The STP survey: Why am I finding it so difficult to have my say?

A letter to the ‘Transformation Board’

Dear Transformation Board

I’ve been reading your document ‘Have your say on the Cornwall and Isles of Scilly Health and Social Care Plan 2016-2021’, the STP. It invites me to have my say and comes with a questionnaire which is supposed to enable me to do that. I’m finding it a real struggle to have my say using your questionnaire. Eventually I worked out why.

The questions all ask to what extent I agree with their ‘priorities’. Question 1 listed the following six priorities:

•   Prevention and improving population health
•   Integrated
care in the community
Transforming urgent and emergency care
Redesigning pathways of care
        (best practice treatment for specific conditions)
Improving productivity and efficiency
System reform to achieve better care

As you can see, some of these so-called priorities take the form of ‘motherhood and apple pie’ objectives, with which no sane person could possibly disagree: e.g. ‘improving population health’, achieving ‘better care’, ‘improving productivity and efficiency’. And others have no built-in objectives at all: e.g. ‘transforming urgent and emergency care’ and ‘redesigning pathways of care’. Transform and redesign with what objective, I asked myself. I didn’t get an answer. Why not? Because this is looking like gobbledygook.

The very idea of ‘priorities’ is a nonsense in this context. We need everything here that contributes to keeping the population in good health, and a spread of resources among them. ‘Priority’ implies that you deal with the highest priority first, then the next: that is clearly not appropriate here.

Maybe managers have a different view of the world, and are comfortable with the language of priorities. But in asking me questions framed like this, they are asking me to put myself in the position of a manager, and to take an overview of the whole system. I am just a member of the public, not a manager, and ‘management-speak’ is not my language.

I can only judge your ‘priorities’ and recommended approaches by envisaging how they would work out in practice. You aren’t giving me that information, information that I need in order to ‘engage’ in the planning process.

Finally on Question 1, you ask ‘To what extent …’ but you aren’t offering me a scale to register ‘extent’, just the two extremes of ‘Agree’ and ‘Disagree’ and the indeterminate one of ‘Neither agree [nor] disagree’. It’s looking as though you are deliberately trying to confuse me!

Question 2 opens with the statement: ‘Health and care services must be delivered within the budget available.’ That is so objectionable! It implies that we must accept whatever that budget is: I want to see a case made, by demonstrating the impact on the ground, for increasing the budget to meet the needs of the people of Cornwall. So I have a question for the Transformation Board: ‘Whose side are you on?’ If you were on our side you would be showing us the impact of the cuts you’re saying we must face up to.

Question 3 says: ‘We recommend investing a minimum of £20 million over 5 years in preventing people getting ill, supporting self-care and targeting citizens who are most likely to have health problems. We believe that focusing resources on preventing ill health is simple common sense and we can do more to keep people healthy, happy and well. Fundamentally, we must also ask people to do more for themselves and support each other in their community. To what extent do you agree with our recommended approach and our prevention priorities?’

Well, I have no way of telling whether £20 million over 5 years is the right amount or not. You are not giving me the information that I need to make a judgment about this: for example what you would spend this money on, whether it represents an increase on last year’s spending, whether the money would come from another programme.

Question 4: ‘We recommend changes to community hospitals so that they become community hubs which offer multiple services to prevent or reduce acute hospital visits. Community hubs will be linked to GP practices providing co-ordinated care and personalised support to keep people well, help people stay out of hospital or leave hospital quicker. Better community and home care should mean less need for community hospital beds and sites so we may reduce these over time, particularly if they need major financial investment. … let us know if you have any alternative suggestions to reducing community hospital beds and sites.’

No-one could possibly object to providing co-ordinated care and personalised support to keep people well’: this is another ‘motherhood and apple pie’ goal. But I have heard so much from senior executives at KCCG and RCHT about the ‘outdated bed-based model of care’ that I suspect that agreeing with your recommended approach will be taken as consenting to your closing community hospitals and continuing your policy of running these down by minimizing maintenance until ‘they need major financial investment’ when – in their blighted state – they will be ‘ripe’ for closure.

