Cornwall’s Sustainability and Transformation Plan

Submission to Cornwall Council Scrutiny Sub-Committee from Keep Our NHS Public Kernow (KONP)

 

Introduction

KONP Kernow is a group of people who care passionately about the NHS and the provision of excellent care to the people of Cornwall. We have members from all over Cornwall and liaise closely with the separate group West Cornwall Health Watch. Members regularly attend relevant meetings of Council bodies, KCCG and the Health Trusts.

This Executive Summary starts with some overall comments on the STP and the engagement process and continues with comments on each section. Some sections are supported by more detailed evidence contained in appendices as shown.

The STP and the Engagement Process

KONP notes and welcomes the numerous meetings arranged to discuss the STP and the very active involvement of so many members of the public. It should be clear to the STP sponsors, as reported to Council by the Leader, that very many members of the public: -

• ·         were highly critical of current underfunding of Health and Social Care services
• ·         regarded the STP as unrealistic and unachievable in the absence of better funding
• ·         regarded the STP paper “Shaping our Future” as inadequate, not giving a clear view of what services will be available and where in the future. This made the engagement process meaningless
• ·         believed decisions had already been taken, that the process was “going through the motions”

It has been suggested that much of this was politically motivated and involved “grandstanding” in advance of the local elections. As an active and long-standing campaigning organisation, we should emphasise that the clear majority of those attending and participating were unknown to us. We also take the view that politicians should expect the public to care about these issues and should welcome their interest. Politicians are often ready to condemn public apathy and it was scarcely the public’s fault that these meetings took place shortly before the elections.

Numerous comments were made in plenary or group sessions about the detail of the STP. Our own comments are noted below. Many issues (such as Mental Health and Technology) came up in more than one section – we have responded where it seems to make most sense.

We have also received several strong criticisms of the survey about the STP with which we agree. We attach (Appendix A) a detailed critique from Dr Peter Levin posted on the website for Social Policy Research for Cornwall (http://spr4cornwall.net). We invite Councillors to agree that the survey is poorly designed and to confirm that they will not rely on its results as the basis for their decisions.

 

 

Prevention and Improving Population Health

As the Plan says “focusing resources on preventing ill health is simple common sense”. This begs the very obvious question as to why cuts in Government grants have forced major (and continuing) reductions in Council spending on Public Health in recent years.  This section starts with a bald statement “what if we invested a minimum of £20m in preventing…?”. Councillors will note that there is no indication of the source of this £20m – which (later) is spread over 5 years leading to an – equally un-evidenced - £17m of savings from the overall budget by 2020/21.

We argue that Councillors must ask some searching questions: -

• ·         About the funding for this section – not only the source of the £20m but also for funding of the affordable housing and insulated homes referred to.
• ·         How does this £20m compare to reductions in the Council’s Public Health budget since 2013?
• ·         Regarding how long it will take for these preventative measures – desirable in themselves – to generate the savings claimed and if the evidence that they will do so is robust. Anti-smoking campaigns have been going on for decades yet many people still smoke.
• ·         About why this section appears to blame the patient? We question whether it is helpful to describe what seem to us to be the effects of long term social disadvantage as “behaviours”. In particular, it seems inappropriate to describe the social isolation of people, often elderly and widowed, in a rural area, poorly supplied with public transport, in this way. Patients – for example young mothers with new babies – go to the GP because they are rightly unable to decide how serious the condition causing anxiety is.

The section also refers to other issues such as the use of technology and mental health which we refer to elsewhere in this paper.

Integrated Care in the Community

This section covers much ground so we have divided our comments into 2 parts – Care in the Community and General Practice.

• ·         Care in the Community

We start by noting: -

• ·         the intense pressure on Adult Social Care, notably on care home provision and domiciliary care, arising from funding cuts
• ·         that the UK has many fewer hospital beds than most other European countries.
• ·         that Cornwall Foundation Trust has already closed 29 in-patient beds and that Edward Hain Hospital remains closed.
• ·         regular statements that many beds in both Acute and Community Hospitals are occupied by patients who are clinically ready to move on.

