is more time for teams to share information and skills.

The way that medical supplies are managed has been improved to help nurses access what patients need more effectively.

It was also really good to hear that patients are being actively encouraged to express concerns or complaints directly to the nurse who visits them or by phone to their Community Nursing team leader or manager.

All complaints are investigated and patients are told about any action taken to address their concerns.

The Community Nursing teams share improvements made in response to patient feedback at a Cornwall-wide forum so that other patients benefit too.

This provides patients and carers with a direct way to help improve the quality of community health services.

If you don’t feel able to complain directly, you can also contact the Patient Advisory and Liaison Service, or PALS, which exists to support patients to raise concerns.

For services managed by the Cornwall Partnership NHS Foundation Trust, like Community Nursing, Community Hospitals and Mental Health services, the PALS number is 01208 834620.

For the service covering West Cornwall Hospital, St Michael’s or Treliske call 01872 252793.

Sharing your experiences and concerns for health and social care services can make a difference and help to make services better and safer for us all.

Your concerns continue to be important to us at West Cornwall HealthWatch, and we are interested in hearing your experiences of giving and receiving feedback. Write to: westcornwallhealthwatch@yahoo.co.uk

Letter published in The Cornishman, Thursday, November 8th, 2018

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As The Cornishman reported last week, the investigation into the tragic death of 6-year-old Coco Bradford identified numerous failures in the treatment she received at Treliske.

It wasn’t recognised that she was clinically dehydrated and in clinical shock when she arrived at the emergency department, these conditions weren’t treated appropriately, and official guidelines weren’t followed while she was on Polkerris Ward. Crucially, Coco wasn’t given the rehydration treatment that she should have been. The abnormal results of tests weren’t identified and acted on, her blood pressure wasn’t obtained until 36 hours after she was admitted to hospital, and there was a delay in starting antibiotics when her clinical picture suggested she had developed sepsis.

Faulty too was the assessment of the pain that Coco was in. On many occasions she was described as ‘distressed’, ‘inconsolable’ or ‘agitated’, but her pain score was recorded as zero, not having pain, and the standard pain assessment tool was not made use of (although she was prescribed paracetamol, which would have been given as pain relief). The hospital’s Learning Disability team was not called in to help in establishing a relationship with this autistic child, who some members of staff thought was ‘unco-operative’ and ‘non-compliant’.

The purpose of the investigation was to learn lessons for the future from this sad affair. So the investigation report avoids saying who didn’t recognise Coco’s condition, who didn’t follow official guidance, who didn’t identify abnormal results, who delayed taking Coco’s blood pressure, who delayed starting antibiotics. It makes general recommendations: that’s all.

I appreciate that, as the investigation report says, when Coco was in Treliske the hospital was under great pressure. Polkerris Ward was full and it was understaffed, especially at night. In such circumstances, staff may find their patience strained, especially with patients and families who present as in some way ‘difficult’.

But individual people and their attitudes do seem to have played a crucial part in Coco’s treatment. We have a clue to this in Coco’s mum reporting that she and Coco’s elder sister (herself a clinical skills tutor in the NHS) were treated with ‘arrogance’.

Arguably, it is arrogance that leads professional people to think that they know best, that they don’t have to follow the rulebook, that they don’t have to answer questions from ordinary folk.

The investigation team were critical of staffing levels and the behaviour of some (unidentified) clinicians, but they made no recommendations for tackling arrogance among the professionals who work at Treliske.

So let me add one of my own. Anyone – patient, relative, child – is entitled to ask a question and receive a respectful, thought-about answer. Every now and again, one of these will give rise to a suggestion worth acting on. I hope the Royal Cornwall Hospitals Trust will be big enough to take this additional recommendation on board.

Peter Levin

A fuller analysis of this case will be published on this website shortly.

[Statements by Coco’s mother, Rachel Bradford, and her sister Chelsea, reported in The Cornishman (1 November 2018), can be viewed here.]

This report can be downloaded in pdf format here.

Submission to NHS England’s consultation on the contracting arrangements for Integrated Care Providers

Observations
1. NHS England (NHSE) is proposing to insert a layer of ‘Integrated Care Providers’ (ICPs) into the NHS hierarchy, and is currently consulting about contracting arrangements for them.

It says the aim is to help bring about joined-up care, especially for patients with multiple conditions.

ICPs will come between Clinical Commissioning Groups (CCGs) and many of the organizations that do the actual work of delivering health and social care services.

These contracts, if implemented, would add another purchaser/provider split to the NHS. Such splits and the associated procurement processes not only impose costs and delays in decision-making in the NHS: they are inherently detrimental to the collaborative working which joined-up care necessitates.

2. It is suggested more than once in the consultation document[1] that the Dudley model provides a template for other parts of the country. This ignores the fact that for Dudley right now this model is primarily centred on integrating primary care with other parts of the NHS system.[2] This is a remarkably limited application of the principle of joined-up care.

Moreover, the Strategy Unit that has evaluated the Dudley New Care Models Programme has warned that NHS England should be ‘very cautious in using the example of Dudley in considering replication’. Indeed, in a recent report the Unit has identified a risk that social care could be ‘lost’: ‘’Better integration with social care’ was one of the founding arguments for the Multi-Specialty Community Provider; yet uncertainty remains as to how/whether/when this might happen.‘[3] The consultation document ignores this warning.

3. In Cornwall, the chief officer of Kernow CCG participates on equal terms with the chief executives of Cornwall Council, the Royal Cornwall Hospital NHS Trust and the Cornwall Partnership Foundation Trust in the ‘Transformation Board’, which, although not a decision-taking body, is overseeing the development of joined-up health and social care plans for Cornwall and the Isles of Scilly. This process has included co-production workshops across the county, in which not only professionals but lay people with experience of receiving services have taken part.[4]

Recently, a partnership bid to the Department of Health & Social Care for a Social Prescribing Scheme for Cornwall, led by a third-sector organization, Volunteer Cornwall, was successful. It brings an investment of £900,000 over the next 3 years, which will ‘enable healthcare professionals to refer patients to a link worker, to co-design a non-clinical social prescription to improve their health and wellbeing.’ So this promising project is coming into being to promote joined-up care without recourse to an ICP or a costly procurement process.[5,6,7]

4. Across the Tamar, in Devon, there have been two major developments recently. The two Devon CCGs have agreed that Devon Children and Families Alliance should be the preferred bidder for community health and wellbeing services across the county. The alliance comprises five Trusts and Livewell Southwest, a community interest company. The contract is worth £166m over seven years, with the potential to extend for three years. The alliance will take over from Virgin Care, the current provider.[8]

A second set of community health services, for children with special educational needs and disabilities in Plymouth, is expected to be awarded to Livewell Southwest, which will run the service in partnership with University Hospitals Plymouth Trust, Plymouth City Council, and charities Barnado’s and The Zone, and mental health support scheme Xenzone. That contract, also for seven years, is worth nearly £88m.[9]

Livewell Southwest is an independent, award winning social enterprise providing integrated health and social care services for people across Plymouth, South Hams and West Devon, as well as some specialist services for people living in other parts of Devon and in Cornwall too. It aims to care for people in new ways that are more efficient, with health and social care professionals who would have previously worked in individual teams now working together: joined-up care, in fact.[10]

It works with a wide range of community groups and professionals so support is responsive and provided within the local community. Its website says: ‘You will find our teams in community hospitals, GP practices, sports centres, health and wellbeing hubs, at community events and even at football matches.’[11]

In 2016 Livewell Southwest was inspected by the Care Quality Commission. It received a rating of ‘good’ overall. Its mental health inpatient unit and community learning disabilities team received a rating of ‘outstanding’. Evidently it is doing good work.

Conclusion
These examples show that at local level, charities, other voluntary bodies and community interest companies are perfectly capable of coming up with sound ideas and schemes for joined-up care. Ways need to be found of encouraging these and helping them to develop.

In Cornwall, where it is estimated that one in three people do voluntary work,[12] staff in health and social care organizations recognise very well the need for joined-up care and are learning to work with third-sector organizations and harness the energy and local knowledge that the best of them have. Adding ICPs into the mix would create complexity and costs, and at the very least set this work back, if not stifle it completely.

It seems that inserting an extra layer into an organizational hierarchy structured by contracts is seen by some at NHS England as a means of bringing about collaborative working. Sad to say, this suggests that the people who commission such systems simply do not comprehend how collaborative working can grow from the grass-roots, and how it can be nurtured.

---

Notes and references (All websites last checked on 4 October 2018.)

[1] NHS England, Consultation on contracting arrangements for Integrated Care Providers (ICPs), August 2018
https://www.engage.england.nhs.uk/consultation/proposed-contracting-arrangements-for-icps/

[2] Paul Maubach, in House of Commons Health and Social Care Committee, Oral evidence: Integrated care: organisations, partnerships and systems, HC 650, 6 March 2018, at Q172
http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-and-social-care-committee/integrated-care-organisations-partnerships-and-systems/oral/80041.pdf

[3] F.Battye, A.Mulla & M.Begum, Evaluation of the Dudley New Care Models Programme: Strategic Level Evaluation, December 2017 (Final report published 26 July 2018)
https://www.strategyunitwm.nhs.uk/publications/evaluation-dudley-new-care-models-programme

[4] Cornwall and the Isles of Scilly Health and Social Care Partnership, Cornwall and Isles of Scilly Transformation Board
https://www.shapingourfuture.info/about/cornwall-isles-scilly-transformation-board/

[5] Volunteer Cornwall, Social Prescribing Boost for Cornwall,
https://www.volunteercornwall.org.uk/latest-news/22-news/285-social-prescribing-boost-for-cornwall

[6] Volunteer Cornwall, Social Prescribing
https://www.volunteercornwall.org.uk/how-we-help/health-social-care/social-prescribing

[7] Cornwall and the Isles of Scilly Health and Social Care Partnership, Social prescribing is just what the doctor ordered, 15 August 2018
https://www.shapingourfuture.info/social-prescribing-is-just-what-the-doctor-ordered/

[8] Nick Carding, Virgin Care set to lose children’s service contract to NHS consortium, Health Service Journal, 25 September 2018 (paywall)
https//www.hsj.co.uk/service-design/virgin-care-set-to-lose-childrens-service-contract-to-nhs-consortium/7023440.article

[9] Information on CCG meetings in Devon can be found at
https://www.newdevonccg.nhs.uk/governing-body/governing-body-meetings-100205

[10] Livewell Southwest (home page)
https://www.livewellsouthwest.co.uk/

[11] As 10.

[12] ‘In Cornwall it is estimated that one in 3 people do voluntary work and the scheme will ensure volunteers can contribute to social prescribing by supporting those on the scheme to access activities and develop new activities.’ Department of Health & Social Care, Social prescribing schemes to receive funding from the Health and Wellbeing Fund: 2018, 2 August 2018
https://www.gov.uk/government/publications/social-prescribing-schemes-to-be-funded-by-the-health-and-wellbeing-fund-2018/social-prescribing-schemes-to-receive-funding-from-the-health-and-wellbeing-fund-2018#volunteer-cornwall

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This report can be downloaded in pdf format here.

Who’s in charge at Treliske?
Last week, I reported on the recent resignation of Kathy Byrne as Chief Executive of the Royal Cornwall Hospitals Trust (RCHT).[1] Judging by precedent, we might have thought we were in for another extended period of searching for a replacement, and perhaps we are, but on the RCHT website today we find Kate Shields, who was previously Kathy Byrne’s deputy (i.e. Deputy Chief Executive), described as Chief Executive:

Kate joined the Trust as Deputy Chief Executive in 2017 and took on the role of Chief Executive in July 2018.[2]

Not ‘acting’, not ‘interim’, just Chief Executive. And in the small print on the agenda for the meeting of the Trust Board that took place last week, on August 2nd, we again find her listed as ‘Chief Executive’.[3]

It took a phone call from the editor of Cornish Stuff to the RCHT press office to elicit the fact that Kate Shields’ appointment is an interim one, so it will last only until an appointment proper is made.[4] This could be twelve months away. Clearly one of Kate Shields’ first tasks will be to address the shortcomings of her central administration and press office.

The need for systems reform at Treliske
But there is a major job of work calling for her attention. The reports by the Care Quality Commission (CQC) on RCHT’s main hospital at Treliske in July 2017 and January 2018 criticised not only particular services but systems:

We had serious concerns that systems to assess, monitor, and mitigate risks to patients receiving care and treatment were not operating effectively. We also had concerns that governance systems and processes were not operating effectively.[5]

[We had] serious concerns that systems to assess and deal with risks to patients in maternity and surgery were not operating effectively. Governance systems were not operating effectively in critical care and the fracture clinic … Systems and processes to ensure equipment was of good repair and properly maintained were not operating effectively. Nor were there effective systems for the management of incidents and Never Events, or to comply with the requirements of the duty of candour.[6]

Problems with governance and systems are invariably deep-rooted. Solving them requires capable leadership. So when such problems persist, they are indicators of defects in leadership. The leadership model operated by Kathy Byrne appears to have been of the classic ‘command and control’ type,[7] which – as The King’s Fund and NHS Improvement have identified – is not fit for purpose in today’s NHS. Something different is needed.

Kate Shields has to make a choice
What are Kate Shields’ options as interim Chief Executive? There are basically two. One is to simply hold the fort until a permanent appointment is made. That clearly would not address the system problems identified by the CQC. And it would amount to a surrender to whatever ‘occupying forces’ are sent in to inflict ‘special measures’ on Treliske.

Her other option is to take the initiative. What should she do?

Her opportunity comes at an interesting time for ‘leadership’ in the NHS. The report by Sir Robert Francis QC on whistle-blowing in the NHS – Freedom to Speak Up, published in February 2015 – stressed that culture is a highly important factor within NHS organizations:

I have concluded that there is a culture within many parts of the NHS which deters staff from raising serious and sensitive concerns and which not infrequently has negative consequences for those brave enough to raise them.’ [8]

This focus on the culture within NHS organizations has been followed up by NHS Improvement[9] and the King’s Fund. It is now widely accepted that healthy cultures in NHS organisations are crucial to ensuring the delivery of high-quality patient care. The King’s Fund has identified six characteristics as being fundamental to a healthy culture: (1) Inspiring vision and values; (2) Goals and performance; (3) Support and compassion; (4) Learning and innovation; (5) Effective teamwork; and (6) Collective leadership.[10] (These are reproduced in the Appendix to this report on pages 4-5.) Such a culture – the King’s Fund model – differs in significant respects from the ‘command and control’ model which seems to have guided Kathy Byrne.

So we have this question: can Kate Shields move the culture of Treliske towards the King’s Fund model? What do we know about her?

Her career is briefly summarized on the RCHT website:

Kate is an experienced NHS leader having worked as Director of Strategy and Partnerships at University Hospitals Leicester. She was a registered nurse and mental health nurse at the beginning of her NHS career. Kate has also worked for NHS England as a Regional Director of Specialised Commissioning and as the National Head of Specialised Commissioning.[11]

We can cautiously take encouragement from the fact that she has experienced working as a nurse, at the ‘sharp end’ of hospital care. So she should be familiar with hospital cultures, and the mix of departmental hierarchies and professional ‘territories’ that are found within hospitals, and – one hopes – she will have developed the personal and interpersonal skills necessary to create an atmosphere of trust and mutual understanding in such a context.

Kate Shields’ clinical background may give her an advantage over Kathy Byrne, who describes herself on ‘LinkedIn’ as having 20 years’ experience as a ‘chief executive in public, commercial and not for profit organisations with particular achievement in customer focused service outcomes, business transformation and enablement through technology’, and as having ‘a significant track record in strategic and operational leadership, change and innovation in challenging environments in five States and Territories of Australia’. She does not mention hospitals.

What role for patients and the public?
Patients and the public in Cornwall should be heartened to read in the King’s Fund report that

• patient-centredness and responsiveness are core
• patient feedback, allied to clear goals, is a necessity
• there has to be an emphasis on learning within the system, and there is a role here for patients’ views and feedback
• collective leadership in the NHS should include patients taking on leadership roles, both in determining their own care and in shaping their health care organisations (via patient representatives and patient groups).

It is important to highlight these, because not only do they specify a proactive role for patients: they provide terms of reference for Kate Shields and they also provide us with a set of criteria by which patients and the people of Cornwall, as well as her own staff, can judge how well she is performing in her role.

So can patients and the public make a useful contribution? And if so, how?

To answer these questions we need to look both at services and at systems, as highlighted by the CQC. The King’s Fund report is clearer about services: patients can give feedback, and ask what has been learned from it and how it has been acted on: this is a necessity, as is learning from such feedback. Patients can be involved not only in the day-to-day provision of services but also in their management, e.g. through consultation when decisions – on the allocation of resources, for example – have to be taken. (They can exercise influence simply by asking questions: it does not follow that clinical autonomy has to be sacrificed.) Even if they do no more than ask questions, they are helping to ensure that learning is taking place.

There can also be a useful role for patient representatives and groups in designing systems, as is badly needed at Treliske. By describing their experiences, they can ensure that the patient experience is not lost sight of but heard and appreciated. Importantly, they can make a worthwhile contribution by asking questions and by scrutinizing proposals for change and teasing out their implications. Many lay people in this day and age have experience of systems, of many different kinds, and it would be silly not to take advantage of this. Moreover, people outside the NHS may be well placed to provide support for proposals and requests for funding when the NHS encounters politics.

Can we expect culture change at Treliske?
Now that Kathy Byrne has completed her contribution to ‘leadership churn’[12] at Treliske and Kate Shields has taken the helm, albeit on an interim basis, what can we expect? It was encouraging to learn that at the beginning of this year she and Jim McKenna (then Chair of the Trust) had written to staff to thank them for everything they were doing for patients during a very challenging time. ‘We wish you a happy new year and let’s make sure we look after each other and support one another in the year ahead.’ The letter also asked for feedback from staff about the current service pressures, including what they were doing well and not so well. ‘We will have made mistakes in recent weeks and we need to learn if we are to improve the care we provide and meet the needs of the local population.’[13] The sentiments in this final sentence do credit to her: that they justify the description ‘extraordinary’ is a mark of how unusual they are.

The role of Chief Executive of an NHS hospital trust is a lonely one. And Kate Shields will be taking on not only the role of heading the Royal Cornwall Hospitals Trust but also the demanding high-level political/strategic role of finding a place for RCHT in some kind of integrated health and social care organization within Cornwall’s devolution scheme. From the point of view of patients and the wider community in Cornwall, we can only say that if she manages to ride both these horses simultaneously and successfully, and to be open to the involvement of patients and the public, she will earn our unstinting gratitude and support. We wish her well.

* * *

[With thanks to my fellow-members of the committee of West Cornwall HealthWatch for their insightful comments and suggestions.]

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Appendix: The King’s Fund on ‘the characteristics of a healthy culture’

The King’s Fund has identified six characteristics as being fundamental to a healthy culture: (1) Inspiring vision and values; (2) Clear goals and performance feedback; (3) Support and compassion; (4) Learning and innovation; (5) Effective teamwork; and (6) Collective leadership. Here is a very slightly edited version of what The King’s Fund says.[10]

1. Inspiring vision and values. Leaders at every level should communicate an inspiring, forward-looking and ambitious vision focused on offering high-quality, compassionate care to the communities they serve. There should be clear values that set expectations for how staff conduct themselves and interact with colleagues and patients. Values are set out in the NHS constitution, and patient-centredness and responsiveness are core. Good leaders reiterate at every level the message that high-quality, compassionate care is the core purpose of all staff, so that everyone understands and acts on this commitment. This takes time, sustained energy and dedication.

2. Clear goals and performance feedback. There must be clear goals, supported by performance feedback. Goals must be set at every level from the board to frontline staff. Board goals should be shaped by patient input. Performance feedback should be based on patient feedback and patient outcomes. Staff in health services report that they are often overwhelmed by their workload and are unclear about the goals they are working towards. This produces stress, inefficiency and poor quality care. Such situations can arise when senior managers insist on too many priorities. A clear vision and mission statement about high-quality, compassionate care provides a directional path for staff. But this must be translated into clear, aligned, agreed and challenging goals at all levels of the organisation. It must be matched by timely, helpful and formative feedback for those delivering care if they are to continually improve quality.

3. Support and compassion. If we want staff to treat patients with respect, care and compassion, all leaders and staff must treat their colleagues with respect, care and compassion. Directive, aggressive or brusque leaders dilute the ability of staff to make good decisions, deplete their emotional resources and hinder their ability to relate effectively to patients, especially those who are most distressed or challenging. There are clear links between staff experience and patient outcomes. Staff views of their leaders are strongly related to patients’ perceptions of the quality of care. The higher the levels of satisfaction and commitment that staff report, the higher the levels of satisfaction that patients report. If leaders and managers create positive, supportive environments for staff, they in turn create caring, supportive environments and deliver high-quality care for patients. Such leadership cultures encourage staff engagement.

