NHS in Cornwall poised to close Minor Injury Units

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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.

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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.

[3] Kernow Clinical Commissioning Group, Minor Injury Units.

[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.

[6] Cornwall and the Isles of Scilly: Sustainability and Transformation Plan: Draft Outline Business Case, 21st October 2016

[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