We invite Cornwall Council to say unequivocally: -

• ·         that the current restrictions on Council budgets render it impossible to deliver a proper Adult Social Care service. Among other effects, this places cost and strain on to private individuals and their families.
• ·         that there should be no closures or reduction in hospitals beds until they have seen robust evidence that Cornwall really has too many hospital beds
• ·         That safe and properly funded alternative facilities must be in place and tested before any further reductions.
• ·         That more District Nurses, Community Matrons, and Therapists of all sorts are required if the aspiration of more and better care in the community is to be achieved
• ·         That improved social care also implies changes in the way primary care and General Practice work (see next section)
• ·         That it is disgraceful that NHS Property has neglected its hospitals to such an extent that several of them are either unsafe or require costly repairs to bring them up to an acceptable standard and that this situation is driving calls for closures rather than any considerations of patient need.

Finally, we believe Councillors will wish to see a clear statement of what provisions will be available for patients moving on to later stages of treatment, where they will be and how they will be funded and staffed.

• ·         General Practice (Appendix B)

A strong primary care system is critical. Primary care accounts for 90% of all patient contacts – but only 8% of the NHS budget. High levels of satisfaction are reported. It is, therefore, a matter of great concern that General Practice faces major challenges of recruitment, underfunding, rising workload, and low morale.

As the STP says, over 20% of GPs and 31% of Practice Nurses are due to retire within 5 years. The Government commitment to recruit an additional 5,000 GPs by 2020 is failing and actual numbers too are falling as GPs retire early or move overseas.

Real terms spending has declined, the GP/patient ratio has worsened and 1 in 20 Practices have closed since 2010.

At the same time the STP intends to load more pressure on GPs and their Practices by asking them to coordinate community teams and hubs; to cope with more patients discharged earlier from hospitals; to avoid hospital admissions and to offer an expanding range of services.

We hope Councillors will: -

• ·         Insist on more detail of how clusters of GP Practices will actually work for patients
• ·         Ask if it is planned or expected that Practices will close 
• ·         Insist on a proper plan and vision from KCCG for how people will access primary care in future covering such aspects as distance to surgery (by various means of transport and especially if closures are envisaged) and opening hours, all bearing in mind the aspiration to provide more care closer to home.
• ·         Ask for realistic proposals regarding the recruitment of more GPs and other clinical staff to replace those leaving
• ·         Ask for evidence as to whether these proposals are supported by our GPs bearing in mind that a recent Guardian Survey found that around 2/3 of GPs nationwide had not been consulted about STPs and only 14% firmly supported the changes.

Transforming Urgent and Emergency Care

The location, number and nature of urgent care centres is of critical importance and the failure to offer clarity about this gave rise to much anger at the recent engagement meetings. As the Council’s own website (mapping section) makes clear many communities are already well over 30 minutes (by public transport) from any hospital of any sort.

Councillors should insist on full details being provided to the public and to Council of where the proposed network of Urgent Care Centres will be and what services they will offer. In the absence of this, Cornwall is being asked to sign a contract without seeing any of the small print.

Councillors may wish to question how the 30 minute figure works – is this by car, public transport (and, if so, at what times of day) or by blue light ambulance? These are very different things.

Councillors will wish to be absolutely clear that there will be no diminution of the range of services at the acute hospitals used by Cornish patients.

An effective 111 and Out of Hours Service would, of course, be welcome and should be in the public sector given the disastrous experience with SERCO.

Redesigning Pathways of Care

This section is very short on both evidence and detail. It gives rise to numerous questions. Our comments separate “pathways of care” from mental health issues

a.       Pathways of Care (Appendix C)

Different pathways of care may produce better treatment and outcomes and should, of course, only be adopted if they do. However, the evidence for this is not contained in the STP. We believe Councillors should seek much more clarity about how any changes will be funded and assurances: -

1.       That changes to existing pathways will only be introduced after robust scrutiny of the evidence and its applicability in Cornwall involving consultation with those directly affected including front line staff, family carers and patients. We note that a 2013 Review of the Liverpool Care Pathway concluded that “there was often too much pathway and too little care”.

2.       That GPs can manage the additional workload on top of other demands on their time. If we understand the paper correctly, there is an intention to move more care away from hospital settings, increasing pressure on primary care.