4. Learning and innovation. Sustaining cultures of high-quality care involves all staff focusing on continual learning and improvement of patient care. Learning and quality improvement are dependent on continual patient input – innovation is most likely where patients’ views and feedback play a strong role. A focus on improvement should ensure that: (a) teams at all levels collectively take time to review and improve their performance; (b) quality and patient safety practices are an ongoing priority for all; and (c) there are high levels of dialogue, debate and discussion across the organisation to achieve shared understanding about quality problems and solutions. All staff should encourage, welcome and explore feedback and treat complaints and errors as opportunities for learning across the system rather than as a prompt for blame. This encourages collective openness to and learning from errors, near misses and incidents.

5. Effective teamworking. Where multi-professional teams work together, patient satisfaction is higher, health care delivery is more effective, there are higher levels of innovation in ways of caring for patients, lower levels of stress, absenteeism and turnover, and more consistent communication with patients. Leadership that ensures effective team and inter-teamwork (both within and across organisational boundaries) is essential if NHS organisations are to meet the challenges ahead. Shared leadership in teams is a strong predictor of team performance.

6. Collective leadership. Leadership in the NHS should be collective and distributed rather than located in a few individuals at the top of organisations. Collective leadership means everyone taking responsibility for the success of the organisation as a whole – not just for their own jobs. It requires organisations to distribute leadership power to wherever expertise, capability and motivation sit within organisations. This includes patients taking on leadership roles, both in determining their own care and in shaping their health care organisations (via patient representatives and patient groups). Collective leadership should also be collaborative, with leaders working together – and with a common style of supportive, enabling and empowering leadership to prioritise quality of patient/service user care overall, not simply in their own areas of operation. It is through collective leadership that cultures of high-quality, compassionate and continually improving care will develop and thrive. Every interaction by every leader at every level shapes the emerging culture of an organisation.

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Notes and references (All online sources last accessed 10 August 2018)

[1] https://spr4cornwall.net/royal-cornwall-hospitals-nhs-trust-is-one-person-able-to-do-the-chief-executives-job/

[2] https://www.royalcornwall.nhs.uk/our-organisation/about/your-trust-board/

[3] https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/TrustBoard/Minutes/1819/201808/Agenda.pdf

[4] https://cornishstuff.com/2018/08/10/deputy-is-new-treliske-boss-for-a-year-at-least/

[5] Care Quality Commission, Royal Cornwall Hospital, Quality Report, 5 Oct 2017, p.2
https://www.cqc.org.uk/sites/default/files/new_reports/AAAG6980.pdf

[6] Care Quality Commission, Royal Cornwall Hospitals NHS Trust, Quality Report, 5 April 2018, p.5
https://www.cqc.org.uk/sites/default/files/20180405_Royal_Cornwall_Hospitals_NHS_Trust_REF.pdf

[7] A major improvement in the functioning of the Emergency Department at Treliske earlier this year has been attributed by the Trust to the ‘Gold Command’ system that had been put in place. Overlooked was the fact that the new system depended heavily for its success on people ‘pitching in together’, i.e. on collective behaviour. See Credit where credit is due! So well done to everyone who helped turn round the situation in A&E at the Royal Cornwall Hospital, Treliske (Truro). Now the right lessons must be learned.
https://spr4cornwall.net/credit-where-credit-is-due-so-well-done-everyone-who-helped-turn-round-the-situation-in-ae-at-the-royal-cornwall-hospital-treliske-truro-now-the-right-lessons-must-be-learned/

[8] Sir Robert Francis, Freedom to Speak Up, February 2015, p.8
http://freedomtospeakup.org.uk/the-report

[9] NHS Improvement, Why is culture important?, September 2017
https://improvement.nhs.uk/documents/1629/01-NHS101_02_Improvement_Mini_Guide-Why__100417_I.pdf

[10] The King’s Fund, Improving NHS Culture, 25 August 2015
https://www.kingsfund.org.uk/projects/culture

[11] As [2]

[12] On ‘leadership churn’, see The King’s Fund, Leadership in Today’s NHS: Delivering the Impossible, 18 July 2018
https://www.kingsfund.org.uk/publications/leadership-todays-nhs

[13] Ginette Davis, The extraordinary thank you letter sent to NHS staff in Cornwall, Cornwall Live, 10 January 2018
https://www.cornwalllive.com/news/cornwall-news/extraordinary-thank-you-letter-sent-1037593

This report can be downloaded in pdf format here.

In recent years, there has been an extraordinary turnover of the occupants of the posts of Chief Executive of the Royal Cornwall Hospitals Trust (RCHT) and Chair of the Trust. With the recently-announced resignation of Kathy Byrne, the Trust is now looking for its sixth Chief Executive (including acting holders of the post) in seven years. And the recent resignation of Jim McKenna as Chair of the Trustees means that the Trust is seeking its fifth Chair in that period.

Ms Byrne herself has emphasized the importance of stable leadership at the Trust, and in October last year, in an interview broadcast on BBC Radio Cornwall, she said: ‘We have finally established a stable leadership team at the Trust’.[1] So it is ironic that only nine months later, after a mere two and a half years in post, she is leaving that team.

Irony aside, the Care Quality Commission (CQC) has made clear the importance that it attaches to stability in management. An inspection team visited Treliske in January 2016, and in its report (published in May 2016) it commented:

There had been significant and continuing instability at board level however the appointment of an experienced chairman in 2015 was having an impact and there was a sense that the leadership team … were working well together.[2]

Sadly, Ms Byrne’s departure is dispelling that optimism.

The effect of changes in leadership is graphically illustrated in another recent report by the CQC, on partnership working to deliver health and social care in Cornwall:

[Talking] with senior system leaders, it was clear that the acknowledged historical differences, together with numerous changes in key leadership roles over several years, had taken their toll on partnership working and relationships. Some leaders were very focused on the ‘long game’, and this included working with an external strategic partner with a view to transformation … Other senior leaders were more rooted in transforming current fragmented systems.[3]

The CQC seems to have uncovered the main reason for the high turnover of RCHT chief executives. Appointees have been expected to take on two very different roles simultaneously: the high-level political/strategic role – the ‘long game’ – of finding a place for RCHT in some kind of integrated health and social care organization within Cornwall’s devolution scheme, and the day-to-day role of getting a large hospital to run smoothly, efficiently, and in a way that conforms to best practice and responds to patients’ needs.

We see this ‘riding two horses’ approach very clearly in the news release that announced the appointment of Lezli Boswell as interim Chief Executive (she was subsequently confirmed in the post) in September 2011:

‘Lezli brings considerable expertise to RCHT, enabling us to maintain our focus on the delivery of our strategic plan and aspiration to be a foundation trust (FT) with all the benefits to patient care that will bring,’ said Royal Cornwall’s chairman Martin Watts.[4]

The potential conflict between patient care and FT aspiration was highlighted, as is well known, in the report by Robert Francis QC on the Mid Staffordshire (Stafford Hospital) public inquiry which he conducted:

There was an unacceptable delay in addressing the issue of shortage of skilled nursing staff. There can be little doubt that the reason for the slow progress in the review, and the slowness of the Board to inject the necessary funds and a sense of real urgency into the process, was the priority given to ensuring that the Trust books were in order for the FT application.[5]

It is no criticism of Ms Byrne to point out that while in post she has been under considerable pressure to devote her time to her strategic role, and to suggest that this may help to account for the fact that the CQC, following an inspection in July 2017, rated the Trust as inadequate overall. Surgery, maternity and gynaecology, end of life and outpatient services were rated as inadequate, although critical care and children and young people’s services were rated as good. The CQC said:

We had serious concerns that systems to assess, monitor, and mitigate risks to patients receiving care and treatment were not operating effectively. We also had concerns that governance systems and processes were not operating effectively.[6]

The CQC served the Trust with a Warning Notice on 29 August 2017. The Notice required it to make significant improvements by 30 November 2017.

The CQC made a further, unannounced inspection of Treliske in January 2018, when it found continuing concerns in surgery, critical care, maternity, and outpatient services. On 6 April 2018 it issued a further Warning Notice requiring the Trust to make further improvements within one week. In particular, it said, there were

serious concerns that systems to assess and deal with risks to patients in maternity and surgery were not operating effectively. Governance systems were not operating effectively in critical care and the fracture clinic … Systems and processes to ensure equipment was of good repair and properly maintained were not operating effectively. Nor were there effective systems for the management of incidents and Never Events, or to comply with the requirements of the duty of candour.[7]

It is hard to resist the conclusion that the CQC’s findings reflected an emphasis at the highest level within RCHT on the high-level political/strategic role as opposed to the day-to-day role of addressing the problems of Treliske hospital identified by the CQC. It may be, too, that those problems required a ‘hands-on’ approach from management rather than an issuing of instructions from on high.

What can be learned from this state of affairs, and what should now be done? Here are three suggestions:

1. The recently resigned Chief Executive and Trust chair should both be asked to submit a report setting out what they have learned in office and offering frank advice to their successor on dealing with the situation they will find. This report should include an honest assessment of the working relationships between the management and senior clinicians. This is surely not unreasonable and should be done as a matter of course as part of the handover process to a new incumbent.

2. Careful thought needs to be given to the job description for the Chief Executive post. It needs to be asked whether it is actually feasible for one person to perform both the strategic ‘long game’ role and the hands-on role identified by the CQC. It may be that the strategic role would be best played by the incoming Chair of the Trust, and the availability of both positions offers an opportunity to bring about such an allocation of responsibilities. So careful thought needs to be given to the job description for the Trust Chair too.

3. The extraordinary turnover of RCHT chief executives in the past seven years does not inspire confidence in the selection processes that have been followed. There should be an obligation on the Trust to show how the members of the selection board have themselves been selected, what their qualifications are, and what criteria they are expected to apply. Like the CQC inspections, these are matters of great public interest to the people of Cornwall, and should be open to the light of day.

* * *

[With thanks to my fellow-members of the committee of West Cornwall HealthWatch for their insightful comments and suggestions.]

Peter Levin

31 July 2018

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Notes and references. All web sources last accessed on 30 July 2018.

1. Kathy Byrne interviewed by James Churchfield on BBC Radio Cornwall,
5 October 2017
https://www.bbc.co.uk/programmes/p05j3xnv

2. Care Quality Commission, Royal Cornwall Hospital, Quality Report,
12 May 2016, p.5
https://www.cqc.org.uk/sites/default/files/new_reports/AAAF3186.pdf

3. Care Quality Commission, Partnership working to deliver health and social care in Cornwall, 4 October 2017, p.7
https://www.cqc.org.uk/sites/default/files/20171004_quality_of_care_cornwall_report.pdf

4. Lezli Boswell starts as interim head of Royal Cornwall Hospitals, Guardian Healthcare, 2 Sept. 2011
https://www.theguardian.com/healthcare-network/2011/sep/02/lezli-boswell-royal-cornwall-hospitals-job-moves

5. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary, p.45
http://webarchive.nationalarchives.gov.uk/20150407084231/http://www.midstaffspublicinquiry.com/report

6. Care Quality Commission, Royal Cornwall Hospital, Quality Report, 5 Oct 2017, p.2
https://www.cqc.org.uk/sites/default/files/new_reports/AAAG6980.pdf

7. Care Quality Commission, Royal Cornwall Hospitals NHS Trust, Quality Report, 5 April 2018, p.5
https://www.cqc.org.uk/sites/default/files/20180405_Royal_Cornwall_Hospitals_NHS_Trust_REF.pdf

Today there is pressure on NHS providers to get patients to do more for themselves to care for their health. As NHS England has said, this requires the providers to work in partnership with patients. This is not something that providers are accustomed to doing. Can they learn how to do it? Sir Robert Francis’s report Freedom to Speak Up has shown that the dominant culture of the NHS today is defensive, which means it is inherently anti-learning. This report, prepared for West Cornwall HealthWatch, uses the story of a patient’s treatment by Cornwall’s Community Nursing Service to reveal the scale of the change required.   

This report can be downloaded in pdf format here.

‘Long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected ‘episodes’ of care.’ NHS England[1]

‘[We must] enable people to look after themselves through improved health education, information and opportunities to self-care and self-manage long-term conditions.’ Cornwall and the Isles of Scilly: Sustainability and Transformation Plan[2]

‘There has been significant progress to how the NHS learns from people’s complaints. However, there is still much to do so that people can see how their feedback has made a difference and has helped to change the way services are delivered.’ Healthwatch England[3]

‘Whistleblowers have provided convincing evidence that they raised serious concerns which were not only rejected but were met with a response which focused on disciplinary action against them rather than any effective attempt to address the issue they raised. … I have concluded that there is a culture within many parts of the NHS which deters staff from raising serious and sensitive concerns and which not infrequently has negative consequences for those brave enough to raise them.’ Sir Robert Francis[4]

1. Introduction
The above quotations highlight two present-day pressures for cultural change in the National Health Service. One is a pressure for patients to be much more involved in their own care and for the NHS to work in partnership with them. This would amount to a fundamental shift from a ‘treatment’ model of care (NHS England describes it as a ‘”factory” model of care and repair’)[5] to one based on ’partnership’, with healthcare providers working together with patients, supporting them to manage their health conditions in their own home or community.

The other pressure for cultural change in the NHS is a pressure for better learning, as emphasized by Healthwatch England. Here the treatment of whistleblowers described in Sir Robert Francis’s report is relevant. It brings out a crucial aspect of parts of the NHS today: the dominant culture is defensive and anti-learning.

Unfortunately these two cultural pressures tend to be addressed in isolation. The notion of partnership between patients and providers barely features in the publications of Healthwatch England, while NHS England scarcely mentioned ‘learning’ in Five Year Forward View. But if the NHS is to adapt to work in partnership with patients, it has much to learn.

In Sections 2 and 3 of this report I relate two stories that have a bearing on this point. Section 2 tells the story of an elderly lady living in Penzance and her experience at the hands of the Cornwall Community Nursing Service, while receiving treatment for a leg ulcer. Section 3 tells the story of my own attempt to find out if and how the feedback ‘made a difference’. Sections 4 and 5 deal with two particular issues arising out of the case-study – continuity of care and patient anonymity – while Section 6 shows why, in the interest of both partnership and effective feedback, dialogue between patient and provider should be encouraged.

2. The patient story
The patient in this case – let’s call her Mrs P – is in her late nineties and lives in Penzance. She is physically frail but her mind is sharp. She worked as a nurse until her daughter was born. The evidence in this case is provided by her own testimony and that of her daughter, who was formerly a barrister. Mrs P chose to remain anonymous: she wanted to avoid being viewed with hostility or suspicion by community nurses or labelled as a troublemaker. And for the same reasons she has not made a formal complaint.

A note comprising the following numbered paragraphs, dated 22 September 2017, was sent to Healthwatch Cornwall and subsequently to the Cornwall Partnership Foundation Trust, which runs the Community Nursing Service.

1. Mrs P broke her hip (fractured neck of femur) two years ago, and was treated in [the Royal Cornwall Hospital at] Treliske. The hip mended very well, but during the surgery the skin of her lower leg was damaged and the damage developed into an ulcer. This was treated weekly for about six months by community nurses, but there was minimal improvement. It was only after six months that one of the nurses applied a paste which had to be left on for a week. That treatment was administered again for a second week. The ulcer was almost completely healed and rapidly disappeared.

2. Four months ago Mrs P accidentally suffered a scratch on her other leg (from her footstool). Her vascular circulation to her lower limbs is very poor, and this scratch, despite treatment from the Community Nurse Service, turned into an ulcer and gradually grew in size. Mrs P asked for the same treatment, the paste which had been so successful, to be applied again. Despite repeating her request several times this has never been done. She subsequently asked for a pressure bandage and after several times of asking this was supplied. (One week a nurse told Mrs P she needed a pressure bandage; the next week a different nurse told her that she did not.) Since then the ulcer has gradually improved, although the competence with which the bandage is applied has varied. The second or third time the bandage was applied she spent the following night with severe pain in the affected leg. In the morning she called the Community Nursing Service: the nurse arrived and asked her what she wanted her to do about it.

3. There is no regular schedule of appointments, which means Mrs P can never be sure on which day she should expect the community nurse to call. (This was also the situation during treatment for the first ulcer.)

4. A different nurse attends almost every week. Very rarely does Mrs P see the same nurse two weeks running. (Again, this was also the situation during treatment for the first ulcer.)

5. Each nurse decides for herself what treatment to give to the leg ulcer. (Once again, this was also the situation during treatment for the first ulcer.) Mrs P has experienced one nurse applying an ointment, only for a different nurse the following week to say that the ointment was not appropriate and ‘scrubbing’ it off.

6. Some nurses appear not to have read the notes on the patient before they visit. One arrived expecting to treat a cut on Mrs P’s arm. She is frequently asked what treatment she has been having.

7. Recently Mrs P had to attend Treliske for eye surgery (laser treatment) as a day patient. She told the community nurse on three occasions about her forthcoming appointment and that she would be out of the house that day. However a nurse did turn up while she was out, and was not best pleased to find that she was not in.

8. Recently Mrs P suffered another fall, and was taken to Treliske by ambulance. A break of her other hip was diagnosed. Her daughter spent the evening with her (getting home at 12.30am) and called the Service the next day, leaving an answerphone message informing them of Mrs P’s situation and saying that she would not require a community nurse to visit until further notice. However, a nurse did call in the week beginning Monday, September 18th (leaving a note, undated).

9. It is apparent that the constant changes in treatment waste money. Mrs P has at least three tubes of various ointments and different dressings ordered by different nurses, used once and then never again. And nurses turning up after Mrs P or her daughter has specifically told them that she won’t be in amounts to a further misuse of scarce resources.

10. While this vital service is doubtless under huge stress, there is clearly scope for making it more efficient. There would seem to be a great need for staff training and firmer leadership. Potentially the Community Nursing Service is a great service, and it is badly needed in this part of the world with so many of its population elderly and housebound.

3. The follow-up story: Seeking a response to feedback
This is the story of my own attempt to see whether the feedback contained in the above Note ‘made a difference’. It takes the form of a ‘trail’ of emails, reproduced here shorn of greetings etc. but otherwise unedited.

30 September 2017 Email from PL to Communications Manager, Healthwatch Cornwall
Is this [i.e. the patient story] of interest? Have you any suggestion as to how we might progress the matter?

10 October 2017 Email from Communications Manager, Healthwatch Cornwall to PL
We can of course add this information to our patient feedback and we may be able to use as a case study.

13 October 2017 Email from Secretary-Coordinator, West Cornwall HealthWatch to Locality Support Manager, NHS Kernow
One of our members sent the attached patient experience story to Healthwatch Cornwall last month but was disappointed by the response.  He is concerned because he wants to see improvements in care in community nursing, and thought that highlighting this story might help focus minds. I would be glad if this can be investigated in some way, and will look forward to hearing from you.

1 November 2017 Email from Communications Manager, Healthwatch Cornwall to PL
If you would like me to use this as a case study, it would be best if I can also contact the person sharing the issue to seek permission to do so. Or perhaps you would like to ask them to call me?

9 November 2017 Email from PL to Head of Patient Experience, Cornwall Partnership Foundation Trust (CPFT), following a telephone conversation.
Good to talk to you just now.

As I said, while Mrs P and her daughter do not wish to register a formal complaint, or indeed to find themselves labelled as troublemakers, they are keen that other patients do not receive the same treatment as Mrs P sometimes did, so I was pleased to receive your assurance that you will pass this information on to the key members of the Service to look into community nursing practices, and will let me know the outcome.

15 November 2017 Email from Head of Patient Experience, CPFT to PL
Thank you for your time last week. I will develop a plan around this and will get back to you with feedback about how this information has been used to improve services.

19 November 2017 Email from PL to Communications Manager, Healthwatch Cornwall
Just to bring you up to date: [Head of Patient Experience, CPFT] is looking into this matter, and has promised to let me know the outcome. So as a case-study it is incomplete at the moment: I’ll be in touch when we have reached some sort of a conclusion – or if we don’t!

12 January 2018 Email from Head of Patient Experience, CPFT to PL
I am still working on this. I will update you in due course.

15 February 2018 Email from PL to Head of Patient Experience, CPFT
As you see, it is now three months since I contacted you about this matter. You told me a month ago that you were ‘still working on this’ and would update me ‘in due course’, but as yet you have told me nothing at all about the plan you said you would develop, nor have you got back to me with your promised ‘feedback about how this information has been used to improve services’.

I have to say bluntly that I do not find this satisfactory. As you will appreciate, In the absence of a response from you I have no alternative but to seek other avenues to bring about some improvement in the community nursing service. To judge by the evidence I provided, such improvement is badly needed.

16 February 2018 Email from Head of Patient Experience, CPFT to PL
Please be assured that I am ensuring that all colleagues who need to be aware of this feedback/patient experience are being made aware of it, and I will certainly pass back to you any changes in service delivery/design made as a consequence of this.