This recommendation takes no account of the valuable function that community hospital beds perform by allowing patients who are recovering from acute treatment to ‘step down’ to recuperative care.

Question 5: ‘We recommend changes to General Practice and grouping more GP practices together so they can better meet rising demand and expand the range of services. Right now GPs are spending too much time on administration and their work load could be reduced through targeted actions such as more effective self-care, early detection, better use of technology and a more flexible workforce. … let us know if you have any alternative suggestions to improve the sustainability of GPs.’

I can only judge these recommendations by envisaging how they would work out in practice. You aren’t giving me the information that I need. But agreeing with your approach could be taken as assenting to closing single practices in outlying places (e.g. St Just), which I would strongly disagree with.

If GPs are indeed ‘spending too much time on administration’ surely what should be done is to identify how the burden of administration can be reduced, and take steps to achieve that. And what would ‘a more flexible workforce’ look like in practice? You don’t tell me, so how can I possibly say whether I agree or not?

Question 6: ‘We recommend an urgent care service that is accessible, reliable and co-ordinated with clinicians at the end of a phone if you need advice. With clinicians visiting you when essential or in Urgent Care Centres so that you only need to visit an Emergency Department in an actual emergency. Better location of Urgent Care Centres (accessible within 30 minutes from homes in Cornwall, on average) should mean we can provide a better, more reliable service than Minor Injury Units but would probably need to be on less sites (sic) so that we could afford them and resource them. To what extent do you agree with our recommended approach and our urgent care priorities?’

Again, I am being invited to agree with ‘motherhood and apple pie’ objectives (accessible, reliable etc), but not told how these would work out in practice. The STP and draft Outline Business Case propose closing all 13 Minor Injury Units and having just three Urgent Care Centres, a reduction of more than three-quarters in places where one can go for treatment. This can only mean a severe reduction in accessibility. Not good!

Question 7: ‘We recommend changing our approach to caring for people with specific conditions such as diabetes, heart disease, stroke, cancer, joint problems and dementia so that citizens get equitable access to high standards of care regardless of where they live or their individual clinician, within the resources available. We want to reduce the number of out of county mental health placements. We also want to explore what other services we can provide locally or what makes sense clinically to provide outside of Cornwall and the Isles of Scilly. To what extent do you agree with our recommended approach and our priorities for redesigning pathways of care?’

‘Equitable access to high standards of care’ – more ‘motherhood and apple pie’ stuff. You don’t say how you would change your approach to caring for people, so – again – I have no idea what the impact on people would be. Why does it take an STP for you to make such changes? And ‘within the resources available’ gives you an easy way out of doing anything genuinely constructive. By all means aim to reduce the number of out of county mental health placements, but – once more – why does it take an STP for you to do that? And you are asking us to comment on your ‘priorities for redesigning pathways of care’, but not actually telling us what you mean by ‘pathways of care’ (if they are just best practice treatments for specific conditions why not just call them ‘treatments’?) or how you would redesign them.

Question 8: We recommend that local care providers change the way they work together to enable joined up care, share expertise and information more effectively and use public sector properties efficiently. A large proportion of the savings we want to make can come from the way we operate and function. Our aim will be to modernise and change organisational form with minimal impact on clinical staff and services. To what extent do you agree with our recommended approach and our priorities for system reform and improving productivity and efficiency?’

Clearly joined-up care, effective sharing of expertise and information and efficient use of public sector properties have to be good things – how could they not be? – but what does it take to bring these about? If I agree to efficient use of public sector properties’ am I consenting to closure of certain (as yet undisclosed) facilities? I need to know what the likely impact ‘on the ground’ would be if I am to be able to answer your questions.’

Peter Levin


This letter can be downloaded in pdf format here.

The survey form is currently available on the Cornwall Council website here. It will continue to be available here.