Cornwall’s new Integrated Care System: what we are hoping for.
Dr Peter Levin
Published 27th June 2021
The go-ahead has been given for setting up an ‘integrated care system’ for Cornwall. This will absorb NHS Kernow, Cornwall’s Clinical Commissioning Group, which currently commissions health services from hospital trusts and other organizations. We wait to see whether Cornwall Council, which currently has statutory responsibility for social care and which commissions places in privately-owned care homes and nursing homes, for elderly people in particular, will lose this duty to the new system. We also wait to see whether the two hospital trusts in the county will be combined or stay separate, and whether GP surgeries will be drawn more into the NHS mainstream. In particular, we wait to see how well equipped the new system will be to identify and respond to the needs of the people who live here.
While we are waiting, we have been reviewing the recent record. Here’s a summary of what we found.
1. NHS Kernow has closed down the two community hospitals in Penwith, Poltair and Edward Hain, depriving the area of the 22 NHS-provided ‘step-down’ beds that they previously offered. NHS Kernow and Cornwall Council appear not to collect data in any systematic way on patients who are discharged to care homes, so they are unable to formulate a policy to help them. This is a failing that the new integrated care system must remedy. It must work to return patients to their home community as early as possible.
2. The G7 summit at Carbis Bay made matters worse for Cornwall’s hospitals, but the problems were concealed. The new integrated care system must be open about the pressures on it and discuss in meetings open to the public how to respond to those pressures.
3. NHS Kernow and Cornwall Council have been naïve in accepting assurances from private sector providers about places in care homes becoming available. The new integrated care system must adopt a business-like approach to ensuring that assurances it is given by providers are actually fulfilled and that timetables are kept to.
4. NHS Kernow has been so keen to replace beds in NHS community hospitals with beds in private care homes that it has failed to notice that reablement facilities are lost by closing those hospitals. NHS Kernow’s single-minded focus on beds has resulted in a narrow and unimaginative approach to step-down care.
5. Unlike a private care home or nursing home, where there is an incentive to maximize profit from the space available, an NHS-owned community hospital would be able to justify providing a ‘social space’ for treatment. Importantly, the Centipede Club set up by our Community Nurses for people with leg ulcers shows: (1) that reablement can take the form of a social process, not just an individual one; (2) how experienced people who work directly with patients can produce excellent, practical ideas; and (3) that such social facilities are excellent at helping patients to span the transition from hospital to home.
6. The Embrace Care project in Cornwall has also demonstrated joined-up thinking by placing hospital trust employees in three care homes. Will this innovation be extended? Three care homes are a start, but there are altogether around 220 care homes in Cornwall. This scheme could be extended by acute hospitals (Treliske and its satellites) using such places in care homes to keep under observation patients who are technically medically fit for discharge. That would be a further and practical step towards implementing the principle of integration. Unifying Cornwall’s two hospital trusts should make this easier to do.
7. NHS Kernow has not paid attention to the impact on end-of-life care of closing community hospitals. The new integrated care system must keep a close eye on people nearing their end of life and ensure that if they are placed in a care home their treatment is not inferior to that received by patients in hospices and community hospitals.
8. Earwax: is this an urgent issue for the NHS or one that doctors want to kick into the long grass? The new system must be alert to the needs that people express by simply asking for them at doctors’ surgeries. It must measure these needs and be prepared to respond to them.
9. NHS Kernow has shown that it is unable to think critically, analytically and imaginatively. The new integrated care system must incorporate a team of qualified people who can identify up-and-coming issues and brief decision-makers on their implications and ways of tackling them.
10. Cornwall Council’s Health and Adult Social Care Overview and Scrutiny Committee does not have the means to exercise its functions effectively. Policy-making processes within the new integrated care system must be transparent. From start to finish they must at least be visible to councillors and – ideally – the public and patient groups, who should have opportunities to put questions and make suggestions.
11. Cornwall Council is supposed to have a care homes strategy. Where is it? The new integrated care system must lose no time in addressing this huge gap in policy-making which urgently needs addressing.
12. Why is Cornwall Partnership Foundation Trust digging its heels in against integrated care? Cornwall currently has two hospital systems which urgently need to be integrated. This is particularly crucial for the many patients who make a transition from one to the other, whether stepping down from acute to community hospital or stepping up in the reverse direction.
13. Are health services in Cornwall actually governable? Residents might justifiably worry about the existence of some professionals within the system who seem to be a law unto themselves. The Care Quality Commission (CQC) reported in February 2021 on an investigation into what could be learned from seven ‘never events’ (literally, events that should never have occurred) that took place within the Royal Cornwall Hospital group during 2020. The CQC took regulatory enforcement action and issued a formal Warning Notice that required the Trust to make significant improvements in the quality of the healthcare it provides. The new integrated care system must be designed to ensure that clinicians do not lose sight of their accountability to the public they serve.
14. Designing a new model of care. An early task for the new integrated care system will be to design a model of care – a set of arrangements for providing health and social care for the people of Cornwall – that meets the needs of today’s population. Some work has already been done towards this end, but this implicitly views a model of care as nothing more than a collection of services. That is not good enough. Care must be integrated along the pathway – the ‘trajectory’ – that patients follow through the system, like the one taken by a patient who is admitted to an acute hospital as an emergency case, then after treatment is discharged – step-down – to a community hospital to continue their recovery, and then discharged to their home.
In Penwith, now with no community hospital, some beds in West Cornwall Hospital (run by the RCH Trust) in Penzance are being used as step-down beds. But at the present time the emphasis is on developing WCH as a ‘Centre of Excellence for Healthcare for the West of Cornwall’. Which will certainly be a great asset, but facilities for step-down patients will be less glamorous and inevitably take second place.
15. Any new model of care should involve the patient participation group (PPG) that every GP surgery should have. Since April 2016, all English practices have been required to set up such a group and make ‘reasonable efforts’ for it to be representative of the people the surgery serves. PPGs can serve as channels of communication from patients to the higher levels of the integrated care system. They should have the means to do this effectively. We hope such arrangements would help to move the current model of the doctor-patient relationship towards something more like an alliance, of people working together towards the common goal of better health for everyone.
The full article with detailed evidence is available on the Social Policy Research for Cornwall website HERE