Apologies for the delay in getting back to you.

1 March 2018 Email from Head of Patient Experience, CPFT to PL
Just a quick note to assure you that I am still following up the feedback further to you sharing an anonymous patient story with us before Christmas. I will get back to you asap.

17 April 2018 Email from PL to Head of Patient Experience, CPFT
Just to say that I am still looking forward to hearing from you.

No further communication has been received from CPFT since the email dated 1 March 2018.

4. Continuity of care
As the patient story relates, during both episodes of treatment almost every week a different nurse attended Mrs P. Very rarely did she see the same nurse two weeks running. This would have been less upsetting for Mrs P were it not that different nurses had different ideas about what was appropriate treatment for a leg ulcer, and often refused to continue a treatment that another nurse was giving.

So not only was there no continuity of personnel: because of that failure there was no continuity of treatment either. Mrs P’s consequent distress, aggravated in the case of the second ulcer by the withholding of the treatment which had dealt successfully with the first, seems to have had no impact on the treatment that she received.

The lack of continuity of care was further aggravated by the evident failure of some nurses to have read the notes on the patient before they visited.

So we see that while the consequences of the lack of continuity of care might have been mitigated by discussions among the nurses involved to agree the appropriate treatment, and by simply reading the case notes before visiting, these opportunities were not taken advantage of.

What seems to be missing from the treatment of Mrs P is any understanding of the impact of the absence of continuity of care on her state of mind. Given also the lack of a regular schedule of appointments, which meant that Mrs P could never know on which day or at what time she should expect the nurse to call, or who would walk in through the door, the situation could hardly be more stressful and anxiety-producing for an unwell elderly person.

5. The anonymity issue
It may be that the Cornwall Partnership Foundation Trust (CPFT) has a problem to do with identifying patients who offer feedback. From their point of view, knowing the identity of a patient who does this enables the staff concerned to be identified and questioned about any treatment given or incidents that took place. But for the patient, different considerations may apply, depending on whether treatment has concluded, e.g. where the patient has fully recovered from an injury or illness, or the patient is continuing to receive treatment.

Where treatment has concluded, the patient will generally have no incentive to conceal any details of the treatment received, or to soften any judgments made. For patients continuing to receive treatment, however, the situation may be very different. Vulnerable patients, like Mrs P, will invariably be reluctant to give their details for fear of being picked on and subjected to ‘worse’ treatment. This is not uncommon: Healthwatch England reported in 2014 that a recent survey found that over half of people who had problems with health and social care, did not make a complaint. Similarly, 3 in 5 who had experienced or witnessed a problem with health or social care services in the last two years had not made a complaint.[6]

The fact that the Cornwall Partnership Foundation Trust has gone quiet on Mrs P’s case leads me to suspect that the fact that she did not register a complaint, which would have involved identifying herself, has been used as an excuse for shelving her case and not responding to emails.

It seems obvious that Mrs P’s story should have prompted a review of how nurses work together and decide on treatment, and of what steps might be taken to minimize the stress that patients are under. One would expect a manager who has an interest in providing the best possible care to be perfectly happy to use feedback from patients in this way, irrespective of whether it is anonymous or not.

6. Conclusion: The need for partnership and dialogue between providers and patients
As we saw in the Introduction, there are currently two significant pressures for cultural change in the National Health Service. One is a pressure for patients to be much more involved in their own care and for the NHS to work in partnership with them. This would amount to a fundamental shift from a ‘treatment’ model of care to one based on ’partnership’ between healthcare providers and patients. The other pressure is for better learning, a need emphasized by Healthwatch England.

The story of Mrs P illustrates the resistance that these pressures will have to overcome if they are to make an impact. In no sense did the behaviour of most of the community nurses who visited Mrs P even hint at any kind of partnership between them and her. And the refusal of the Cornwall Partnership Foundation Trust to engage in any dialogue on the subject of her treatment is a clear demonstration of the defensive, anti-learning culture identified by Sir Robert Francis in his report on whistleblowing in the NHS.

Patients’ responses to the care that they receive and to consultation and explanation constitute what is widely known as ‘feedback’. It may be provided on an individual basis by patients, as in Mrs P’s case, or in aggregate form, as in responses to surveys. As we have seen, Healthwatch England is keen to see how learning from feedback is improving care. It also emphasizes the need for people to be able to ‘see how their feedback has made a difference and has helped to change the way services are delivered.’ So feedback on its own is not enough: there has to be a response as well. Two-way communication – dialogue – is called for.

There are several reasons why dialogue between providers and patients should be encouraged:

(1) The provider can use dialogue to ‘play back’ what he or she thinks they have heard, and check whether they have drawn the correct inferences from the feedback.

(2) A provider’s response to feedback can take the form of explaining why a certain action has been taken. This both acknowledges the patient’s entitlement to an explanation, and can provide a basis for negotiating a compromise. For example, in the case of home visits by a community nurse, a phone call beforehand could avoid the ‘surprise’ visit for which the patient is not prepared.

(3) Paying attention to feedback and responding to it shows respect for the patient, it acknowledges their right to have a say, while ignoring it shows disrespect, and discourages future attempts to give feedback. Failure to respond conveys a stark message: ‘We are not interested in what you have to say.’ Patients will be discouraged from continuing to provide feedback if they cannot see any positive response to the effort they have made.

(4) Dialogue is a necessity if partnership is to be genuine. It positively encourages patients to take an active part in looking after their health.

(5) In formulating a response to feedback, providers have to talk to one another. It is not merely a matter of partnership between provider and patient: partnership between providers is called for. This could help to redress the situation where a community nurse visits a patient unaware of the patient’s treatment history.

Finally, it is worth reminding ourselves of Healthwatch England’s emphasis on seeing how learning from feedback is improving care:

[There] is still much to do so that people can see how their feedback has made a difference and has helped to change the way services are delivered.[7]

Amen to that!

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Notes and references. All websites last accessed on May 20th, 2018.

[1] NHS England, Five Year Forward View, October 2014
https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

[2] Cornwall and the Isles of Scilly: Sustainability and Transformation Plan: Draft Outline Business Case. October 2016, p.11
https://www.cornwall.gov.uk/media/22984634/cornwall-ios-stp-draft-outline-business-case.pdf

[3] Healthwatch England, Six areas we want NHS England to focus on in 2018, 10 January 2018
https://www.healthwatch.co.uk/news/six-areas-we-want-nhs-england-focus-2018

[4] Sir Robert Francis, Freedom to Speak Up, February 2015, p.8
http://freedomtospeakup.org.uk/the-report

[5] As [1], p.10

[6] Healthwatch England, Suffering in Silence: Listening to consumer experiences of the health and social care complaints system, October 2014, pp.2,10
https://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/hwe-complaints-report.pdf

[7] As [3].

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West Cornwall HealthWatch is a voluntary, independent campaigning
health watchdog that has been serving West Cornwall since 1997. It
monitors developments and campaigns to safeguard and improve
services provided in West Cornwall by the National Health Service.

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We shouldn’t underplay the seriousness of the situation at Treliske revealed by the Care Quality Commission’s recent warning notice and last week’s  Cornishman, but it’s not all bad news from Treliske, as a recent report tells us.

‘In March there were significant improvements 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 extra resources to support patients’ discharge, and improvements have been made in transport booking to support patients to be in the best place for their needs. Many staff made themselves available for extra shifts. In the lead up to Easter, 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. Performance on the 4 hour Emergency Access Standard was the best for any Trust in the South of England.’

Credit where credit is due! So well done everyone who helped turn things round. But now the right lessons must be learned. The chief executives are celebrating the turn-round as a triumph of their ‘Gold Command’ approach, which brought together Chief Executives, senior clinicians and operational managers from across health and social care. But it is also a triumph of ‘pitching in together’: involving GPs, who aren’t part of any hierarchy, for example, and staff making themselves available for extra shifts. These don’t come about as a result of instructions from a ‘Gold Commander’ at the top of the hierarchy. They are the result of teamwork.

In a team, the organization is relatively flat compared to the pyramid you find in most hierarchical organizations. There are different levels of seniority, but the lead in a situation is taken by whoever is best informed and most capable, not necessarily the most senior person. Communications tend to be ‘lateral’, with your ‘opposite number’, rather than ‘vertical’ (‘decisions handed down’), so they are more like consultation than command. And the incentives that motivate people – to put in extra hours, for example – stem from a community of interest rather than a contractual relationship.

There is an important lesson here. With Cornwall Council and health bodies negotiating to create an integrated, ‘strategic’ health and social care system, it is tempting for their leaders to celebrate the turn-round as a triumph of the ‘Gold Command’ way of doing things. They must not overlook the importance of creating conditions where cross-authority teams can flourish within that hierarchical structure.

 

PL

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

‘There have been significant improvements … 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.’

This is an extract from a report submitted to the Transformation Board which is overseeing work on the Shaping our Future programme for reshaping health and social care services in Cornwall and the Isles of Scilly.[1] It shows that a major turn-round was achieved in A&E at Treliske Hospital (Truro) in March this year. At the time of writing the Royal Cornwall Hospitals Trust has unaccountably failed to highlight this good news story, so I am happy to fill the gap.

The Report
First of all, here is the report itself, as submitted to the Transformation Board:

What we can achieve working as an integrated care system
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 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.

The co-ordination and co-operation across our health and social care system has been outstanding, and provides strong demonstration of what can be achieved by a joined up, cohesive system putting patient care before the interests of individual organisations. Working as an Integrated Care System, there is a determination to maintain and build on the progress over recent weeks.

What we can learn from this report?
Besides telling us about what was achieved, this report is giving us two different messages. One message is about hierarchy, the ‘Gold Command approach’ which brought together Chief Executives, senior clinicians and operational managers from across health and social care.

The other message is about ‘pitching in together’: involving GPs, who aren’t part of any hierarchy, for example, and staff making themselves available for extra shifts. These don’t come about as a result of instructions from a ‘Gold Commander’ at the top of the hierarchy. They happen because a ‘team system’ has been created.

In a team, the ‘structure’ of control and communication is relatively flat compared to the pyramid you find in most hierarchical organizations. There will be different levels of seniority, but the lead in a situation will be taken by whoever shows themself best informed and most capable, not necessarily by the most senior person. Communications tend to be ‘lateral’, with your ‘opposite number’, rather than ‘vertical’ (‘data up, decisions down’), so they are more like consultation than command. And the incentives that motivate people – to put in extra hours, for example – stem from a community of interest rather than a contractual relationship.[2]

There is an important lesson to be learned here. At a time when Cornwall Council and health bodies are negotiating to create an integrated, ‘strategic’ health and social care system, it is tempting for their leaders to celebrate the turn-round as a triumph of the ‘Gold Command’ way of doing things. They must not overlook the importance of creating conditions where teams can flourish within that hierarchical structure.

* * *

This post is a slightly revised version of a post originally published on 13 April 2018.

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[1] Transformation Board: Agenda paper for meeting 6 April 2018, Item 6.
http://doclibrary-shapingourfuture.cornwall.nhs.uk/DocumentsLibrary/ShapingOurFuture/TransformationBoardMeetings/Minutes/1819/201804/DevelopmentOfAnIntegratedCareSystem.pdf

[2] The distinction between hierarchies and networking teams draws on the classic work by Tom Burns and G.M. Stalker, The Management of Innovation (Tavistock 1961, Oxford UP 1994). They distinguished between mechanistic  and organic structures: the term ‘mechanistic’ is little used these days, while ‘organic’ has acquired a dietary connotation.

 

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.

The Bungles
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’.

* * *

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.’

 

This report shows how NHS England required NHS Kernow (the local clinical commissioning group) to produce a Sustainability and Transformation Plan (STP) but gave no advice on how to do it. NHS Kernow hired management consultants but allowed them to pursue their own agenda. NHS Kernow seem not to have considered  ways of attracting funds from NHS England, and have missed opportunities to do so. Health care leaders have been distracted by high-level negotiations on ‘strategic integration’ from getting on with the day job: very recently the Care Quality Commission issued a Warning Notice requiring the Royal Cornwall Hospital Trust to make significant improvements at Treliske Hospital within a week(!), because longstanding concerns were persisting about the safety and quality of some services. And after health and social care staff at all levels recently ‘pitched in together’ and turned round a bad situation in the Emergency Department at Treliske, the important lesson from that is being missed.

* * *

There are two versions of this report. This is the FULL REPORT. It can be downloaded as a pdf here. There is also a SHORT REPORT, published simultaneously on this website. It too can be downloaded as a pdf, here.

Background
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 (officially Kernow Clinical Commissioning Group), 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, which is 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 of these bungles and their consequences, and identifies lessons that, if learned, could help avoid similar bungles in future. The body of the report is divided into three parts: Part I – Edicts from the Centre; Part II – The Bungles; and Part III – Lessons.

The period covered by the report runs from October 2014 to the present. The most significant events on the ‘timeline’ are shown in Box 1.

Box 1: The timeline October 2014: NHS England publishes Five Year Forward View. July 2015: The Cornwall Devolution Deal is signed. December 2015: Delivering the Forward View: NHS planning guidance: 2016/17 – 2020/21 published, introducing Sustainability and Transformation Plans. October 2016: Cornwall and the Isles of Scilly: Sustainability and Transformation Plan: Draft Outline Business Case published.[1] March 2017: Next Steps on the NHS Five Year Forward View published: Sustainability and Transformation Plans get only one slight mention.

Part I – Edicts from the Centre

October 2014: NHS England publishes Five Year Forward View
In Five Year Forward View,[2] NHS England argued that ‘the health service needs to change’. The document made no significant references to plans, but set out a variety of new ‘care models’ that it would support (See Box 2). Accepting that ‘England is too diverse for a one-size-fits-all care model to apply everywhere’, it promised that local health communities would be supported by the NHS’s national leadership ‘to choose from amongst a small number of radical new care delivery options, and then given the resources and support to implement them where that makes sense’.

These new models of care were all described in non-technical language, rooted in day-to-day experience rather than a ‘vision’ or a ‘theme’. And Five Year Forward View gave concrete examples of ’emerging models’ already in use in various parts of the country.

Box 2: New Models of Care The Multispecialty Community Provider (MCP) would permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care. Primary and Acute Care Systems (PACS) where hospital care and primary care are integrated, so ‘combining for the first time general practice and hospital services’. Urgent and emergency care services ‘redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services’. Help for smaller hospitals to remain viable, including forming partnerships with other hospitals further afield, and partnering with specialist hospitals to provide more local services. Midwives would have new options to take charge of the maternity services they offer. The NHS would provide more support for frail older people living in care homes. List-based primary care would continue to be the foundation of NHS care, but a ‘new deal’ for GPs was needed. … ‘GP-led Clinical Commissioning Groups will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services.’

One of those warmly commended emerging models was very close to home:

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.[3]

This is evidently a reference to the Living Well scheme, which was set up and run by Age UK Cornwall.

Finally, finance was a major factor in the thinking behind Five Year Forward View. It was calculated that with growing demand, if there were no further efficiency savings and funding were kept flat in real terms, by 2020/21 patient needs would exceed resources by nearly £30 billion a year in England. It was hoped that new models of care would help to bring demand, efficiency and funding into balance.

NHS England would support these changes by providing ‘meaningful local flexibility’ in the way payment rules etc were applied. Local leadership and a variety of solutions would be supported, and innovation emphasised. But Five Year Forward View did not contain any requirement for clinical commissioning groups to produce plans.

December 2015: Delivering the Forward View: NHS planning guidance: 2016/17 – 2020/21 is published
It was 14 months after the publication of Five Year Forward View that Sustainability and Transformation Plans (STPs) came on the scene. They were announced in Delivering the Forward View: NHS planning guidance: 2016/17 – 2020/21, published in December 2015.[4] NHS organizations in different parts of England were asked to come together to develop plans for the future of health services in their area, including by working with local authorities and other partners. In Cornwall, the relevant area was the county, and conveniently only a single local authority, Cornwall Council, was involved.

The planning guidance required NHS bodies to produce two separate but connected plans:

A five-year Sustainability and Transformation Plan (STP), area-based, which would ‘drive’ the Five Year Forward View; and

A one-year Operational Plan, the first of which was to cover 2016/17, organisation-based but consistent with the emerging STP.

Every health and care system – clinical commissioning groups, [provider] trusts and local authorities – was being asked ‘to come together, to create its own ambitious local blueprint for accelerating its implementation of the Forward View’.

But how was the plan to be created? The planning guidance did not provide any kind of manual: there was no step-by-step set of instructions. All it had to say on the subject was this:

Producing an STP … involves five things: (1) local leaders coming together as a team; (2) developing a shared vision with the local community, which also involves local government as appropriate; (3) programming a coherent set of activities to make it happen; (4) execution against plan; and (5) learning and adapting.

Success also depends on having an open, engaging, and iterative process that harnesses the energies of clinicians, patients, carers, citizens, and local community partners including the independent and voluntary sectors, and local government through health and wellbeing boards.

… The STP must also cover better integration with local authority services, including, but not limited to, prevention and social care, reflecting local agreed health and wellbeing strategies.

The planning guidance did have something important to say about funding:

For the first time, the local NHS planning process will have significant central money attached. The STPs will become the single application and approval process for being accepted onto programmes with transformational funding for 2017/18 onwards.

There would also be additional dedicated funding streams for transformational change, covering initiatives such as the spread of new care models and to drive clinical priorities.

The earliest additional funding would go to the most ‘compelling and credible’ STPs. The selection criteria would include

The quality of plans, particularly the scale of ambition and track record of progress already made. The best plans will have a clear and powerful vision [and] create coherence across different elements.

The reach and quality of the local process, including community, voluntary sector and local authority engagement;

The strength and unity of local system leadership and partnerships, with clear governance structures to deliver them; and

How confident we are that a clear sequence of implementation actions will follow as intended … .

These are very subjective criteria, very much matters of judgment. To satisfy them, one has to know more precisely what the people in charge are looking for and what will please them. What, one might ask, will give a plan ‘funding appeal’? For some suggestions, see Box 6 below.

March 2017: Next Steps on the NHS Five Year Forward View is published
This document, published on the NHS England website,[5] took stock of the progress that had been made since Five Year Forward View was published. It affirmed the NHS’s national leadership bodies’ shared vision of the Forward View and their approach to implementing it.[6] Interestingly, Next Steps … described itself as ‘this plan’, but primarily it amounted merely to a list of actions that NHS England was committing itself to take in the next two years. These included taking new models of care forward, especially those that had been developed in the fifty geographical areas that had taken part in the ‘Vanguard’ programme. See Box 3.

Box 3: The Vanguard programme The Vanguard programme focused on: Better integrating the various strands of community services such as GPs, community nursing, mental health and social care, moving specialist care out of hospitals into the community (‘Multispecialty Community Providers’ or ‘MCPs’); Ÿ Joining up GP, hospital, community and mental health services (‘Primary and Acute Care Systems’ or ‘PACSs’); Ÿ Linking local hospitals together to improve their clinical and financial viability, reducing variation in care and efficiency (‘Acute Care Collaborations’ or ‘ACCs’); and Ÿ Offering older people better, joined-up health, care and rehabilitation services.

Both MCP and PACS Vanguards had seen lower growth in emergency hospital admissions and emergency inpatient bed days than the rest of England.

As we see, Next Steps … reverted to the format of Five Year Forward View in that it highlighted practical developments, such as MCPs and PACSs, rather than plans which would require management consultants to flesh out.

So 15 months after the launch of Sustainability and Transformation Plans, with a fanfare and intimations of their importance for funding etc, they had been quietly dropped. What would take their place with regard to funding was not stated. But instead of the Plans there was to be a new way of working. Within an area, participating organisations, including all NHS bodies, would work in Sustainability and Transformation Partnerships. These would replace Sustainability and Transformation Plans as a mechanism for delivering the Forward View. Confusingly, the initials STP would now be used to refer to a Partnership.[7]

These partnerships were and still are seen as a way of bringing together GPs, hospitals, mental health services and social care. The emphasis is on integration. They would be a ‘forum’ in which health leaders linked together services and shared staff and expertise, so care would be safer and more effective. In contrast to the previous doctrine that competition was the guarantor of efficiency in the NHS, collaboration was now the order of the day.

A certain amount of local autonomy was also envisaged. The way the new STPartnerships worked would vary according to the needs of different parts of the country. The national health bodies did not want to be ‘overly prescriptive’ about organisational form. The new health and care systems were to be defined and assessed primarily by how they practically tackled their shared local health, quality and efficiency challenges.

Community participation and involvement
As the authors of Next Steps … saw it, the partnerships – the integrated health systems – needed to engage with communities and patients in new ways, to mobilize collective action on ‘health creation’ and service redesign. Making progress and addressing challenges could not be done without genuinely involving patients and communities.