3.       That extended use of technology will be an option not a requirement for the patient. We note that 20% of people in Cornwall have never been on line (Inclusion Cornwall web-site) and would expect many of these to be exactly the section of the population making most use of health and social care services. Mobile and broadband coverage is not universally available and can be unreliable.

4.       That increased use of private sector providers does not form part of this Plan. Use of private providers in health provision has far too often failed (e.g. SERCO, Winterbourne View, Morleigh Care) with dreadful consequences for both patients and costs.

 

b.      Mental Health (Appendix D)

Many public figures have stated that more attention (and funding) needs to be given to Mental Health – without, unfortunately, action to match. In Cornwall 5% of people report long term mental health problems which is above the national average. We also have high rates of suicide, self-harm, and intentional injuries. People with mental health problems tend to die younger than others.

We believe Councillors should seek evidence and assurances: -

• ·         That there is a robust, urgent, and properly funded plan to reduce admissions of Cornish patients to mental health beds outside Cornwall to an absolute minimum by provision of more Mental Health beds within the County.  Detained Mental Health patients have no choice in where they go.
• ·         That plans are in place to reduce the number of delayed transfers of care for Mental Health patients who, because of their circumstances, may have no home to return to when psychiatrically fit.
• ·         That plans are in place to establish and fund child and adolescent Mental Health beds in Cornwall, including for those with learning disabilities.
• ·         That staff will be fully involved in any proposed reforms.
• ·         That there is a strategy for the recruitment and training of psychiatric nurses in Cornwall
• ·         That small voluntary sector support organisations will continue to be supported. These provide valuable assistance to people with Mental Health problems and allow those responsible for health and social care to gain the insight of experts by experience. We are concerned that KCCG has cut financial support to a number of these recently (e.g. Carrick Mind and Restormel Mind)

Improving Productivity and Efficiency (Appendix E)

The underlying issues within this section are those common to the whole of the Plan. There is insufficient detail to comment in detail or with any certainty. It raises several significant and extremely worrying possibilities.

Specifically, Councillors will wish to seek more information regarding: -.

• ·         Job losses and consequent Redundancies
• ·         the impact on the remaining workforce particularly about pay and conditions of service and about unknown/unfunded retraining requirements.
• ·         Outsourcing and privatisation of shared services and building ownership and/or management.
• ·         Closure of existing hospitals and other NHS and social care facilities.
• ·         Funding for investment in buildings, IT&M, training, and staff retraining.
• ·         The ability of health and social care providers to recruit a sufficiently skilled workforce, particularly GPs, other Drs, nurses, and pharmacists.
• ·         Insufficient detail and capacity for implementation. Councillors may want to consider establishing a structure, to give clear direction and focus to workforce planning across health & social care.

Health and Social Care are funded very differently at present. Whilst evidence from elsewhere (e.g. Plymouth) indicates that integrated budgets are key to well-integrated care, we believe the Council should insist on a clear understanding of how this would work in practice – such factors as the overall budget, who pays what and what happens in the event of any overspend.

We argue that the Council must be assured in advance that the proceeds of any rationalisation of the estate will be available to fund care in Cornwall. At present, much of the estate is owned by NHS Property Services or by others under PFI deals.

The Council should be assured that front line clinicians and others will be able to spend more of their time using their professional skills. Whilst waste and duplication is obviously undesirable, an effective “back office” is essential to enable them to focus on their core activities and any changes which impede this should be resisted.

We agree that better sharing of information and records is over-due.

System Reform to Achieve Better Care (Appendix F)

We agree that better coordination, elimination of disputes over “who pays” and reduction of cross referrals are all desirable.

Shaping our Future refers to “various organisational models we could adopt … and we need to do further work on the options….” However, the letter from the various Chief Executives dated 19/12/16 says “Our thinking now is that we will need to move with pace to establish an Accountable Care Organisation ….” It appears that this decision has already been made without consultation.

Evidence regarding ACOs from the USA is mixed and a pioneer in the UK (in Torbay) has already run into financial difficulty with a substantial overspend in the first year. Torbay Council papers indicate that this presents “a substantial financial risk to the authority”. A report dated 4/1/17 to Cornwall’s own H&ASC Scrutiny Committee noted “significant financial risks” in Cornwall.