Nationally, we will continue to work with our partners, including patient groups and the voluntary sector, to make further progress on our key priorities. Locally, we will work with patients and the public to identify innovative, effective and efficient ways of designing, delivering and joining up services.

Healthwatch England had set out five steps to ensure local people have their say: See Box 4.

Box 4: Five steps to ensure local people have their say (Healthwatch England): Set out the case for change so people understand the current situation and why things may need to be done differently. Involve people from the start in coming up with potential solutions. Understand who in your community will be affected by your proposals and find out what they think. Give people enough time to consider your plans and provide feedback. Explain how you used people’s feedback, the difference it made to the plans and how the impact of the changes will be monitored.

PART II – The Bungles

 Bungle Number 1  The so-called ‘planning guidance’ on delivering the Five Year Forward View (which was actually not published until 14 months after Five Year Forward View appeared) required the production of Sustainability and Transformation Plans (STPs) but gave no guidance on how to produce them. It is clear that neither NHS England nor NHS Kernow had much idea how to do that. And 15 months after the ‘planning guidance’ appeared, the next policy document – Next Steps … – said nothing at all (apart from a brief passing mention) about STPs.

By any logic it would have made sense for the forward view and the planning guidance associated with it to be published together. The fact that they were not is a clear indication that central NHS policy-making machinery was not functioning well. The fact that a reorganization of regulatory/supervisory machinery was taking place at the time[8] will not have helped. 

The late arrival of the instruction to prepare STPs had serious consequences for Cornwall. Not only, it appears, did NHS Kernow officers not know how to produce a Sustainability and Transformation Plan – it was demonstrably not something for which their training or previous experience had prepared them – but the so-called planning guidance provided almost zero actual guidance about how to go about creating these plans. NHS England officers side-stepped responsibility for this by placing the onus on local bodies to create ‘compelling’ plans and urging them to hire management consultants.

So for 15 months NHS Kernow officers were under pressure to devote time, money and scarce staff resources – already fully occupied – to producing an STP. They had to hire management consultants, at considerable expense – probably around £1.5 million. (Over England as a whole there were 44 STPs: the cost to the NHS must have been of the order of £60 million.) And then the plans were quietly put to one side. By any reckoning, this was a major and costly bungle by NHS England.

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.

The ‘Target Operating Model’ was presented in Outline Business Case[9] as a kind of culminating achievement. Its stated purpose was ‘to provide a high-level understanding of how we will work together as a single, co-ordinated system in order to deliver services on a whole population basis …’. The diagram and language are not those of Five Year Forward View or even the ‘planning guidance’: they come straight from the world of business management consultancy, as a web search for ‘target operating model’ instantly reveals. Although their involvement was nowhere acknowledged, it is apparent that Outline Business Case was at least in part ghost-written by management consultants. The firm Price Waterhouse Coopers (PwC) was involved at this stage.[10]

In February 2017 NHS Kernow’s Interim Chief Officer informed its Governing Body:

We have engaged GE Healthcare Finnamore as a Strategic Partner for Shaping our Future. [This title had been adopted as the ‘brand name’ for the STP programme.] The first task is to establish the robust evidence, modelling and activity analysis required for the proposals for the pre consultation business case and how developed this currently was.(sic) [11] [12]

Not only does this statement illustrate how easy it is to slip into using management-consultant-speak: observe how smoothly Finnamore has been elevated to the position of ‘strategic partner’. This would accord them a status well above that of a hired contractor.

The first fruits of this contract, which is said to have cost up to £1.2 million,[13] emerged in March 2017, in the form of a report, entitled Final Report – Part 1 Support, which was subsequently obtained through a Freedom of Information enquiry and published by Cornwall Reports.[14] Much of the report is written in management-consultant-speak – ‘Testing the TOM for Architectural Coherence’, ‘Granularity of OBC content and supporting documentation is not at the level of maturity required to achieve a PCBC in the timescales proposed’ – but the consultants reported, clearly enough, that they had ‘assessed readiness for the development of a pre consultation business case (PCBC) to take forward the STP priorities in Cornwall’.

In a detailed analysis of the organization’s readiness, the consultants found that ‘two thirds of the elements required for a PCBC have not yet commenced or need additional work. Workstream leads recognise that there are considerable gaps in the data and information needed for a PCBC’. Much additional work would be needed over the coming months to deliver a robust and comprehensive case.

There is no sign of NHS Kernow having carried out a risk analysis before hiring management consultants and putting unquestioning trust in them. Although in clinical commissioning groups (and NHS trusts and local authorities) it is normal for the risk attached to a spending proposal to be assessed (conventionally using a coding of red, amber and green to denote high, medium and low levels), that evidently was not done in this case.

But risks are certainly entailed. The risks of hiring management consultants to work on health and social care are summarized in Box 5.

Box 5: The risks of hiring management consultants to work on health and social care They will have their own agenda, which will not be the same as yours. They will want a distinctive product to help them market their services to prospective future clients, which will not be one of your concerns. Ÿ They will speak their own language, management-consultant-speak. If you do not, this will make it difficult for you to question their methods and assumptions. They will not necessarily have an intuitive grasp of concepts like ‘funding appeal’. And they may not be schooled in political sensitivity, an invaluable attribute in the world of health and social care and central-local relations. You will become their ‘captive’, dependent on their advice. So (a) you will get to think in their terms, use their language, and see issues in the way that they do; and (b) there will be difficulties and penalties attached to going against their advice, and consequently your freedom of action will be diminished. They will cost you. On the other hand, if you allow independent consultants to examine how your organization operates, they may be able to identify – from their experience elsewhere – obstacles to effective working, and ways of getting round them, that you are too involved or too inexperienced to see. The benefits of this ‘carrier pigeon’ function of independent consultants should not be overlooked.

An investigation by the King’s Fund found that the use of management consultants was routine. ‘Some leaders felt that STPs had created an industry for management consultants – and questions were raised about why money is being invested in advice from private companies instead of in frontline services.’ In one area, STP leaders even felt under pressure from NHS England’s regional team to increase the amount of money they were spending on management consultancy support. And in one STP area that had not directly commissioned external support to develop its plan, NHS England’s regional team had commissioned a management consulting firm to carry out analytical work on behalf of its STP areas.[15]

In the NHS, public spending on management consultants more than doubled from £313 million in 2010 to £640 million in 2014. A recent study carried out in English NHS hospital trusts by Ian Kirkpatrick et al found that instead of improving efficiency, the employment of management consultants was more likely to result in inefficiency. They concluded that while efficiency gains are possible through using management consultancy, this is the exception rather than the norm. ‘Overall, the NHS is not obtaining value for money from management consultants and so, in future, managers and policy makers should be more careful about when and how they commission these services.’ More thought could also be given to alternative sources of advice and support, from within the NHS, or simply using the money saved on consulting fees to recruit more clinical staff.[16] However, as noted at the foot of Box 5, their contribution may come in other forms besides ‘advice and support’.

Bungle Number 3  NHS Kernow failed to talk to NHS England in their own language. 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.

There is one very obvious illustration of this failure. NHS Kernow was asked to produce a Sustainability and Transformation Plan: what they submitted – no doubt as a consequence of their reliance on business management consultants – was a business case. A business case sets out a justification for a course of action, but it is not of itself a plan.

Again, in March 2017 GE Healthcare Finnamore were anticipating that the next step in the STP process would be to develop ‘a pre consultation business case (PCBC) to take forward the STP priorities in Cornwall’, and this has gone unchallenged by NHS Kernow. Once again, a case, even a refined one, does not amount to a plan.

Similarly, NHS Kernow failed to register that when Five Year Forward View highlighted new models of care that it would promote or permit, 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 that NHS England had said it intended to promote or permit, such as MCTs and PACSs.

As already noted, for proposals to gain funding, they must have ‘funding appeal’, and to this end they must be expressed in language with which those who control funds are comfortable and feel at home. For some suggestions, see Box 6.

Box 6: ‘Funding appeal’ In effect, what Delivering the Forward View provided was a kind of recipe for ‘funding appeal’: how to construct and present an STP in such a way as to attract the maximum of funding from NHS England. Not all of the criteria are crystal clear: how does one assess ‘the reach and quality of the local process’, for example, or gauge what will be found ‘compelling and credible’ by different national NHS bodies? But probably the prime criterion by which applications would initially be screened would be that the winners recognise that they have to think about what is meant by ‘reach and quality’: it won’t even occur to the laggards that they need to do this. As probably every successful grant-aided voluntary organization knows, to succeed with a grant application it is necessary to master the brief: not only to read the rules but also to read between the lines and understand and interpret the message at every level. Then the submitted application should use the same or similar language, meet implicit as well as stated requirements, and give relevant practical examples. It is clearly counter-productive if the grant giver has to spend time deciphering or puzzling over your bid for funds.

Bungle Number 4  NHS Kernow damaged its own credibility by abandoning the Living Well project and putting nothing in its place. It was one of very few local bodies to get a mention in Five Year Forward View: As noted above, ‘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.

The Living Well programme 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.

What is significant is that no steps were taken to ensure that the learning from the project was not lost, or to find ways of continuing the work under different auspices or on a lesser scale. So NHS Kernow gave up this source of its credibility with NHS England. Shooting oneself in the foot in this way is hardly likely to reflect well on an organization’s leadership qualities, which would be a factor in assessing any request for funding.[17]

It is noteworthy that in the summer of 2017 a team from Cornwall Council and NHS Kernow, charged with commissioning a new contract for Home Care Services and Supportive Lifestyles, reported on work they had been doing on a new ‘delivery model’ for services for adults over the age of 18 years who have eligible health and/or social care needs and include people with physical disabilities, learning disabilities, sensory loss and age related needs.[18] The team had organized engagement sessions and workshops with care and support providers, people receiving services or who might require services in the future, and staff from health and social care partners. These sessions/workshops had looked at ‘the current market position, exciting new marketing opportunities for present and future businesses and highlight the gaps in the market’. Strikingly, the report makes no mention whatever of volunteers and how they might be deployed alongside paid staff.

Five Year Forward View had highlighted the importance of involving volunteers within the NHS and wider communities. ‘Volunteers are crucial in both health and social care. Three million volunteers already make a critical contribution to the provision of health and social care in England.’[19] This aspiration had evidently not registered in Cornwall. The Living Well project, and the volunteers mobilized as part of it, might never have existed.

Bungle Number 5  Bundling together of ‘communications’ and ‘engagement’ is rife all over the NHS, in management positions, teams, strategies etc.[20] Unfortunately they are fundamentally very different activities, calling for very different skills, and when they are confused, as has happened in Cornwall, so-called engagement can engender a great deal of suspicion.[21]

Communications experts, who in many cases have had a training in journalism, are trained to make use of the media: to ‘put the message out’ and put a positive gloss on it, to persuade, and even to ‘spin’. Insofar as they listen, it is in order to see how their message has been received and to improve their delivery of it.

In contrast, successful engagement requires some of the attributes of the social researcher. It calls for the asking of unbiased, non-loaded questions. It involves dialogue, two-way communication: it requires skills in listening rather than selling, in appreciating what others are saying, in responding appropriately, in gaining other people’s confidence and being open and ‘straight’ with them and able to negotiate compromises. It is a completely different skillset from that of the ace communicator.

So when we have communications specialists involving themselves in engagement, we often find persuasion slipping in. An example of this is provided by the ‘co-production workshops’ that are coming to form an important part of the Shaping our Future programme:

A place-based model of care is being developed … in six local areas in Cornwall … Up to four waves of co-production workshops are being held in each locality to design the new model …[22]

These workshops are a mixture of presentation and discussion. It is the presentations and the information packs handed out with them that are problematic, because here is where persuasion slips in. For example, at the first set of workshops the information pack included a section on ‘The case for change’, which contained five snippets of quantitative data on hospital services:

Around 60 people each day are staying in acute hospital beds in Cornwall and they don’t need to be there.

35% of community hospital bed days are being used by people who are fit to leave.

Older people can lose 5% of their muscle strength per day of treatment in a hospital bed.

83% of admissions to community hospitals are from acute services compared to 42% nationally.

62% of hospital bed days are occupied by people over 65 years old.[23]

Taken in conjunction with the reference in the draft Outline Business Case to ‘outdated, expensive bed-based’ care,[24] the first three snippets can be read as an attempt to persuade workshop participants that it is futile and wrong-headed to resist the closure of hospital beds, especially those in community hospitals. They are a particular selection of facts that support a ‘case for change’: they impart a certain ‘slant’ to the discussion. (As for the fourth and fifth snippets of data, including them seems to have no purpose other than making the case for closure appear to be supported by more statistics.)

Of course, people who no longer need to be in an acute or community hospital are not necessarily fit to go home, although – in the absence of information about other options, such as care homes or sheltered housing – this seems to be the conclusion we are intended to draw. Interestingly, we are not told what percentage of their muscle strength older people can lose per day if they are sent home to convalesce, without on-site re-ablement services.

As we see, the information presented in the information pack, seemingly calculated to justify the closing of hospital beds, is scanty and arbitrary, and presented in the form of snapshots. These represent situations at particular points in time or over particular periods. We are not told at what particular points in time, or over what particular periods, the data were collected. This is not good professional practice, and reflects poorly on the South West Academic Health Science Network, which provided the data.[25]

The infiltration of presentation techniques into what are ostensibly ‘engagement’ events is continuing at the present time. A current example is the technique of ‘spurious endorsement’. A briefing note for the Wave 3 ‘co-production workshops’ refers to a modelling tool as having been ‘endorsed by … the London School of Economics’ when in fact it had been endorsed by one individual professor.[26][27] Likewise, a draft specification for a GP-led Urgent Treatment Centre service referred to it having been ‘shared with’ the Citizen Advisory Panel: it was not approved by, or even scrutinized by, the Panel, but merely shown to them.[28] What we have here is what one might call ‘endorsement by name-dropping’: a presentation/ communication technique, but not one of genuine engagement.

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’.) At the time of writing, the Transformation Board, which itself started life as the Joint Strategic Executive Committee, is in the process of mutating into a ‘System Assurance Group’.[29] And a debate is taking place about the structure required for a strategic integrated commissioning function. In all this, the local leaders have been taking their eyes off what has been happening to patients and clients, as a string of critical reports from the Care Quality Commission attests.[30]

But while this high-level debate has been going on, something remarkable has been happening very recently at the ‘coalface’. In Box 7 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’, as one might say.[31]

Box 7. A remarkable turn-around 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.’

However, comments by people concerned with governance reveals that they see things differently:

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.[32]

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 system to oversee it. We are witnessing a failure to learn from this recent experience and grasp the notion of ‘pitching in together’.

The right lesson is not being drawn from this heartwarming story. Given the resources, the freedom 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. They have taught themselves to work in an ‘organic’ as opposed to ‘mechanistic’ or ‘hierarchical’ way.[33] Arguably, too, this kind of experience – bottom-up, not top-down – will do more to attract funding from NHS England than any amount of tinkering with governance.

But we have to ask: Is the Transformation Board and are the staff working under it actually equipped to learn from the experience at Treliske? Are they able to analyse it, to understand the part played in its success by different factors, such as communication, hierarchy (or the lack of it), and personalities? This is a situation where independent research could make an invaluable contribution.

Part III – Lessons

This study suggests a number of lessons, one for each of the bungles identified.

1. A lesson for NHS England: When local health and social care systems are being asked to do something that they haven’t done before, they should be given properly-tested guidance at the time, not left to divert already-stressed staff resources into having to guess what is required of them.

2. Before agreeing to hire business management consultants, local bodies should be very clear what they need and should conduct a risk analysis. They should not be regarded as ‘partners’.

3. Local bodies must appreciate that it is crucial for them to be able to talk to NHS England and other central agencies in their own language. There may be scope for consultants to offer masterclasses in reading the publications of NHS England and NHS Improvement.

4. Before deciding to create or abandon a project, local bodies should assess not only the immediate financial implications, such as their attractiveness to funding bodies, but the wider impact too, such as their scope for involving volunteers.

5. Central and local bodies should appreciate that ‘communications’ and ‘engagement’ are very different activities, and require different skillsets. They should emphatically not entrust communications specialists with organizing engagement events. And they should appreciate that for engagement to be effective it needs to take place throughout a planning process, as Healthwatch England has pointed out, not tacked on in a public consultation phase when many possibilities will already have been pre-empted and foreclosed.[34] (See Box 4.)

6. Local leaders should avoid being distracted by high-level ‘strategic’ organizational issues from paying attention to what is happening on the ground. Designing an organizational structure should start from ground level, from seeing ‘what works’: working from the bottom up, not from the top down. And it should be appreciated that this is difficult, not to be left to people who find themselves in senior positions but who have never had the benefit of studying how organizational structures can be created. NHS England would do well to sponsor research and instruction in this field.

---

Notes and references. All websites accessed on April 8th, 2018.

[1] I apologise to the inhabitants of the Isles of Scilly, but it is in the interest of brevity that elsewhere in this report I refer to the Sustainability and Transformation Plan as Cornwall’s STP. Officially it is indeed the STP for Cornwall and the Isles of Scilly.

[2] NHS England, Five Year Forward View, October 2014
https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

No author given, but the Foreword says: ‘It represents the shared view of the NHS’ national leadership, and reflects an emerging consensus amongst patient groups, clinicians, local communities and frontline NHS leaders.’ And the back cover bears the imprints (logos) of Care Quality Commission, NHS England, Health Education England, Monitor, Public Health England, and Trust Development Authority.

[3] As [2], p.17

[4] NHS England et al, Delivering the Forward View: NHS planning guidance: 2016/17 – 2020/21, December 2015
https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

[5] (Authorship not stated) Next Steps on the NHS Five Year Forward View, March 2017
https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf

[6] These bodies were NHS England, NHS Improvement (formed in April 2016 by combining Monitor, NHS Trust Development Authority and other regulatory and supervisory bodies), the Care Quality Commission, Public Health England, Health Education England, NHS Digital and NICE, and various patient, professional and representative bodies.

[7] To avoid confusion, in this report I shall continue to use STP to refer to the plans and STPartnership to refer to the organization.

[8] The organization NHS Improvement was in the process of being formed by combining Monitor, NHS Trust Development Authority and other bodies.

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

[10] Cornwall Reports, 15 February 2017 : Cornwall’s STP brings in the Chicago gang to advise on £264 million health and social care cuts
https://cornwallreports.co.uk/cornwalls-stp-brings-in-the-chicago-gang-to-advise-on-264-million-health-and-social-care-cuts/

[11] Minutes of KCCG Governing Body meeting 7 February 2017
https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/KernowCCG/OurOrganisation/GoverningBodyMeetings/1617/201703/GB201617143GBMinutesAndActionGrid.pdf

[12] GE Healthcare Finnamore started life as the British consultancy Finnamore: it was taken over by the American global conglomerate General Electric in 2014.

[13] As [10].

[14] GE Healthcare Finnamore, Final Report – Part 1 Support, 23 March 2017
https://cornwallreports.co.uk/wp-content/uploads/2017/08/GE-FIRST-REPORT-ilovepdf-compressed-2.pdf

[15] Hugh Alderwick, Phoebe Dunn, Helen McKenna, Nicola Walsh, Chris Ham, Sustainability and transformation plans in the NHS: How are they being developed in practice? November 2016
https://www.kingsfund.org.uk/publications/stps-in-the-nhs

[16] Ian Kirkpatrick et al, Using management consultancy brings inefficiency to the NHS, March 2018
http://blogs.lse.ac.uk/politicsandpolicy/using-management-consultancy-brings-inefficiency-to-the-nhs/
I Kirkpatrick et al, The impact of management consultants on public service efficiency, Policy & Politics, April 2018http://www.ingentaconnect.com/content/tpp/pap/pre-prints/content-pppolicypold1700072r2;jsessionid=25vwj4q8vscjk.x-ic-live-01

[17] On this saga see P. Levin & K. Maguire, Where now for ‘Living Well’ in Cornwall?, 13 August 2016
http://westcornwallhealthwatch.com/where-now-living-well-cornwall

[18] Cornwall Council, NHS Kernow, Home Care and Supportive Lifestyles Services, September 2017
https://www.cornwall.gov.uk/media/29035134/stakeholder-engagement-and-coproduction-report.pdf

[19] As [2], p.13, and see NHS Employers, Recruiting and retaining volunteers, 19 April 2016
http://www.nhsemployers.org/case-studies-and-resources/2016/04/recruiting-and-retaining-volunteers

[20] See NHS Improvement, Toolkit for communications and engagement teams in service changes programmes, undated, but June 2016
https://improvement.nhs.uk/documents/163/10473-NHSI-Toolkit-INTERACTIVE-04.pdf

[21] Peter Levin, Communications and engagement in health and social care: A cautionary tale from Cornwall, 12 July 2017
https://spr4cornwall.net/communications-and-engagement-in-health-and-social-care-a-cautionary-tale-from-cornwall/

[22] Transformation Board meeting, 19 December 2017: Consolidated Performance Management Report, November 2017. p.15.
http://doclibrary-shapingourfuture.cornwall.nhs.uk/DocumentsLibrary/ShapingOurFuture/TransformationBoardMeetings/Minutes/1718/201712/ProgrammeDirectorHighlightReport.pdf

[23] https://spr4cornwall.net/170707-info-pack-west-cornwall-final/

[24] p.43. The OBC does put the case for hospital bed closures in the context of the need for more housing options, which the handout failed to do.

[25] https://www.swahsn.com

[26] Briefing on Shaping Our Future urgent care work stream progress (undated, but February 2018).
https://spr4cornwall.net/wp-content/uploads/Briefing-on-Shaping-our-Future-Urgent-Care-work-stream-progress-Feb-2018.pdf

[27] NHS England, Urgent & Emergency Care: Consolidated Channel Shift Model: User Guide, Feb 2017
https://www.england.nhs.uk/wp-content/uploads/2017/03/uec-channel-shift-model-user-guide.pdf

[28] DRAFT Service Specification, GP-led Urgent Treatment (UTC) Service (undated, but February 2018).
https://spr4cornwall.net/wp-content/uploads/DRAFT-Specification-GP-led-UTC-Service.pdf

[29] Transformation Board: Minutes of meeting 19 December 2017, Item 4c.
http://doclibrary-shapingourfuture.cornwall.nhs.uk/DocumentsLibrary/ShapingOurFuture/TransformationBoardMeetings/Minutes/1819/201804/TransformationBoardMinutesDecember2017.pdf

[30] On 6 April 2018, CQC issued a Warning Notice requiring the Royal Cornwall Hospital Trust to make significant improvements within a week. Professor Ted Baker, Chief Inspector of Hospitals, said: ‘It is disappointing to report that our longstanding concerns persist about the safety and quality of some services at Treliske Hospital.’
https://www.cqc.org.uk/news/releases/cqc-inspectors-call-further-improvements-patient-services-royal-cornwall-hospital

[31] Transformation Board: Agenda paper for meeting 6 April 2018, Item 6.
http://doclibrary-shapingourfuture.cornwall.nhs.uk/DocumentsLibrary/ShapingOurFuture/TransformationBoardMeetings/Minutes/1819/201804/DevelopmentOfAnIntegratedCareSystem.pdf

[32] As [31].

[33] On mechanistic and organic structures, see the classic work by Tom Burns and G.M. Stalker, The Management of Innovation (Oxford UP, Revised edition 1994)

[34] Peter Levin, Cornwall’s STP: Why we need to see what’s going on, 12 September 2017
https://spr4cornwall.net/cornwalls-stp-why-we-need-to-see-whats-going-on/

 

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

The planning of Urgent Treatment Centres for Cornwall reveals a great deal of confusion within NHS Kernow. It is now evaluating all Minor Injury Unit sites for ‘upgrading’ to UTCs, but saying nothing about what will happen to MIUs that are not being upgraded. There is a draft proposal from Cornwall GPs for UTCs which has much to commend it, but it is a one-size-fits-all model for UTCs only, so further work is needed. ‘Co-production workshops’ are supposed to be contributing, but the latest briefing paper for these is deeply flawed, and the approach that the workshops take amounts to ‘Planning by Post-It Note’. And yet again, NHS Kernow is calling in consultants despite, it appears, not being clear how they could help.  

Background
In January this year, NHS Kernow (the Kernow Clinical Commissioning Group) took umbrage at the suggestion that it was poised to close most of Cornwall’s minor injury units (MIUs) in pursuit of NHS England’s aspiration to see urgent treatment centres (UTCs) covering the whole country.[1][2][3] NHS Kernow has now said that it will evaluate as potential sites for a UTC all 14 MIUs in Cornwall, including the Emergency Department at Treliske (which serves as a minor injury unit for the local population) and two MIUs that are currently closed.

Presumably, then, some of the existing Minor Injury Units will be upgraded to Urgent Treatment Centres. But what will happen to the others? It appears that no thought is being given to them.

This news emerged at the recently-held third wave of ‘co-production workshops’ held across Cornwall by NHS Kernow as part of the Shaping our Future (SoF) programme. This is the programme aimed at producing a Sustainability and Transformation Plan (STP) for Cornwall and the Isles of Scilly.[4] An insight into NHS Kernow’s thinking is given by two documents that were circulated in advance of the workshops: a briefing paper and a draft specification for UTCs drawn up by a group of Cornwall’s GPs and other clinicians.

What our GPs would like to see
The GPs’ plan is for a UTC led by GPs.[5] While it is still at the draft stage, and has not as yet been costed, the services it proposes would be a significant improvement on the national specification set out by NHS England[6] (which also would be GP-led). Having been produced by medics who are familiar with the locality and existing health services, it does draw on their detailed knowledge of how the system works at present and where inefficiencies occur. But the plan doesn’t draw on any survey of patients, to gather their views as ‘consumers’ of the system and learn from their experiences. And the specification is as yet uncosted, and we don’t know how the expenditure involved would be viewed by NHS England. Moreover, while a well-equipped UTC will doubtless provide a splendid service, if only four or five or six MIUs are to be upgraded, what is to happen to the others? Are they to be closed? Could they become mini-UTCs? Is any work being done to investigate this possibility? The final version of the specification needs to address these questions. The system must be treated as a whole.

NHS Kernow’s briefing paper
The other document provided to the workshops is a 9-page briefing paper, Briefing on Shaping Our Future urgent care work stream progress.[7] Among other things, this document reported on learning from previous co-production workshops, and included this statement:

The key challenge facing our emergency departments is not [that there are] too many people walking in with minor injuries and illnesses as these people can be seen relatively easily and quickly, but [that there are] too many people arriving, often by ambulance, with complex health needs requiring an assessment in a hospital. Therefore, this is the cohort of people we should be trying to support to receive care closer to home in a more local urgent treatment centre. For patients this will mean shorter travel times to receive care for more serious conditions currently only available in acute hospitals. (Para 3.2)

As we can see, this sweeping statement makes light of the workload created by ‘people walking in with minor injuries and illnesses’, even though NHS England is very keen to discourage such people from turning up at Emergency Departments.[8] And – crucially – it confuses assessment with care, by equating ‘too many people … requiring an assessment in a hospital’ with ‘the cohort of people [requiring] care closer to home’.

Assessment and care are different, as the GPs’ draft specification for UTCs recognises. Their specification provides for short stay assessment beds in a UTC, enabling frail patients in particular to stay overnight while diagnostic examinations and tests are carried out and the results awaited. In effect, the GPs are querying the implication in the briefing document that assessment necessarily takes place ‘in a hospital’.

The briefing paper also asserts that people with ‘complex needs [should] receive care closer to home in a more local urgent treatment centre’. But is it appropriate for someone with complex needs to be taken to an urgent treatment centre? Arguably, for someone with complex needs to get better they require a period of time in a restful environment, not one where the staff are under the pressure of urgency and the need for a rapid turnover of beds.

Thorough research needed
The lesson here is that health policy decisions, which involve massive expenditure on staff, equipment and buildings, need to be based not on casual, unsystematic observation but on organized research, asking insightful questions and carefully studying the processes at work. In the case of urgent treatment in Cornwall, the place to start would be the Emergency Department at Treliske. And we would need to ask questions about the flow of patients through the Department.[9] Questions like these:

Is it the case that patients typically see the most junior members of an emergency team before they access senior decision makers in emergency care? (It is the latter who are best able to ensure that patients quickly get on the right pathway.)

Is the assessment unit ‘processing’ patients speedily, or is it really operating more as a ‘holding bay’ in a bid to ease pressure on emergency care, while potentially adding delay and confusion at a point which could be critical to the overall outcome of a patient’s care?

When assessment requires a procedure extending beyond the assessment unit, as when a sample has to be sent to a laboratory for analysis, is the patient kept waiting, possibly requiring an overnight bed, for the result? (Do delays arise because patients tend to arrive later in the day while laboratory staff go home at 5? In which case, can something be done to alter working hours?)

Are patients kept in hospital for their discharge assessment even when they are medically fit and the assessment might be more meaningful in their own home?

Confusion in the briefing paper
Sadly, the briefing paper provided to the Wave 3 workshops contains more examples of confusion. For example, we find a reference to

A cost benefit analysis of West Cornwall Hospital which will seek to identify if the current additional investment in the GPs and enhanced diagnostics which set it apart from a nurse-led Minor Injury Unit makes a difference in terms of reducing ambulance journeys and Emergency Department attendances and admissions. (Para 3.6.1)

‘Cost-benefit analysis’ is a technical term. It is the name given to a well-established technique for comparing alternative courses of action in terms of a single criterion, usually the equivalent money value of the costs and benefits that would be entailed.[10] That is clearly not what is meant here. The term has been used without its meaning being grasped.

And again, we read that it is proposed to use

a modelling tool known as “Channel Shift” to evidence the impact of national Vanguard systems piloting new ways of delivering service. It has been endorsed by NHS England and the London School of Economics. (Para 3.6.2)

Suffice it to point out that the model is correctly known as the Consolidated Channel Shift Model, that the ‘national Vanguard systems’ referred to are seven pilot projects up and down the country in which local organizations (such as A&E Delivery Boards and Urgent & Emergency Care groups) took part,[11] and that the London School of Economics does not endorse models or ‘modelling tools’.

Another example: the briefing document presents a diagram that purports to show a ‘critical path’ of steps involved in identifying ‘options for the configuration of urgent care services’ (Para 3.7). ‘Critical path’ is another technical term with a very specific meaning: in project management, the technique of critical path analysis involves finding the sequence of steps through an often complex network that necessarily takes most time (this is the critical path), and then ensuring that when actually implementing the project no other sequence will take up more time.[12] That is clearly not what the diagram in the briefing document does.

Garbled and inaccurate descriptions of methodology and inappropriate citations of authorities do not inspire confidence. Nor does the fact that the briefing paper does not carry a date of publication or the name(s) of the author(s).

Mixed messages from NHS England
In a previous report[13] I pointed out how NHS Kernow was attempting to help satisfy NHS England’s ambition to roll out ‘standardised new Urgent Treatment Centres’.[14] Having heard from patients and the public about ‘the confusing mix of walk-in centres, minor injuries units and urgent care centres, in addition to numerous GP health centres and surgeries offering varied levels of core and extended service [with] a confusing variation in opening times, in the types of staff present and [available] diagnostics’, NHS England started off by determining that UTCs should be governed by a core set of standards to establish as much commonality as possible.

Subsequently, however, the message became more nuanced:

There will inevitably be variation in what each urgent treatment centre may provide as the needs will be different for different populations and geographies. [Moreover, we know] that there will be some exceptions where … a service that does not meet [our] standards [will be justified], most likely in more rural or sparsely populated areas.[15]

So NHS England is now being flexible. This flexibility presents an opportunity for Cornwall.

What will NHS Kernow do now?
People who attended the latest co-production workshops were informed (in a photocopied handout) of another new development. NHS Kernow has commissioned a study of travel times between people’s homes and the fourteen MIU sites. Because a ‘common concern [is] how long will I have to travel if you move a service that provides my care from A to B? … it’s really important that we … calculate how long it takes to travel by all methods of transport’.

Careful consideration should be given to a study of this kind before a contract is entered into. In particular, the question needs to be asked: How will the results be used? Clearly in any calculation the travel times will need to be weighted by population numbers, so will it be possible for a sizeable town to outweigh a group of small villages? And there is more to travel than distance and modes of transport. For example, Camborne is midway between Penzance and Treliske, but if Camborne doesn’t have its own UTC, can we expect half the inhabitants of the town to choose to attend the UTC at Penzance? Unfortunately NHS Kernow appears, as it has done in the past, to have seized on a project offered by consultants without seriously questioning it, with a consequent risk that decisions will be taken on the basis of crude theories of ‘geographical determinism’.

A planning role for GPs
It can only be a good thing that (so far as we can tell) local GPs are on board with the UTC project, because of the experience and local knowledge that they bring, and their draft UTC specification is a valuable contribution. However, the fact that it is only a single specification brings with it the risk of it being seen as a ‘one size fits all’ solution.

Interestingly, in Devon it is well understood that a range of provision is needed. As NEW Devon CCG has pointed 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.[16]

Exactly the same is surely true of Cornwall, and it now seems to be appreciated by NHS England. So it would be good to see the guiding principle, adopted in Devon, of meeting local needs rather than going for standardization and consistency, adopted so far in Cornwall too by our GPs, which must mean reaching beyond their single draft specification.

Can ‘co-production workshops’ contribute more than ‘Planning by Post-It Note’?
What have the co-production workshops yielded so far? At the February 2018 Wave 3 workshops, participants were shown a Powerpoint presentation. The Agenda slide showed ‘Lessons Learned in Wave 2’: these were based on three lists of ‘Pan-Cornwall Wave 2 Themes’, which are shown below:

Prevention & Self Care •Ÿ  It’s everyone’s responsibility •Ÿ Ÿ Target children and those most at risk Ÿ•Ÿ  Early intervention •Ÿ  Provide more in the community & be holistic Ÿ•Ÿ  Reduce access to unhealthy choices •Ÿ  Reduce isolation & increase social prescribing Ÿ•Ÿ  Work with Voluntary Sector (VCSE)

 

Integrated Care •Ÿ  Be holistic(housing, finance telehealth etc.) •Ÿ  Integrate teams (trust, co-location shared MDTs) •Ÿ  Workforce (capacity training, Terms & Conditions, blended roles) •Ÿ  Governance (trust, budgets, clinical & info. governance) •Ÿ  Estates (expanded usage of community & care settings) •Ÿ  Model of care (time to think beds, mental health, transport, Single Point of Access •Ÿ  (SPA), 111, Out of Hours (OOH), discharge)

 

Location •Ÿ  Arterial routes •Ÿ  Parking •Ÿ  Congestion •Ÿ  Seasonal fluctuations •Ÿ  Rurality •Ÿ  Fear of change (keep services local)

What we see here is a classic example of ‘thinking in themes’. This way of thinking may lend itself to structuring an undergraduate essay in sociology, but it is of limited use in solving practical problems, and it gives rise to a ‘fragmentary’ way of thinking. Hundreds of contributions from workshop participants have been recorded[17], but around two-thirds of them are of only one or two lines, and would fit comfortably on a Post-It Note. No indication has been given of how these fragments will be put to use.

Conclusion
The process of planning Urgent Treatment Centres in Cornwall reveals some confusion within NHS Kernow. The draft proposal from Cornwall GPs for GP-led Urgent Treatment Centres has much to commend it but is a one-size-fits-all model, and needs further work. The briefing paper for the latest ‘co-production workshops’ is deeply flawed, and the approach taken by the workshops amounts to ‘Planning by Post-It Note’. Most worryingly, NHS Kernow is calling in consultants despite, it seems, not being clear how they could help.

---

Notes and references (Websites last accessed on 28 February 2018)

1. Peter Levin, NHS in Cornwall poised to close Minor Injury Units, 3 January 2018.
   https://spr4cornwall.net/wp-content/uploads/NHS-in-Cornwall-poised-to-close-MIUs.pdf
   
2. (From Cornish Stuff [www.cornishstuff.com] 4 January 2018) NHS Kernow calls MIU Report ‘scaremongering’ – Dr Levin responds
   https://spr4cornwall.net/wp-content/uploads/MIUs-NHS-Kernow-statement-and-PL-response.pdf
3. Peter Levin, Minor Injury Units: “Absolutely no decisions have been made …” Which means what, exactly? 15 January 2018.
   https://spr4cornwall.net/wp-content/uploads/MIUs-Absolutely-no-decisions.pdf
4. See 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
5. DRAFT Service Specification, GP-led Urgent Treatment (UTC) Service (undated, but February 2018).
   https://spr4cornwall.net/wp-content/uploads/DRAFT-Specification-GP-led-UTC-Service.pdf
6. 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
7. Briefing on Shaping Our Future urgent care work stream progress (undated, but February 2018).
   https://spr4cornwall.net/wp-content/uploads/Briefing-on-Shaping-our-Future-Urgent-Care-work-stream-progress-Feb-2018.pdf
8. NHS England, Urgent Treatment Centres (undated)
   https://www.england.nhs.uk/urgent-emergency-care/urgent-treatment-centres/
9. Improving Patient Flow, The Health Foundation, April 2013
   http://www.health.org.uk/sites/health/files/ImprovingPatientFlow_fullversion.pdf (and see publications by Dr Kate Silvester)
10. See e.g. An Introduction to Cost Benefit Analysis, http://www.sjsu.edu/faculty/watkins/cba.htm
11. NHS England, Urgent & Emergency Care: Consolidated Channel Shift Model: User Guide, Feb 2017
    https://www.england.nhs.uk/wp-content/uploads/2017/03/uec-channel-shift-model-user-guide.pdf
12. See e.g. Critical Path Project Management,
    https://www.thebalance.com/critical-path-project-management-cpm-2276128
13. NHS in Cornwall poised to close Minor Injury Units
    https://spr4cornwall.net/wp-content/uploads/NHS-in-Cornwall-poised-to-close-MIUs.pdf
14. NHS England, Next Steps on the NHS Five Year Forward View, March 2017
    https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf
15. As 6, p.5.
16. NEW Devon CCG, Minor injuries service in Sidmouth. https://www.newdevonccg.nhs.uk/2016-news-archive/minor-injuries-service-in-sidmouth-101975
17. See e.g. Wave 2 co-production workshops, West Cornwall output report
    https://www.shapingourfuture.info/wp-content/uploads/2017/11/Wave-2-Report-West-Cornwall.pdf

— 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] https://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

 

— 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]

 

— 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

 

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

Nonsenses revealed
The much-loved Edward Hain community hospital in St Ives, Cornwall, was closed ‘temporarily’ in April 2016, to great local concern. It is still closed ‘temporarily’. Recent reports to Cornwall Council’s Health and Adult Social Care Overview and Scrutiny Committee on the matter have revealed five kinds of nonsense that face both the hard-working people trying to bring together health and social care services in Cornwall and the members of the public who are trying to make head or tail of a complicated situation. The reports [1,2.3], which were presented by the Chief Executive of the Cornwall Partnership NHS Foundation Trust (CPFT), demonstrate:

♦ The nonsense of ‘silo thinking’: one organization taking a decision while ignoring the potentially damaging implications of that decision for others

♦ The nonsense of an organization presenting partial information in order to justify its case

♦ The nonsense of ‘we won’t decide until you’ve decided’ as the model for a decision-making process

♦The nonsense of calling the closure ‘temporary’ when no reopening date has been set, so in fact the closure is ‘indeterminate’

♦ The nonsense of labelling the bed-based model of hospital care as ‘expensive’.

This report asks what lies behind these various nonsenses. Is there a hidden – or not so hidden – agenda?

The backstory
The Edward Hain Memorial Hospital, founded in 1920, is a community hospital that until February 2016 ago provided 12 beds for in-patients needing rehabilitation, alcohol detoxification or end-of-life care. Admissions included orthopaedic patients who may have had hip replacements, patients with leg ulcers, oedema, stroke, amputees, spinal problems, chronic or acute breathing problems and cardiac patients. Some of these patients were bed-bound and able to be moved only with the assistance of a hoist, but others were mobile, with assistance if necessary. It was the only hospital serving the Penwith peninsula that provided a specialist rehabilitation/reablement service.

Since April 2013 the building has been owned by NHS Property Services (NHSPS), a limited company wholly owned by the Department of Health. At that time the hospital was run by Peninsula Community Health (PCH). In February 2016 PCH closed the 12 inpatient beds, following a fire safety review which found there was no provision for moving beds out in case of fire. PCH had previously been relying on using ‘evacuation mats’, on which immobile patients could be placed and dragged out of the building. Evidently the leaders of PCH had changed their minds about the acceptability of that manoeuvre.

To give effect to the closure, patients were initially transferred to a ward at Camborne and Redruth Hospital. For approximately 6 months local GPs supported patient treatment and discharge on that ward. However, this medical cover could not be sustained and it was discontinued.[1]

In April 2016, Cornwall Partnership NHS Foundation Trust (CPFT) took over the running of the hospital from PCH. They continued to keep the 12 inpatient beds closed. The Trust’s leaders understood that NHS Property Services were working on a programme of remedial work to allow the hospital to reopen those beds.

In June 2016 NHS Property Services produced a report recommending certain remedial works, to start the following September. When CPFT staff looked at the plans they realised that after the works there would still be no provision for moving beds out if there were a fire. We read: ‘The Trust believes (sic) the use of a mat is an extreme approach to evacuation which is likely to cause injury to both patients and staff. Relying on this approach as the sole means of evacuation does not sit comfortably with the Trust’s obligation to maintain a safe environment.'[1]

In July 2016 CPFT undertook an evacuation exercise in Edward Hain with a live subject, using the drag mats. It was concluded that the time, physical demands of the procedure and the need for staff to return again and again into what would become a very dangerous environment was unacceptable as the main evacuation procedure. (This process was filmed: the film can be viewed here.)