• ·         What Evidence is there that an ACO is the right way forward?
• ·         What alternatives have been considered?
• ·         Who is an ACO accountable to – Cornwall Council? NHS England? The Department of Health?
• ·         What are the financial risks? Are they acceptable?

 

Appendix A – The STP Survey

 

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

A letter to the ‘Transformation Board’ by Dr Peter Levin (17/01/2017)

Posted on the website for Social Policy Research for Cornwall (http://spr4cornwall.net)

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:

•   Preventionandimprovingpopulationhealth
•   Integratedcareinthecommunity
•   Transformingurgentandemergencycare
•   Redesigningpathwaysofcare
        (bestpractice treatmentforspecificconditions)
•   Improvingproductivityandefficiency
•   Systemreformtoachievebettercare

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.’

 

 

Appendix B - Primary Care

Primary care has arguably been one of the most successful and cost effective areas of the NHS . GPs account for 90% of patient contact but just 8% of the NHS budget. It is highly valued by patients. The Patient Satisfaction Study results, published in July 2015, show that 85.2% of patients reported a good overall experience of their GP surgery. In addition to the GP Patient Survey, from December 2014 it became a contractual requirement for GP practices to offer the “Friends and Family test” (FFT). The latest results for May 2015 shows that 88% of patients would recommend their GP practice to their friends and family

Currently general practice faces major challenges: recruitment, chronic underfunding, rising workload and low morale. The proposed solutions are: working at scale, a reliance on new technologies and a change in skill mix meaning that patients will no longer see GPs as a matter of course but may be directed to other members of a multidisciplinary team.

The Problems

GP Recruitment

It is clear from the STP outline business case that there will be less GPs, with additional roles and a significant transfer of workload from secondary care

"Over 20% of GPs and 31% of practice nurses are due to reach retirement in 5 years time"
( in a previous document it was 30 % of GPs in 3 years- perhaps 10% have already gone )

"The supply of practitioners will not be able to meet current or future demand". The STP aspires to recruit more GPs. The question is how given that most areas are reporting a severe shortage of GPs some of as much as 50%. The new model will also require the recruitment of other scarce professionals- practice nurses , district nurses, community matrons, physios, pharmacists etc.

Health Education England (HEE) data which showed that “NHS England estimated demand for GP services equivalent to around 35,500 FTE for 2014 – almost 3,000 FTE more than the recorded level”
(Evidence given to Health Select Committee). And plans to recruit 5,000 extra GPs are failing - see
http://www.pulsetoday.co.uk/your-practice/practice-topics/employment/gp-workforce-shrunk-over-the-past-year-in-major-blow-to-5000-target/20033720.article

Funding

Primary care funding has been falling in real terms and as a proportion of total NHS spending. Practice income has been falling for ten years. The evidence given to the Health Select Committee in 2016 from The Department of Health was that “there has been a decrease in investment in general practice of around 0.8% per cent in real terms since 2008/09”. The King’s Fund added that:
“Relative to other health services (e.g. the acute hospital sector), General Practice’s share of NHS funding has been declining: between 2005/6 and 2013/14, total investment in General Practice fell by 6 per cent–equivalent to nearly £560 million. This is in contrast to a real rise in total NHS spending of 4.4 per cent since 2010/11.97 (Evidence given to health select committee 2016).

As real terms spending on primary care has declined, so have practice incomes. The Government’s evidence showed that “between 2004/05 and 2012/13 there has been an annual average percentage decrease of 2.1 per cent per year” in practice income. Shrinking funding is a major factor in rising numbers of practices nearing closure. Figures obtained by Pulse show more than 160,000 patients across the UK having to register with another practice as a result of their practice closing over the past two years. There has been a 500% jump in the number of practices seeking advice from NHS managers about closure or merging.