CPFT asked NHS Property Services to go back to the drawing board and produce a design conducive to bed evacuation. Four alternative designs were produced for a meeting in August 2016, and one was chosen. It involves widening of doors and corridors and would cost around £900K. ‘The Trust understands that the League of Friends have offered NHSPS £600K towards this work, leaving a potential shortfall of £200-300K. It is the decision of NHSPS whether or not to accept the generous offer from the League of Friends. … The Trust is due to meet with NHSPS Executive Team by October 2017 to discuss the potential options for the re-opening of the facility.'[1]

The CPFT chief executive also told the Overview and Scrutiny Committee: ‘We need to consider any work at Edward Hain alongside our Shaping Our Future plans (Cornwall’s Sustainability and Transformation Plan, STP). These  plans are being developed alongside health and care partners across Cornwall and the Isles of Scilly. We have completed a round of six locality-based engagement events with around 300 clinicians, volunteers, councillors, patients and staff sharing their insight, experiences and views to co-design proposals to transform the way health and social care is delivered. All the information captured during these workshops along with the feedback that has been received will be collated and will help to tailor a series of two further workshops taking place throughout September and November. This co-design process will enable us to then develop a “service specification” for out of hospital services for the locality within which St Ives sits. Until this work is complete which may well then require formal public consultation we will not be clear on the long term use of Edward Hain as a facility.’

The nonsense of ‘silo thinking’: one organization taking a decision while ignoring the potentially damaging implications of that decision for others
The ‘Comprehensive Impact Assessment’ presented to the Overview and Scrutiny Committee said the aims of the assessment were (1) To establish the impact of the temporary closure on patients, carers and staff; (2) To determine if the temporary mitigations are delivering safe care; and (3) To present findings to support the consideration of the longer term future as part of STP.[1] As we see, there was no aim to establish the impact of the closure on the running of Treliske hospital.

A second report presented to the Committee, as a supplementary ‘impact assessment’, included a brief section on financial impact (capital, revenue, risks, sustainability).[2] Here we read:

Implications for NHS organisations: No impact.

Implications for the wider Health Community: No impact as community beds are available in Cornwall.

So neither of the impact assessments covers Edward Hain hospital’s role of taking patients from the Royal Cornwall Hospital at Treliske after they have had surgery, so-called ‘transfers of care’. (Treliske is run by the Royal Cornwall Hospitals Trust, RCHT.) Edward Hain took patients through rehabilitation/’reablement’ procedures, equipping them to return to normal life. In May 2015 Edward Hain was already running at 92.7% of capacity, with 316 of its 341 available bed-nights occupied in that month. Figures show that all the other community hospitals in Cornwall were also running at more than 90% of capacity (including a staggering 99% at Camborne-Redruth).[4] Which makes a nonsense of the statement that ‘community beds are available in Cornwall’.

Where would patients who had undergone surgery go when Edward Hain was closed? It would not be surprising to find that the closure of Edward Hain had resulted in a high count of ‘delayed transfers of care’ (DTOCs) out of Treliske, and indeed reports to the RCHT Board show that in August 2016 patients awaiting transfer took up an average of 7.1% of beds at Treliske, more than twice the national expected maximum of 3.5% and equating to an average of 55 patients per day: the ‘worst performance for at least five years’. In August 2017 the equivalent figures were 9.3% and 54 patients, i.e. maintaining that ‘worst performance’. The top causes of delay were the need for further non-acute NHS care (i.e. precisely the kind of care that Edward Hain formerly provided), followed by the need for domiciliary packages and completion of assessment.[5]  Evidently, then, there was a major impact on Treliske and this went completely unmentioned in the CPFT reports to the Overview and Scrutiny Committee.

The nonsense of an organization presenting partial information in order to justify its case
While the ‘Comprehensive Impact Assessment’ listed the categories of patient who had been cared for in Edward Hain, it gave no figures. So we have no idea what proportion of patients were there for rehabilitation, alcohol detoxification or end-of-life care, or were bed-bound and/or needed a hoist to be moved. Conceivably it would have been possible to restrict admissions to patients who were not bed-bound, but lacking the information that figures provide we are unable to exercise our own judgment, or check the judgment of those who took the decision to close the hospital to inpatients.

And note the language used: ‘The Trust believes the use of a mat is an extreme approach to evacuation which is likely to cause injury to both patients and staff. Relying on this approach as the sole means of evacuation does not sit comfortably with the Trust’s obligation to maintain a safe environment.’ Reliance on belief and the emotive term ‘sitting comfortably’ is not the same as using hard evidence to justify a significant public policy change.

Note too that the filmed experiment with evacuation mats used a well-built, middle-aged man as their model. It clearly required a considerable effort to drag him along the floor, much more than would be required to move a frail, elderly woman. Once again, we have a select piece of information used to justify a decision.

The nonsense of ‘we won’t decide until you’ve decided’ as the model for a decision-making process
One of the reports presented to the Overview and Scrutiny Committee on September 27th (contained in a supplementary information paper circulated to Committee members only two days before) was entitled Fire Position Statement – The Management of Fire Safety. Buried in it (on Page 27 of 30) is this information:

NHS Property Services [has] developed alternative proposals  including improved layout that will enable horizontal bed evacuation and bed holding areas. To deal with the external fire control issues a sprinkler system would be introduced that will restrict fire growth quickly and in the majority of cases prevent the need to remove patients from the building.

This revised proposal is accepted by [CPFT] as it would create an environment where we could reasonably keep staff patients and visitors safe in the event of a fire incident. The plan is to reopen inpatient services on this site when this work has been undertaken.[3]

If this proposal has been accepted, why isn’t work proceeding? It transpired at the Committee meeting that CPFT is waiting until the building has been made safe. But NHS Property Services has decided to wait to see whether Edward Hain has a long-term future. Kernow Clinical Commissioning Group is waiting to see the outcome of the Sustainability and Transformation Plan process, and will not give any guarantee about Edward Hain’s future until it does. And, of course, we may expect there to be a further wait until the powers that be (NHS England or the Secretary of State for Health) have decided what to do about the STP. (These are further examples of silo thinking, of course.)

So CPFT is waiting for NHSPS, which is waiting for KCCG, which is waiting for the STP, which will wait for higher approval.

The role of NHS Property Services here is crucial. The property company, which has not responded to the ‘generous offer’ made by Edward Hain’s League of Friends, has taken it upon itself to keep this community hospital out of use for reasons that are entirely its own and have nothing to do with health care. As its website shows, it prides itself on realising large sums from the sales of ‘surplus’ property.[6] So its decisions have taken no account of the burdens that are falling – and will continue to fall – on Treliske hospital and on patients.

We can think of planning as a process of colonizing the future. KCCG’s attitude appears to be that while planning is taking place the present needs to be frozen. To bring Edward Hain hospital up to scratch would be to create a bridgehead into the future, so a certain amount of ‘thawing’ would be required. It should not be beyond the wit of KCCG’s managers to envisage alternative scenarios in which a safe Edward Hain building could be seen as offering opportunities for being usefully employed. Planning in the field of public policy always takes place in a dynamic situation. The world does not stop. The planners have to deal with that, to adapt, to look for ways of incorporating those dynamics into their plans. If they make no attempt to do so, we must question their competence.

As things stand, the planners have given NHS Property Services, which has an interest in seeing land and buildings declared surplus to requirements, a veto over the use of Edward Hain in the immediate future. (Meanwhile the expenses of rates, security and basic maintenance will still be incurred, of course.)

The nonsense of calling the closure ‘temporary’ when no reopening date has been set, so in fact the closure is ‘indeterminate’
It would be legitimate to describe the closure of Edward Hain hospital as temporary if the reopening were contingent on some tangible process with a completion date, like the actual carrying out of works under a contract. But when the chief executive of CPFT chooses to call an indeterminate closure ‘temporary’ should he be surprised when local people feel they are being taken for fools?

The nonsense of labelling the bed-based model of hospital care as ‘expensive’
The Outline Business Case for the STP published in October 2016 put forward a case for change that incorporated several references to ‘expensive bed-based care’.[7] Bed-based care is also described as ‘outdated’ (on page 43). Interestingly, hardly anything else in this substantial document is described as ‘expensive’. In normal usage the adjective ‘expensive’ is a relative one: X is expensive compared with Y. But here we are given nothing to compare bed-based care with.

We are also told, among a number of ‘facts that support the need for change’, that ‘Around 60 people each day are staying in an acute hospital bed in Cornwall and they don’t need to be there'[8] – which looks to be at least in part a consequence of the closure of Edward Hain, of course. Further, we are told ‘Older people can lose 5% of their muscle strength per day of treatment in a hospital bed’: we aren’t told, however, what percentage of muscle strength per day you would lose staying unwell at home in your own bed, being visited for limited periods by a physiotherapist who spends a good deal of her or his professional time driving from one patient’s home to the next. It would appear that these so-called facts are being trotted out to support the argument that bed-based care is ‘expensive’.

Is there a hidden – or not so hidden – agenda?
This question is essentially about the interests that motivate the people who commission and provide health and social care services in Cornwall.

The officers of Kernow CCG are manifestly under pressure from their masters in NHS England, to whom they account for their spending, which in 2016 showed they were heading for a budget deficit of £264 million by 20220/21. NHS England have also been pursuing a national policy of saving money by cutting the number of hospital beds, and  a number of clinical commissioning groups have produced STPs which show large reductions. We cannot expect KCCG to be immune from this pressure, which would explain the labelling of bed-based care as ‘expensive’ and their ‘scraping the barrel’ efforts to find other justifications for closing beds.

Recently-published research by the King’s Fund[9] and the Nuffield Trust[10] has high-lighted the harmful consequences of this policy, and it may be that KCCG officers are in two minds as to whether it is in their interest to continue with it or not. That would be consistent with their ‘kicking the can down the road’ policy of deferring any decision until they see the STP – although it is of course within their power to determine what actually goes into the STP!

The front-line player in the Edward Hain saga is the Cornwall Partnership Foundation Trust (CPFT). CPFT describes itself as a ‘mental health provider'[11] and on his LinkedIn profile its chief executive describes as his achievements that CPFT was one of only a small number of mental health providers assessed as Good by the Care Quality Commission, that he successfully managed local PFI companies regularising the arrangements and securing compensation in excess of a four million pounds, and that he ‘successfully delivered two transactions, children’s services for £12 million in 2011 and adult community services for £78 million in 2016’, as well as growing the organisation from £70 million to £160 million in six years.

We might infer from this that his main priorities are mental health provision and financial success, in which fields success can be attributed to him and his organization alone. His interest in providing ‘intermediate care’ and working with other health care providers would come correspondingly low down in his priorities. We might say that in keeping more than 90% of the beds in his community hospitals occupied he is using them efficiently, but the consequence for Cornwall’s provider of acute hospital services, RCHT, is that the managers there have no idea from day to day whether they will be able to move out a patient who is recovering from surgery. The CPFT chief executive’s interests appear not to extend to providing an integrated service.

The CPFT chief executive continues to affirm that CPFT’s plan is to reopen inpatient services at Edward Hain hospital when the fire safety work has been undertaken.[3] Is that genuinely his intention? He shows no sign of trying to find a way forward that would encourage NHS Property Services to carry out those works, while NHSPS know that if they can promote the idea that the building and land are surplus to requirements they can highlight their achievement in raising a large sum from selling it. It does appear that the CPFT chief executive’s agenda is not one in which the reopening of Edward Hain hospital will feature.

What can we say about the interests of RCHT? Management and staff appear to have a common interest in getting on with the job, and are frustrated by the continuing difficulty of moving out patients who have undergone surgery and are fit to leave. Unfortunately, because their interests are evidently narrowly focused on moving patients out, when collecting data they focus only on patients’ fitness to leave: they do not collect data on where those patients are fit to move to. If they were to distinguish between fitness to go home, given an appropriate home-care package, and fitness to move to an intermediate care hospital such as Edward Hain, which would provide rehabilitation/re-ablement care, they would be able to add their voice and inside information to the case for keeping Edward Hain open.

Cornwall Council, the local authority with responsibility for social care, does keep a record of the number of delayed transfers of care that are attributable to adult social care from acute hospital per 100,000 population.

Officers have told HASCOSC that the Council has been working closely with health partners to improve delayed transfers of care. In March 2017 the Government announced a national adult social care grant for local authorities. Cornwall’s share is approximately £12m. In July the Department of Health (DoH) attached targets to this funding.  For Cornwall this amounts to achieving a performance of 6.3 DTOCs per 100,000 18+ population by September. Later data are not available, but such an achievement would have been a remarkable feat, given that the figure for June was 16.4. Council officers say they are addressing ‘issues with delays for assessments, market stabilization, patient flow and prevention’.[12] It is evidently in the interest of Council officers to attain the DoH target, but they are encountering obstacles.

Council  officers are also working on Integration of health and social care through the Shaping our Future Programme, as work on the STP has been rebranded. The focus here is on ‘recommissioning Integrated Community Teams and Community Hubs (including community hospitals and bed provision)’. As of mid-June 2017, they have reported, ‘despite some progress, the status of the programme is now Red (i.e. out of tolerance with no current approved plan to bring the situation back under control) because: (1) There is insufficient capacity within the central team for Integrated Community Care to deliver at the pace required given the acknowledged complexity of the programme; (2) Because of the complexity of the organic and locally based nature of integrated practice across primary care and community health and social care, the central team have not yet identified a way to fully understand this, increase the visibility of positive operational change and construct this into a coherent framework for Cornwall; and (3) Based on learning from North Devon, we are not currently collecting the acuity data needed to show the impact of Integrated Community Care on hospital bed demand.'[12]

Reading between the lines, it seems evident that what we have here are council officers with a keen awareness of the position of community hospitals and bed provision who have found the ‘central team’ very limited (to put it politely) in its capability to address the issue. Yet it is this self-same central team that has been entrusted with producing the STP on which the future of Edward Hain hospital depends.

The STP team is ostensibly working under the supervision of a four-person collective, comprising the chief officers of Cornwall Council, the Royal Cornwall Hospitals Trust, Cornwall Partnership Foundation Trust and Kernow Clinical Commissioning Group. They reported to HASCOSC in July that they have three programmes of work running in parallel under Shaping our Future: (1) Development of business case for new integrated model of care; (2) Moving to an Accountable Care System; (3) Developing a strategic case for Devolution.[13]

This is all ‘high-level stuff’: it reveals the overwhelming interest of those involved in gathering powers and creating a power structure, rather than in sorting out the complex situation on the ground identified by the less senior council officers. It is hard to see the future of Edward Hain hospital featuring high on their agenda.

And with that being the case, it is not hard to envisage the other members of the ‘gang of four’ leaving it to the chief executive of CPFT to do whatever he wants, despite the five kinds of nonsense identified in this report, and ride out any little local difficulty that might ensue.

If the League of Friends of Edward Hain Hospital want to save it, the last community hospital remaining in Penwith, they must not only challenge the hidden agenda of CPFT and NHS Property Services to close it: they must also raise it up the agenda of those who might otherwise close their minds to the issue. And if they make a great noise in doing so, can anyone say they are being unreasonable? It is currently anticipated that there will be a round of public consultation on community hospital closures in February 2018. [2] This story is not over yet.

Notes

[1] Comprehensive Impact Assessment, Version 7, February 2017 https://democracy.cornwall.gov.uk/documents/s103287/Appendix%201%20-%20Edward%20Hain%20-%20Impact%20Assessment.pdf

[2] Proposed Service Change or Development: Substantial Variation Impact Assessment, submitted to HASCOSC 22 September 2017
https://democracy.cornwall.gov.uk/documents/s103485/Appendix%202%20Edward%20Hain%20Substantial%20Variation%20Impact%20Assessment.pdf

[3] Fire Position Statement (incorporated in supplementary information paper for HASCOSC)
https://democracy.cornwall.gov.uk/documents/b24077/Supplementary%20Information%20Provided%20for%20Edward%20Hain%20Hospital%2027th-Sep-2017%2010.00%20Health%20and%20Adult%20S.pdf?T=9

[4] See Community Hospitals Under Threat https://spr4cornwall.net/community-hospitals-under-threat-are-decisions-being-taken-on-scrappy-information-and-limited-understanding/

[5] Integrated Performance Report to RCHT Board, 28 September 2017
https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/TrustBoard/Minutes/1718/201709/App05IntegratedPerformanceReport.pdf

[6] http://www.property.nhs.uk/

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

[8] In Taking Control, Shaping our Future (A summary of the Draft Outline Business Case), p.15
https://www.cornwall.gov.uk/media/22983857/taking-control-shaping-our-future.pdf

[9] Ewbank et al, NHS hospital bed numbers: past, present, future, The King’s Fund, 29 September 2017  https://www.kingsfund.org.uk/publications/nhs-hospital-bed-numbers

[10] N.Edwards, What’s behind delayed transfers of care?, Nuffield Trust, 8 February 2017
https://www.nuffieldtrust.org.uk/resource/what-s-behind-delayed-transfers-of-care

[11] NHS Benchmarking Network, Current Members
https://www.nhsbenchmarking.nhs.uk/current-members

[12] Cornwall Council, Health and Adult Social Care Overview and Scrutiny Committee – Performance Dashboard, Quarter 1 2017/18
https://democracy.cornwall.gov.uk/documents/s103141/Appendix%202%20Work%20Plan%20Performance%20Dashboard%20Q1.pdf

[13] K. Byrne, Shaping Our Future, report to HASCOSC 27 September 2017
https://democracy.cornwall.gov.uk/documents/s103143/Shaping%20our%20Future%20Report.pdf

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When we are told ‘Don’t worry: no decisions will be taken before the public are consulted’ we have every reason to worry!

Right now work is going ahead on preparing a Sustainability and Transformation Plan (STP) for health and social care in Cornwall and the Isles of Scilly. Under the brand name Shaping our Future (SoF), a team of people are beavering away to produce a ‘plan’ of some kind. It seems that this is due to be unveiled in a few months’ time, and is to take the form of a Pre-Consultation Business Case.

For anyone who is concerned about what the ‘plan’ will mean for them and their family and neighbourhood, the problem is this. During the planning process, as in all planning processes, things happen to narrow down the options that are available at the point when the public are eventually consulted. For example:

♦  Time and staff resources are used up. Once a deadline has been set, there is simply not the time and manpower to go back to square one and start again. If no alternatives have been investigated and considered, there is no time now to investigate them. Even if alternatives have been considered, these will have been reduced to a shortlist, and it won’t be possible to resurrect any that didn’t make it on to the shortlist.

♦  The staff working on the plan become psychologically committed. They take decisions about the kind of plan they want to see, and about working methods, i.e. how they are going to produce the plan: to go back on these decisions, and write off some of the work that has been done, will generate stress and involve loss of face. Similarly, people make assumptions and become wedded to these: even if evidence turns up that shows that their assumptions were unrealistic or – like budgetary limitations – could have harmful consequences, they may disbelieve and deny that evidence (the phenomenon of cognitive dissonance).

And the staff working on the plan will have their own motivations. They will have personal ambitions, such as advancing their careers, and typically will want to produce something distinctive and striking. Such ambitions too generate commitment.

♦  The planning team may have a budget for research, and agree a contract with an outside research outfit for it to do this work. This contract will set out ‘terms of reference’ for the work, e.g. to explore and evaluate the implications of possible plans X and Y. Then as the planning team forges ahead it may become apparent that there’s a third possibility, option Z. But it may be that the research budget has all been used up, and there is no money to explore and evaluate option Z. So option Z gets ruled out by default, long before a point of formal decision is reached.

♦  Some people, particularly members of powerful interest groups, will have easier – ‘preferential’ – access to the planning process than others. For example, in the NHS senior managers and consultants may get together privately to find and agree a course of action that suits both groups. Once that agreement has been reached, it will be very difficult for members of allied health professions, let alone the public, to get it reviewed and altered.

♦  The situation on the ground changes. A facility may be closed for repairs, and it happens that staff drift away, local people at first protest and then find ways of coping, the building gets starved of maintenance and begins to decay, so the option of restoring it to use becomes increasingly expensive and consequently difficult to justify (the ‘planning blight’ syndrome). Or a service that up to now has been provided at local level gets abruptly withdrawn, to be replaced on grounds of economy by centralized provision, transferring costs to patients who have more travelling to do and importantly making it difficult to restore the service at local level.

Never underestimate the effect of these dynamics. By closing off options they pre-empt formal decisions. As a former very senior civil servant has 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 huge penalty attached to throwing it overboard at that stage.

It is true that the widespread criticism of the previous ‘engagement’ over the STP for Cornwall caused the process to be restarted. However, this appears to be very much the exception that proves (in the sense of ‘proofs’, or tests) the rule. Anyone who bets on this happening again would be virtually certain to lose their money.

We have to be alert to the fact that managers who are familiar with these phenomena can deliberately take advantage of them. Thus they can limit the number of staff working on the plan and impose unrealistic deadlines, they can impose stringent budget limitations, they can reach deals with the more powerful interest groups, and they can change the situation on the ground. Indeed, they may have reached their present positions in their organizations precisely because they are skilled in using strategies like these.

So while these managers may be absolutely correct when they say that no formal decisions will be taken before the public are consulted, they may have a host of strategies under way to guarantee that they get the result they want. We have every reason to worry!

What can we do about it?

Public money is being spent on producing plans for new health and social care arrangements. It is my contention that those spending it should be directly accountable to the public for their work, not via paymasters with their own personal and political agendas. Such accountability requires – and it is an essential and fundamental requirement – transparency.

Transparency needs to be good enough to enable us to follow every step in the planning process. So we need to see what terms of reference the planning team have been given. We need to see what they tell the Transformation Board or whoever it is that supervises them, and what instructions and ‘steers’ they get from that Board. We need to know what skills the members of the planning team have, so we can see whether there are gaps in their range of skills. We need to know what contracts they give to researchers and management consultants, so we can see for ourselves what limitations are built in to these contracts, and we need to see the reports that these people produce. We need to know about deadlines, so we can gauge the impact of these on the process. And we need to keep a close eye on the situation on the ground, so we can judge how day-to-day decisions are closing off options for the future.

In a nutshell, we need to see what’s going on!

– – –

*Lord Bridges (Cabinet Secretary 1938-46, Permanent Secretary to the Treasury and Head of the Home Civil Service 1946-56), ‘Whitehall and Beyond’, The Listener, 25 June 1964. Cited in Peter Levin, ‘Opening up the Planning Process’, in Stephen Hatch (ed), Towards Participation in Local Services, Fabian Tract 419, 1973 and in Peter Levin, Making Social Policy, Open University Press 1997 (p.44).

 

 

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

Work on the Sustainability and Transformation Plan (STP) for health and social care in Cornwall and the Isles of Scilly, now rebranded as Shaping Our Future (SOF), has reached a critical stage. We risk being gulled into earnest round-table discussions while an organizational bulldozer lightly camouflaged with poor quality information lumbers towards us. Community hospitals are under threat and decisions are evidently being taken on scrappy information and limited understanding.

This report examines recent developments and draws some pessimistic conclusions, but goes on to suggest a more positive way forward.

Recent development (1): Local area workshops have been held.
In July 2017 half-a-dozen ‘local area workshops’ were held across Cornwall. They brought together people from three groups: people who work in the health and social care services, people who work for voluntary bodies (the ‘third sector’) in delivering those services, and people who have recently received support from these services, or their full-time carers.

The stated aim of these three-hour events was ‘to ensure that any changes to the health and social care system achieve our aims of improving the health and wellbeing of our local population by improving the quality of local health and care services in ways that are financially sustainable’, and the idea was that the three groups of participants would work together, setting aside organizational roles, ‘to help produce detailed options for what local people can do themselves, for local community support, and for local services’. The term ‘co-production’ is sometimes used as shorthand for working-together endeavours of this kind.

So patients and carers have sat round a table with service providers and members of voluntary organizations, and (as I have witnessed) some worthwhile exchanges have taken place. At the time of writing this, we wait to see what written records emerge from these exchanges and how frankly they reflect them. And, importantly, what can be built on them.

Recent development (2): Information packs of poor quality have been handed out.
At each local area workshop, an information pack was handed out. It included a section on ‘The case for change’, and here we find four snippets of quantitative data on hospital services (p.5):

(1) ‘Around 60 people each day are staying in acute hospital beds in Cornwall and they don’t need to be there.’

Comment This statement could be extremely misleading, because it does not necessarily follow that people who no longer need acute treatment are fit to go home, although this seems to be the conclusion we are intended to draw. It may be that many of these people are awaiting transfer to a community hospital. Evidently the Royal Cornwall Hospitals Trust does not collect data on the fitness of patients for a particular destination. It exists within its own ‘silo’, not looking beyond its own boundaries, so we are given this number out of context. Also we aren’t told what date or period the figure of 60 people refers to: it is a snapshot taken at an unspecified time.

(2) ‘35% of community hospital bed days are being used by people who are fit to leave.’

Comment Similarly, we are not told what destinations the people in community hospital beds who are judged ‘fit to leave’ are fit to go to, or on what date or over which period this percentage figure was gathered.

(3) ‘83% of admissions to community hospitals are from acute services compared to 42% nationally.’

Comment While this statement does recognise the connection between acute and community hospitals, and it does provide a national comparison (though we aren’t told whether ‘national’ denotes England, Great Britain or the UK), we could draw quite different inferences from it.

We could infer that community hospitals are coming under greater pressure in Cornwall than elsewhere to take patients who have been discharged following acute treatment, and conclude from this that Cornwall needs more community hospital beds or more provision in care homes and/or people’s own homes.

Or we could infer that among the ‘national’ population there is a need for care that is different from ‘step-down’ (rehabilitation) from acute treatment, and that in other parts of the country this need is being met by community hospitals, whereas in Cornwall the community hospitals are close to being monopolized by patients moving out of the acute hospital at Treliske. Maybe part of the pressure that we know is experienced by the Emergency Department at Treliske comes from patients who, elsewhere, would be admitted directly into a community hospital. Again, we could conclude that Cornwall needs more community hospital beds.

(4) ‘62% of hospital bed days are occupied by people over 65 years old.

Comment It is impossible to draw any sensible conclusion at all from this piece of information. We are given nothing to compare it with. We aren’t told whether this figure applies to Cornwall & IoS only or to a larger area, and when, or whether the proportion has increased over recent years. 65 years was formerly the state pension age in the UK for men. For women state pension age was formerly 60. At present those ages are in the process of being both raised and equalized, so the very benchmark of 65 years seems entirely arbitrary.

As we see, the information presented in the information pack to justify reorganizing our hospitals – a mere four statistics – is of extremely poor quality. It is scanty and arbitrary. It is silo-dominated, and indeed it could be taken to imply that managers do not care where discharged patients go so long as they vacate their beds. The fact that acute hospitals count numbers of patients while community hospitals count percentages (another silo effect) makes it very difficult to compare the stress that they are under.

Moreover, the information presented is in the form of snapshots. These represent situations at particular points in time or over particular periods. We are not told at what particular points in time, or over what particular periods, the data were collected. This is not good professional practice. And such truncated information ignores dynamics, how situations change over time, and – importantly – it largely ignores processes that link organizations together, such as the movements of patients through the health and social care system. Failing to state the sources of data or the relevant dates or periods it applies to is an unprofessional way of managing and presenting information.

To sum up: As a basis for taking decisions, information of this calibre is not fit for purpose and is likely to pull wool over the eyes of people who don’t have specialized knowledge. It is not the demonstrated outcome of careful research, and no serious reasoning from it is presented. So we may conclude that it is offered to support a case, to sell a message, the message seemingly being that Cornwall is over-supplied with community hospital beds and consequently some community hospitals should be closed.

Recent development (3): The Transformation Board say they support the co-production approach, but they are not taking responsibility for ensuring it is put into practice.
At the head of the Shaping Our Future (SOF) operation is the Transformation Board, which has 20-plus members, mainly appointed as representatives of various organizations. The key members are Kate Kennally (Chief Executive, Cornwall Council), who is in the chair; Kathy Byrne (Chief Executive, Royal Cornwall Hospitals NHS Trust); Phil Confue (Chief Executive, Cornwall Partnership Foundation NHS Trust); and Jackie Pendleton (Interim Chief Officer, Kernow Clinical Commissioning Group).

Until recently the Transformation Board met every month, but as from May 2017 it will meet only every two months. The papers that are presented to the Board are not published, and nor are the minutes of its meetings until they have been approved by the following meeting, so it can be the best part of four months before the public gets to know what was on the agenda and what was agreed. (The latest minutes currently available are those of the May 2017 meeting.) It appears, then, that the four leading members will have considerable autonomy.

At the May 2017 meeting of the Transformation Board it was reported, under the heading of ‘Communications and engagement strategy: co-production plan’, that ‘senior communication and engagement support had been secured … with a view to them taking over the strategic lead for this work’. This refers to the secondment to SOF of the current NHS Regional Head of Stakeholder Engagement and the Regional Head of Communications and Engagement Specialist Projects. The minutes also record that ‘[there] was full support from Transformation Board members for the co-production approach’. And Jackie Pendleton of KCCG is recorded as saying: ‘It is important to be able to give answers to questions raised in the first phase of events to show the public that we have listened and we will continue to listen.’

While we might take encouragement from this, other items recorded in the minutes of the May meeting are worrying. We learn that the leading Board members want to be a ‘first wave Accountable Care System’ and have put in an application to NHS England to that effect. And we learn that it was proposed to establish two ‘delivery groups’ (‘Model of Care’ and ‘System Reform’), and that the ‘Programme Board’ was to be renamed the ‘Portfolio Board’, ‘to reflect the scale and scope of work’. No mention is made of publishing the minutes of these bodies. In a nutshell, this is all about fashioning the organizational bulldozer.

What recent developments tell us
1. Experience of the local area workshops tells us that it is possible to bring together round a table people who work in the health and social care services, people who work in the voluntary sector and people on the receiving end of services. Particularly noticeable is the part played by stories – accounts of personal experiences – in these conversations.

2. The quality of the information packs on the subject of how the system works is so abysmally poor, although lavishly illustrated, that it could be taken to indicate either incompetence, i.e. a lack of appreciation of what data are significant and why, or, more sinisterly, an attempt to coerce the reader into conceding without quibble that a case has been made for change. A third possible explanation for these poor quality scraps of information on hospital services presented to the public in the information pack may simply be that they were deemed good enough for us. If that was so, it indicates an attitude of condescension, if not contempt, towards the public. This can only breed suspicion and contempt in return: not a healthy state of affairs for our society and no basis for genuine co-production.

3. At Transformation Board level there is no shortage of expressions of goodwill towards public engagement and co-production. But it may be that in some quarters this is seen as a useful manipulative tool, a means of ‘selling the message’ and ‘nobbling’ influential lay people so they won’t be obstructive when proposals are published. Tellingly, among the proposals for reorganizing the SOF enterprise there is no mention of a co-production delivery group. And the two engagement specialists who have been brought in from regional level have been given the absolute bare minimum of support staff. Judged on these criteria, within the SOF set-up engagement and co-production have a very low priority indeed.

The way forward
1. The local area workshops have shown that when people talk about their experiences of health and social care services they are invariably telling a story. One of the great values of stories, along with their authenticity (the fact that they represent genuine experiences as recounted by the people who experienced them) is that they are dynamic. Unlike the information presented as snapshots in the information pack, they tell us what took place over a period of time and how the different parts of the system interacted with one another. It follows that those in charge of ‘engagement’ have the task of finding a way of taking these stories and using them, drawing lessons that can be fed into the planning process.

There is an unfortunate tendency among academically-schooled planners, in all disciplines, to disparage the worth of individual stories. If they are acknowledged at all, they are placed in a category labelled ‘anecdotal evidence’, a rank some levels below statistical evidence. (Some will recognise this as a variant of Gresham’s law: ‘Quantitative evidence drives out qualitative.’)

This was vividly illustrated in the information pack, where the reader was presented with a jumbled mass of data, collated and summarized in the form of figures and charts, and presumably expected to draw conclusions from it, or to accept the conclusions that other people have drawn.

There is no obvious, meaningful way in which individuals’ stories about their experiences can be integrated into the kind of ‘framework’ presented in the information pack.

Here is a little true story that illustrates that point. A 95-year-old Penzance woman living in her own home fell and broke her hip (fractured neck of femur). An ambulance took her to Treliske, where they mended her hip very efficiently, but she was left with some damage to the skin of her leg, so she was not fit to go home. She needed to go to a community hospital for rehabilitation. A bed became available for her in Edward Hain community hospital, but only after several days, during which she was kept in the noisy and disorientating Trauma Ward, where she visibly deteriorated. After a week in Edward Hain, however, which provided the necessary therapy in a calm atmosphere, she was able to return home and continue her recovery in the care of her daughter, district nurses and carers.

What this story does, like many others, is to draw our attention not only to this one ‘statistic’ but also to patients’ ‘trajectories’ through the hospital and social care system. These trajectories reveal with perfect clarity the interactions that linked the parts of the system: acute hospital, community hospital and home in this case.

Here, then, is a role for the public, to contribute the stories that transcend organizational boundaries, and give an insight into the interactions at work (or that fail to work) and the obstacles that hinder effective interactions.

And the corresponding role for those in charge of ‘engagement’ must be to find ways of searching out these stories, of acknowledging their validity, and – in feeding them into the planning process – of drawing out and responding to the lessons to be gained from them. This is the role that future local area workshops should play. And the people in charge of this stage must be given the human resources that they need to enable them to perform this role.

2. The information pack, as we have seen, provided numerical information about hospital services that was scanty, arbitrarily selected, silo-dominated, and in the form of snapshots, and its presentation did not meet professional standards. If this is all that is available to the planners, they will be forced to work on the basis of ‘design principles’, ‘models’ and other such general abstractions, and any attempts on their part to foster public engagement will be – and will be seen to be – a waste of time and effort. If this very poor presentation denotes an attitude of condescension towards the public, again, attempts to foster public engagement will come to nothing.

In either case, the planners need to be challenged to demonstrate their professional competence by researching and presenting a much sounder – properly investigated and more complete – information base, one that both takes a view of the system as a whole and covers patients’ encounters with and trajectories through the health and social care system. They need to know why, for example, 83% of admissions to community hospitals are from acute hospitals compared to 42% nationally. This information needs to be set alongside, checked against and integrated with information from patients’ stories.

We don’t know who the planners are. Are they KCCG staff? People hired on short-term contracts to work on SOF? Or are they employees of the American firm of consultants, GE Healthcare Finnamore who are also working on SOF? The information pack contains no information about who wrote it, who supplied the information in it, who supervised it, or who authorized it for publication. It would be reassuring if these people were prepared to be publicly accountable for what they do. It is to be hoped that they will respond to this challenge, whoever they are, because it is seriously against the public interest for far-reaching plans, policies and public expenditure to be based on the pathetically flimsy foundation that we have seen so far.

3. Within the Transformation Board, some transformation needs to take place. Halving the number of meetings, holding meetings in private, not publishing the agenda in advance and the minutes for several months after the meeting: these are characteristics of a body that is uncomfortable with transparency and shuns the light. It and the people working for it seem to be more concerned with securing power, autonomy and status than with doing a good job for the public they ostensibly serve. For starters, let us have more transparency and let us have a co-production delivery group.

Peter Levin

7 August 2017

 

Appendix: Bed occupancy in community hospitals

Here is a table drawn from data supplied two years ago by Peninsula Community Health (PCH), which formerly administered community hospitals in Cornwall: it shows that in May 2015 all of the community hospitals in Cornwall were running at an average bed occupancy rate of 90% or more, with several registering more than 95% and in one case a staggering 99.4%.

The position was clearly very tight in 2015, and presumably it still is. On average, in only five of the 17 community hospitals in Cornwall itself was it likely that a bed could be found on a randomly-picked night for an emergency case (see Column G). Strikingly, in 2017, there was no information whatever in the information pack on bed usage and availability in community hospitals. Is that information no longer collected? Or is it collected but someone consciously choose not to include it in the presentation? Certainly, the bed occupancy figures in the table provide a prima facie case for more community hospital beds in Cornwall, not fewer.

The information presented in this table is informative but it is not a sufficient basis for understanding how the system works, because it is silo-dominated. No doubt PCH managers could pride themselves on making extremely efficient use of their resources two years ago, but what were the consequences for the managers at Treliske? They can have had no day-to-day control whatever over resources on which they crucially depended. The two sets of managers were working in separate compartments – silos – from one another.

Occupancy of Community Hospital Beds in Cornwall, May 2015

A	B	C	D*	E	F	G
Hospital ward	May 2015 average occupancy (%)	Beds (as at June 22nd)	Bed nights available in May [C x 31]	Bed nights taken up in May [B x D]	Bed nights not taken up in May [D – E]	On average, one or more beds available every night
Bodmin Anchor	94.1	12	372	350	22	No
Bodmin Harbour	92.8	23	713	662	51	Yes
Bodmin Woodfield (stroke)	98.2	9	279	274	5	No
CRCH Lamorna (Camborne-Redruth)	99.0	23	713	706	7	No
CRCH Lanyon (stroke) (Camborne-Redruth)	99.4	21	651	647	4	No
Edward Hain (St Ives)	92.7	11	341	316	25	No
Falmouth	97.3	24	744	724	20	No
Fowey	90.6	10	310	281	29	No
Helston	98.0	24	744	729	15	No
Launceston	93.3	19	589	550	39	Yes
Liskeard Oak	94.2	25	775	730	45	Yes
Liskeard Willow	94.5	19	589	557	32	Yes
Newquay	95.8	19	589	564	25	No
SACH Harold White (St Austell)	95.6	22	682	652	30	No
SACH Heligan (St Austell)	95.7	22	682	653	29	No
Stratton	90.6	13	403	365	38	Yes
St Barnabas (Saltash)	90.3	9	279	252	27	No
St Mary’s, IoS	23.5	10	310	73	237	Yes

*For Column D it is assumed that the June 2015 figure for the number of beds was applicable throughout May.

Note 1 The above table contains no information on turned-away patients. It appears that figures on these were not kept.

Note 2 In May 2015 the number of community hospital beds in Cornwall (excluding the Isles of Scilly) was 305. Of these, only 11, at Edward Hain Hospital, were located in Penwith. There is clearly some geographical imbalance here, especially as Edward Hain is not now in use. These are supposed to be community hospitals.

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NB As stated on the front page of this website: ‘All posts on this website are my own responsibility … and should not be taken as representing the views of West Cornwall HealthWatch or the Citizen Advisory Panel.’

 

This post can be downloaded as a pdf here. 

Executive summary
This report demonstrates why, in the field of health and social care, responsibility for communications and engagement should not be combined in a single position. It tells the story of Cornwall’s Sustainability and Transformation Plan from late 2016 to mid-2017, focusing on the problems of securing ‘engagement’ by the public. It reveals how communications between health bodies and the local authority, Cornwall Council, have come close to breaking down, and identifies the root cause of this as the combining of responsibilities for communications and engagement in a single position.

Communication: necessary but difficult
Under the terms of the Cornwall devolution deal, the organizations responsible for health and social care in the Duchy are supposed to be getting together to produce supposed to be getting together to produce a business plan for the integration of health and social care services. Health care is the responsibility of NHS Kernow (the clinical commissioning group), a number of ‘provider’ Trusts, and independent GP practices, while social care is the responsibility of Cornwall Council, the local authority, with its elected members and salaried officers. The ‘third sector’, made up of charities and voluntary bodies, also plays a significant part in both health and social care.

With such a wide range of people involved, from a wide variety of types of organization, it is crucial that they communicate with one another. Communication is not easy. There are always obstacles to be overcome – lack of trust, differences in rank, organizational loyalties pulling in different directions, people covering their own backs, professional rivalries, different views of what is important, competition for funds, and so on. So to communicate effectively everyone has to make an effort. And just one person can foul everything up.

The STP survey
Recent work on the integrated care plan for Cornwall – it used to be known as the ‘Sustainability and Transformation Plan'(STP) but has now been rebranded as the ‘Shaping our Future’ plan (SoF) – reveals the problem.

Over the winter of 2016-17 a questionnaire-based survey was carried out in Cornwall. Its wording was widely criticized. The questionnaire elicited responses from 1896 people (fewer than 1 in 250 from Cornwall’s total population of more than half a million). I learned four weeks ago, by accident, that a team based at the University of Exeter had examined the data collected and produced two reports: a summary report and a detailed analysis. These reports, which can be read here and here, have never before been placed in the public domain.

We learn from the University of Exeter reports that while 1896 people completed the survey, around 30% of them – i.e. around 570 – were a ‘health and care professional or support worker’. So only 1330 or so were ‘lay’ respondents, members of the general public. Moreover, among the 1896 there were no fewer than 762 references (around 40% of all respondents) to ‘needing more information’ and 352 references (around 18% of all respondents) to ‘not understanding the question’.

Further analysis of the data will show whether the 570 health and care staff had difficulty with the questions: if in the main they did not, it could follow that as many as 50% of lay respondents felt they needed more information and as many as 25% of them did not understand the question. These are not insignificant proportions.

In their summary report (p.16) the University of Exeter authors noted that the consequence of many participants needing more information and not understanding the question is that ‘caution should be taken in drawing firm conclusions from the data. Specifically with regard to inferring that a high level of ‘agreement with priorities’ translates to an overall participant endorsement of the STP’.