There are now 66.5 family doctors per 100,000k people in the UK, down from 70 in 2010.
Reference:

 http://www.theguardian.com/society/2014/jun/14/gp-numbers-fall-recruitment-crisis-bites

There are now 7,962 GP practices in England – one in 20 has disappeared since 2010. The rate of loss of local surgeries has speeded up. NHS figures show that 656 surgeries have been merged, taken over or closed completely since 2010
Reference: http://www.theguardian.com/society/2015/jul/05/gp-surgery-closures-london-crisis-refugee-patients

Workload

GPs now see 370 million patients – 70m more than 5 years ago. The crude annual consultation rate per person increased by 10·51%, from 4·67 in 2007–08, to 5·16 in 2013–14. Consultation rates were highest in infants and elderly people.  The greatest increases in age-standardised and sex-standardised rates were in GPs, with a rise of 12·36% per 10,000 person-years, compared with 0·9% for practice nurses. GP telephone consultation rates doubled, compared with a 5·20% rise in surgery consultations, which accounted for 90% of all consultations. The mean duration of GP surgery consultations increased by 6·7%, from 8·65 min (95% CI 8·64–8·65) to 9·22 min (9·22–9·23), and overall workload increased by 16%. These results suggest that English primary care as currently delivered could be reaching saturation point.
Reference: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)00620-6.pdf

A 2015 British Medical Association (BMA) survey of more than 15,000 GPs found that 93% felt their workload was negatively affecting patient care, while a third were considering leaving the profession as a result in the next five years.
Reference: http://www.theguardian.com/healthcare-network/2015/may/21/general-practice-permanent-decline

The main reasons for doctor dissatisfaction are excessive workload, un-resourced work being moved into general practice, and not enough time with patients.
Reference: http://www.bbc.co.uk/news/health-32307459

Morale

A survey of 1,001 GPs working across the UK published by the Health Foundation in February 2016 underlined just how fragile morale is amongst GPs. GPs in the UK report higher levels of stress and lower satisfaction with practising medicine compared to primary care doctors in other countries. 67% of UK GPs report being satisfied, compared to an average of 79% across the other 10 countries featured in the survey. 59% of GPs in the UK describe their job as extremely or very stressful, higher than anywhere else.

The Proposed Solutions

Working at Scale

The new model will centralise GPs services into "clusters" with 15,000-40,000 and a larger tier - Multi-Speciality Community Providers serving 80,000-100,000 patients. GPs will be encouraged to merge into larger practices and "new funding mechanisms" will make this attractive.

According to the STP plan, NHS Kernow deem practices with <9,000 patients to be unviable
In Cornwall there are 40 such smaller practices in Cornwall with <9000 patients. In fact this is the majority of a total of 64 Cornish Practices- 62.5%.

According to the emerging models of care it is unclear what the status of GPs will be in future.
Will they be employees, shareholders or sub-contracted independent practitioners? Or a combination of these options? What is the model envisaged in Cornwall?
https://www.bma.org.uk/-/media/files/pdfs/practical%20advice%20at%20work/doctors%20as%20managers/managing%20your%20services/po-focusonlocalimplementationnewmodelscaregp2-20-11-2015.pdf

Increased investment in Primary Care

The General Practice Forward View promises more money for Primary care- some directly from NHS England and some from the STP boards. It promises £2.4 billion a year by 2021 into General Practice services, meaning that investment will rise to more than £12 billion a year by 2021. Capital investment is included – this will amount to £900 million over the next five years. A Sustainability and Transformation package of more than £500 million over the next five years will support struggling practices, develop the workforce, tackle workload and encourage care redesign.

Much of the new money promised for General Practice in the Five Year Forward View will be distributed via the CCG to ensure that the commitments in the Forward View are met and will be subject to conditions e.g. Extra weekend and evening appointments , more appointments overall and CCG monitoring of practice activity. The latest guidance to Sustainability and Transformation areas is that between 15 per cent and 20 per cent of their allocation should be spent on investments to support General Practice

There is evidence that the money currently allocated to General Practice is not being spent to improve primary care.  In her speech at the Annual Primary Care Conference, Dr Maureen Baker, chair of the RCGP, said: “The failure to spend money earmarked for General Practice on General Practice is a national disgrace
http://www.nationalhealthexecutive.com/Health-Care-News/general-practice-at-risk-of-losing-760m-under-stps-warns-rcgp-chair

General Practice risks losing £33m this year and £760m by 2020 due to CCG underspends and the roll out of Sustainability and Transformation Plans (STPs), the Chair of the Royal College of General Practice (RCGP) has warned. RCGP analysis of CCG budgets shows that they are due to underspend their budgets for general practice by £33m this year. In the GP Forward View, NHS England promised £2.4bn more funding for general practice by 2020 in a bid to ease pressures on the sector. But Dr Baker said that College research has found that few of the 44 new STPs have drawn up plans to boost investment in general practice.