The involvement of Cornwall councillors
Cornwall Council has a Health and Adult Social Care Overview and Scrutiny Committee (HASCOSC). It set up an STP sub-committee which took a close interest in the STP survey. It held several information-gathering sessions, with the final one on March 10th, 2017.

The University of Exeter summary report is dated March 3rd, 2017, i.e. a week before the final STP sub-committee’s final information-gathering session. (The team’s detailed analysis is dated March 30th, but a version was presumably available by March 3rd or it would not have been possible to summarize it.) However, the summary report was not shown to the sub-committee.

Following its meeting on March 10th, the STP sub-committee went on to submit a position statement to HASCOSC, in which it concluded, among other things, that ‘the process of engagement with the public was inadequate and seriously flawed [and that] the questionnaire contained closed questions, was ill conceived and was unprofessional’. They were ‘disappointed that the report from the engagement events was not available when they were considering this issue’. ‘The engagement process was poor and ill-judged.’

HASCOSC met on March 15th. The Committee had in front of it the STP sub-committee’s position statement and an update report from the SoF Communications and Engagement Lead, Garth Davies (who is also Associate Director of Communications and Engagement at the Royal Cornwall Hospital Trust). Tabled at the meeting was Mr Davies’s own report on the ‘engagement activity’. He was asked if advice had been sought on the structure and nature of the questionnaire. The minutes of that meeting tell us that he ‘confirmed that advice was taken from the University of Exeter’. Later on March 15th I emailed Dr Michael Leyshon of the University of Exeter team and asked him: ‘Were you involved in designing the survey questionnaire?’ He replied the following day: ‘The simple answer to your question is no.’

So Mr Davies had withheld the University of Exeter reports and instead written and published his own views on the ‘engagement activity’. His report included (p.5) the following statement:

Overall, it is clear that respondents supported the priorities and case for change set out in the Shaping Our Future documents with many saying it is hard to disagree with the positive approach. Respondents said the top priorities should be ‘Prevention and improving population health’ and ‘Integrated care in the community’.

As we see, he effectively disregarded the academics’ warning against inferring that a high level of ‘agreement with priorities’ translates to an overall participant endorsement of the STP.

It is relevant here to note that both of the University of Exeter reports carry the statement: ‘This report has been produced for the sole use of the NHS Communications team, namely Garth Davies, in order to write the STP Engagement Report. The report is not for circulation nor use by any other party.’ Given that the reports draw on responses from the public and have been paid for with public funds, that prohibition is clearly wholly unmerited.

Interestingly, while the summary report reveals that among the 1896 responses to the STP survey there were 762 references to ‘needing more information’ and 352 references to ‘not understanding the question’, these figures do not appear in the detailed report: evidently some editing to remove embarrassing findings took place between March 3rd and March 30th.

In an email to a colleague on April 24th, Mr Davies wrote: ‘I will publish the analysis reports and survey summary report on the website.’ Assuming that the website to which he referred is www.shapingourfuture.info, by 11th July 2017, more than 11 weeks later, the reports had still not appeared.

On March 17th, the SoF Transformation Board (see below) met. The chair, Kathy Byrne, is recorded in the minutes as saying that the STP sub-committee’s position statement ‘was not particularly helpful for public confidence and noted that the framing of [it] has made the job harder’. She also ‘noted the importance of working more closely in the future’.

Members of Cornwall’s public might perhaps share my view that withholding information from councillors and misrepresenting survey findings – and continuing to do so – does the very opposite of inspiring me with confidence, nor can I see how it might contribute to ‘working more closely’.

The engagement report: what it tells us and what it doesn’t
I noted above that while 1896 people completed the survey, around 30% of them – i.e. around 570 – were a ‘health and care professional or support worker’. So only 1330 or so were ‘lay’ respondents, members of the general public. The engagement report tells us more. Of the 1896, 1258 were of working age (19-65). These working-age respondents will have included nearly if not all of the health and care professionals/support workers. So that group will have contributed around 570 to the 1258 working-age respondents. In other words, nearly half of the working-age respondents (45%) were health and care professionals or support workers.

People employed in health and social care amounted to around 13% of the working-age population of Cornwall in 2011. So they were considerably over-represented among respondents to the survey. By no stretch of the imagination, then, can the survey be said to have been a survey of a representative sample of the general public.

Unfortunately the engagement report does not distinguish between the responses of lay people and health/care workers. It lumps everyone together as ‘respondents’ or ‘people’. So when Mr Davies concludes in his engagement report ‘Overall, it is clear that respondents supported the priorities and case for change set out in the Shaping Our Future documents with many saying it is hard to disagree with the positive approach’ we have no idea of how far these results could have been skewed by the over-representation of health/care workers. And if we look at how those priorities were set out in the survey, we see that they mostly took the form of ‘motherhood and apple pie’ aspirations, inherently impossible to argue against.

And here’s another thing. If you look at the pie chart below, which shows the six priorities offered in the STP questionnaire, you will see that another priority, ‘Transforming urgent and emergency care’, tied for second place (at 19%) with ‘Integrated care in the community’.

Evidently Mr Davies chose to include ‘Prevention and improving population health’, along with ‘Integrated care in the community’, as top priorities, but to exclude ‘Transforming urgent and emergency care’ although it came equal second in the ratings. This ‘cherry picking’ is not an acceptable way of presenting the results of a survey. And it leads us to ask what else has been cherry picked to go in the engagement report.

When we read on, we learn that ‘The main concerns people identified were:

Potential reduction in community hospitals with concerns about travel times and the impact on the major hospitals without alternatives yet in place.

Financial with people wanting to see more investment in community services and many questioning whether the plans could be delivered within the budget.

Workforce with people wanting to see more investment in community staff and training.’

It is hard to match these up with the ‘top priorities’. And the second and third of these concerns could well reflect the over-representation of health/care workers among respondents.

The use of impressionistic language in the engagement report – ‘Many people commented …’, ‘Many said …’, ‘People wanted …’, ‘Others thought …’, ‘People felt …’, ‘Many respondents said …’,‘An overwhelming majority of people agreed …’ – and the withholding of actual numbers (we are never told how many is ‘many’) means that we have to depend on the author’s predilections and judgment. The language used and the instance of cherry picking from the pie chart must raise doubts as to the reliability of everything the engagement report says.

Recent developments: (1) The Transformation Board
Ideally one would want to see the unfortunate STP survey and engagement report consigned to history. Is this happening? Seemingly not.

Work on the ‘Shaping our Future’ plan is now being overseen by a Transformation Board, which is chaired by Kathy Byrne, who is also Chief Executive of the Royal Cornwall Hospital Trust. Its membership includes some officers and elected members of Cornwall Council, as well as numerous ‘system leaders’ from health provider bodies. (Members’ names and affiliations and the minutes of its meetings can be seen here.)

Ms Byrne submitted a report on Shaping our Future for the meeting of HASCOSC on July 12th, 2017. It includes a section on ‘Consultation and Engagement’ which reads as follows:

Between November 2016 and February 2017, local people were asked to give their views on the Shaping Our Future outline proposals through a survey, written responses or by attending a series of community and stakeholder events.

Over 5000 local people responded or took part in the events and said top priorities should be ‘Prevention and improving population health’ and ‘Integrated care in the community’.

As we can see, this is simply talking up the numbers and parroting the engagement report. As in that report, ‘Transforming urgent and emergency care’ does not appear as a top priority despite tying in the ratings with ‘Integrated care in the community’. What are we to conclude? It appears that Ms Byrne has rubber-stamped the engagement report, rather than subjecting it to careful and critical examination.

Sadly, we may expect similar behaviour from other members of the Transformation Board. Having been set up as a ‘stakeholder body’, its members are likely to read documents that come their way solely with a view seeing how the interests of the body that they represent could be affected. 

It follows that there is a great need for members of Cornwall Council’s Overview and Scrutiny Committee to bring their knowledge and critical faculties to bear and do some thorough scrutinizing. They should have investigative staff to help them in this: it is not a job for the secretariat that normally supports council committees. Ideally such staff should be able to link to voluntary and campaigning bodies, since many of these have good local knowledge and grasp of the policy process. 

Recent developments: (2) Working with people from local communities
In her report to Cornwall Council’s Health and Adult Social Care Overview and Scrutiny Committee on July 12th, Ms Byrne noted: ‘Two engagement experts have been secured from NHS England and the South West Commissioning Support Unit to help shape our engagement programme.’ One of these, Dr Lou Farbus, is now running a series of ‘co-production’ workshops across Cornwall and the Isles of Scilly, in which people who have recently received or who care for someone who has recently received some kind of health or social care support can meet people who are involved in delivering a service, to exchange views and perspectives and explore possible ways forward. Having myself taken part in one such workshop, I can vouch for their effectiveness in broadening one’s mind, in helping one to appreciate the work that other people do and the issues that they face, and in stimulating constructive, ‘out of the box’ thinking.

A fatal flaw in the NHS
A common feature of NHS bodies is that they bundle together responsibilities for communications and engagement. These are fundamentally different activities. Communications experts, who in many cases have had a training in journalism, are trained to use the media, to ‘put the message out’ and put a positive gloss on it, even to ‘spin’. In contrast, successful engagement involves dialogue, two-way communication: it requires skills in listening, in appreciating what others are saying, in responding appropriately, gaining other people’s confidence, being open and ‘straight’ with them, and able to negotiate compromises. These are two different skillsets.

The experience of the STP in Cornwall constitutes just a single case study, but it shows what can happen, and did happen in a particular situation. It has highlighted the differences between communications and engagement, and there are indications that these may cause problems elsewhere, not just in Cornwall. So perhaps the main lesson to draw from the experience of the STP in Cornwall is this: Do not combine responsibilities for communications and engagement in a single position. And indeed, beware the communications expert who fancies himself (or herself) to be an expert in engagement too.

Peter Levin

www.spr4cornwall.net

 

This post can be downloaded as a pdf here.

Background
Work is currently going on to produce a health and social care plan for Cornwall and the Isles of Scilly. It is officially known as a Sustainability and Transformation Plan (STP). A draft Outline Business Case (OBC) was published in October 2016, followed shortly after by what was described as a summary of the OBC, entitled Taking Control, Shaping our Future. In that document some elements of the OBC don’t appear, while others appear to have been added. The latter publication incorporated a questionnaire-based survey, the STP survey.

The STP survey was the second to be undertaken within the space of a year. In January 2016 NHS Kernow (Kernow Clinical Commissioning Group) and Cornwall Council published a health and social care integration questionnaire. As a survey questionnaire this was seriously defective in a number of ways, as I described in a report for West Cornwall HealthWatch entitled How not to run a health and social care survey.

The recent STP survey questionnaire put serious problems in the way of anyone trying to respond to it. In a post in January this year I set out the reasons why I was finding it so difficult to answer the questions in it. Last month (March 2017), Cornwall Council’s sub-committee on the STP, on the basis of the evidence they received, said they found the survey to be ill-conceived’ and ‘unprofessional’. So what can be done with the responses received to it? In March the STP team produced two reports on the engagement process, an interim ‘update report’ and a ‘final report’, which drew heavily on the responses to the STP survey. In the following sections of this report I examine the final report and ask what credence can be attached to its conclusions, given the defects of the survey.

Nearly half the working-age respondents were health and care professionals or support workers
The update report tells us that 1896 people completed the survey. But the final report reveals that 30% of them – i.e. around 570 – were a ‘health and care professional or support worker’. So only 1330 or so were likely to approach the survey primarily as members of the general public. Of the 1896, 1258 were of working age (19-65). These working-age respondents will have included nearly if not all of the health and care professionals/support workers. So that group will have contributed around 570 to the 1258 working-age respondents. In other words, nearly half of the working-age respondents (45%) were health and care professionals or support workers.

People employed in health and social care amounted to around 13% of the working-age population of Cornwall in 2011. So they were considerably over-represented among respondents to the survey. By no stretch of the imagination, then, can the survey be said to have been a survey of a representative sample of the general public.

The response to the survey was tiny
To get a sense of scale: the figure of 1896 is about one-third of one per cent of the current resident population of Cornwall and the Isles of Scilly (around 550,000) so it’s a tiny sample. Notably, the figure of 1330 non-health or social care workers who responded to the survey is little over half the 2450 who completed the previous health and social care survey in early 2016, further evidence of the off-putting nature of this latest survey.

The reports present very little quantitative data
We see that in the final report there is a remarkable dearth of quantitative data. Other than a breakdown of respondents by age, and an unclear map showing responses by postcode, a pie chart on p.13 showing ‘First choice priority’ is the only significant quantitative evidence presented. We are told: ‘Overall, people responded favourably to the priorities set out in the Shaping our Future documents and many thought it was hard to argue with the positive approach.’ Since those priorities, as set out in the survey, mostly took the form of ‘motherhood and apple pie’ aspirations, difficulty in arguing against them should not be surprising.

Very little analysis is put forward
Even with the limited data collected, some search for correlations would have been possible. Were there significant differences in responses by age or geographical location? Asking such a question could have generated useful information about the likely impact of future ageing of the population or difficulties with physical access to healthcare facilities in certain parts of Cornwall. And were there significant differences between health and care professionals or support workers and the general public? The ‘top priorities’ could have been very different for the two groups, and indeed it is hard to see the man and woman in the street spontaneously saying what is needed is ‘System reform to achieve better care’ or ‘Preventing and improving population health’ (sic) as in the pie chart below. It is a matter for regret that no search for correlations appears to have been carried out.

This approach lends itself to ‘cherry picking’
There is a striking illustration of the way that this approach allows the writers of reports to pick and choose what they include. The final engagement report says: ‘Respondents said the top priorities should be ‘Prevention and improving population health’ and ‘Integrated care in the community’’. If you look at the pie chart below you will see that another priority, ‘Transforming urgent and emergency care’, tied for second place (at 19%).

Evidently the author of this document felt able to pick and choose for presentation the information that supported a particular case. That is not an acceptable way to present the results of a survey.

Impressions are no substitute for facts
Instead of figures, what we find – on almost every page of the engagement report – are impressions: ‘Many people commented …’, ‘Many said …’, ‘People wanted …’, ‘Others thought …’, ‘People felt …’, ‘Many respondents said …’,‘An overwhelming majority of people agreed …’. We are very rarely given the actual numbers. We are never told how many is ‘many’. We must depend on the author’s predilections and judgment, his interpretation of responses and their impression of how close together these responses are. This is what allows them to be lumped together. The language used and the instance of cherry picking from the pie chart, described above, must raise doubts as to the quality of analysis and interpretation.

Using impressionistic language like this allows cherry picking of survey responses that support a particular view. Considerable passages of the survey questionnaire and the reports are couched in ‘management-speak’. This language may be appropriate shorthand for internal documents, but it is not appropriate for those that are public facing. The use of this style may in itself influence the choice of responses to be quoted in the report, making it more likely that those using a similar linguistic style will be chosen.  At the time of writing it is understood that the completed questionnaires will be made available for independent scrutiny, so it may be possible to discover whether this was indeed the case.

The University of Exeter: a key player?
The introduction to the final report has this to say about its authorship:

This report has been written by Garth Davies, Associate Director, Communications and Engagement for the Shaping Our Future programme but with special thanks to the Social Innovation Group at the Centre for Geography, Environment and Society at the University of Exeter for their data analysis and independent view on the findings. Dr Michael Leyshon at the University of Exeter has confirmed that the report is a ‘fair account of our analysis’.

Suffice it to point out (1) that the report does not actually present any data analysis; (2) that Dr Leyshon, a social and cultural geographer whose academic profile does not mention expertise in the NHS or social survey research methods, was not involved in the design of the survey questionnaire; and (3) that the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, South West Peninsula, which includes the Universities of Plymouth and Exeter as well as local NHS organizations, and undertakes high-quality applied health research focused on the needs of patients and supports the translation of research evidence into practice in the NHS, was not involved in any aspect of the STP survey process.

Evidently what we have here is an attempt to give the STP survey an academic stamp of approval which it does not deserve.

‘Engagement’: At best nothing more than a case of unsystematic communal brainstorming
The process by which those in charge of the STP attempted to engage with the public took two main forms: a series of meetings and the STP survey. The meetings provided an opportunity for local people to give vent to their feelings about health and social care issues, such as the closure of community hospitals, and these have been reported, albeit in a general and impressionistic fashion, in the final engagement report.

As a survey, this exercise has been seriously deficient. At best it has amounted to nothing more than a kind of unsystematic communal brainstorming. Such an exercise may be productive in terms of ideas and highlighting matters that have been overlooked, but it is not a serious tool of social investigation. That much could have been predicted from the questionnaire itself, composed as it was of unanswerable questions, leading questions and questions that look like multiple choice but don’t actually offer a choice (such as questions which ask ‘To what extent …?’ but don’t offer a scale on which to register ‘extent’).

Governance issues
Work on the STP is in the hands of a team of officers under the supervision of a Transformation Board. The Board has four leading members: the Chief Executives of Cornwall Council (who is in the chair), Royal Cornwall Hospitals NHS Trust and Cornwall Partnership NHS Foundation Trust, together with the interim Chief Officer of NHS Kernow (Kernow Clinical Commissioning Group).

There are two important questions to be asked about this organizational structure:

(1) How was it that the design and implementation of the STP survey came to be entrusted to a specialist in public relations, self-identified as Associate Director, Communications and Engagement, and an employee of the Royal Cornwall Hospitals NHS Trust, rather than to someone with experience in social surveys and research methods?

(2) Over the past year West Cornwall HealthWatch has pointed out the inadequacies of the surveys that are supposed to underpin the Sustainability and Transformation Plan, and in an attempt to be constructive we have actually produced a set of guidelines for managers on the design and use of survey questionnaires. Why has the Transformation Board shown no sign of taking on board what has been spelled out to them?

We don’t know what the process was that led to the assigning of a social research project to a public relations specialist. But the failure to learn from the experience of the earlier health and social care survey is seriously worrying. If there is one thing that an innovative project, such as transformation, calls for it is the ability to learn.

The inability of an organisation to learn has a number of unhappy consequences. Mistakes are repeated, with a consequent waste of time and money. Communication channels become narrowed or blocked off, creating a hierarchical structure that supports the status quo. This prevents learning from other people engaged on a similar task elsewhere who are doing things differently. Addressing the public inappropriately with ‘management-speak’, using words such as ‘theme’, ‘vision’ and ‘priorities’, may lead to further spiralling misunderstanding and frustration. We have seen all of these in the present case.

When it comes to public engagement, we need to ask whether the four leading official bodies actually ‘get it’. NHS Kernow’s Governing Body includes a Lay Member, who is supposed (by law) to help to ensure that, in all aspects of its business, the public voice of the local population is heard and that it responds in an effective and timely way to feedback and recommendations from patients, carers and the public. The individual concerned worked for 31 years in the NHS, and at the point when he retired was Chief Executive of two primary care trusts. While his experience may well make him a valued member of the Governing Body, we may legitimately question whether it enables him to speak with authority for the public.

Recently the Director of Healthwatch Cornwall (no connection with West Cornwall HealthWatch!) has been invited to join in the deliberations of the Transformation Board. While this arrangement may be of value, the fact is that she has spent 18 years in the NHS in a variety of senior management and leadership roles. Again, we may legitimately ask whether such experience is an unmixed blessing when it comes to listening to people’s experiences of publicly funded health and social care services and thereby contributing these to the decision-making process.

To negotiate between the institutional world of health and social care provision and the ‘real’ world in which we all live requires an openness of mind along with the ability to learn and the ability to mediate between very different cultures. It is not immediately apparent that long experience in the institutional world confers and demonstrates such openness and abilities.

Postscript
The final engagement report has a message on branding. It says: ‘To give our plan a strong sense of local identity going forward we are referring to our five year plan as ‘Shaping our Future’ rather than the STP.’ We may justifiably wonder how excluding any reference to ‘health’, ‘social care’, ‘plan’ and Cornwall and the Isles of Scilly is calculated to impart ‘a strong sense of local identity going forward’.

Peter Levin

9/4/2017

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Update
We have recently learned that since the final engagement report was published, the STP team has taken on additional expertise in the form of Dr Lou Farbus. She is the NHS’s Regional Head of Stakeholder Engagement and is currently on secondment to the Cornwall and Isles of Scilly STP team. She has many years’ experience of teaching questionnaire design and applying this skill specifically to service redesign programmes. She is currently in the process of putting together a package of engagement related training modules, to include questionnaire and survey design, which will be delivered to relevant members of the STP team.

West Cornwall HealthWatch warmly welcomes Dr Farbus in her new role, especially in the light of our experience with STP engagement so far, and we shall be glad to cooperate with her in any way we can. It is heartening to learn that someone in NHS Kernow has – albeit belatedly, we have to say – taken our point about the need to strengthen the STP team to handle engagement and surveys.

13/4/2017