GP Recruitment:

The GP 5 year Forward View promises to double the rate of growth of the medical workforce to create 5,000 additional doctors working in General Practice by 2020/21. However last year the numbers of full time equivalent GPs fell by 2% and this year (despite a rise in the number of trainee GPs and £20,000 inducements to join practices in under-doctored areas) the number of FTEs fell again due to failure to retain GPs .
http://www.pulsetoday.co.uk/your-practice/practice-topics/employment/gp-workforce-shrunk-over-the-past-year-in-major-blow-to-5000-target/20033720.article

The plan is to recruit 5,000 additional health service workers into General Practice- mental health therapists, practice nurses, pharmacists, physiotherapists etc. Importantly this includes investment by HEE in the training of 1,000 physician associates to support General Practice and the introduction of pilots of new medical assistant roles.
http://www.rcgp.org.uk/policy/~/media/Files/Policy/General-Practice-Forward-View/RCGP-NHS-England-General-Practice-Forward-View-2016.ashx

Patients will no longer see their GP as a matter of course.

The STP claims that the new model will be better as "Fragmented support results in uncoordinated Care, missed opportunities for prevention , risk of falling through the gaps, higher costs and negative impact on outcomes".  However the model appears to increased the risk of fragmentation and impose multiple appointments on the patient. A “change in skills mix" could result in, for example, a patient seeing a physio for their musculoskeletal problem; a pharmacist to review their medication and a mental health professional to assess the depression resulting from this chronic illness - a typical scenario dealt with daily by GPs in a single 10 minute consultation. We are not aware of any evidence that this model would be cheaper or deliver as good or better outcome.

The STP asserts : " We will improve ...early identification". However discouraging patients from seeking help by "moderating demand" and relying on consultations by less experienced, less well trained practitioners may hinder earlier diagnosis.

There is an assumption that GPs " playing a leading role in planning co-ordinating and delivering care

and support in communities" " leading and coordinating Integrated Care Teams " will be a positive development. However, this will result in the scarce resource of GPs being diverted from face to face contact into organisational/managerial roles when they are uniquely trained as generalist clinicians - 8 or 9 years training in medicine and almost no training in administration and management.

It is claimed that "new technologies can help us better meet demand" meaning " triage,telephone consultations, online tools and apps". There was a  "15% increase in patient contacts between 2010/11 - 2014/15" and "63% increase in telephone consultations ". This latter probably reflects the widespread introduction of telephone triage during this period - which unfortunately did not reduce workload. A large study, published in The Lancet on 4 August 2014 and funded by the UK National Institute for Health Research (NIHR), concluded that patients who receive a telephone call-back from a doctor or a nurse following their request for a same-day consultation with a GP are more likely to require further support or advice when compared to patients who see a doctor in person. The research concluded that ‘telephone triage’ systems did not reduce overall practice workload.

GP Premises

As most GPs own their premises the STP " strategy will provide options for practices wishing to divest from their estate and move to co- located points of delivery". Buying the premises of practices and adapting or building new premises will cost millions. Where is funding to be found?

Will the money for capital investment pledged in the GP Forward View materialise and will it be enough? Is PFI proposed? In many parts of the country struggling practices are being referred to Virgin Care or other tax haven based private health companies

Closure of GP Practices?

The STP does not explicitly refer to the closure of practices but this can be inferred from the
references to small practices being deemed unviable, funding measures to encourage mergers and encouragement for practices to divest of their properties. Co-location explicitly means closure of small practices. It seems likely that many smaller communities will lose their local practice although some will persist as branch surgeries. Closure of surgeries is at direct odds with the aspiration to provide services closer to home. It is likely that regarding small practices as unviable will be a self- fulfilling prophecy - GPs will be a scarce resource and young doctors will not choose to join small practices.

Potential Benefits of Centralisation

Centralisation will allow economies of scale, an increase of out of hours and weekend provision and specialisation of GPs. What will be lost? A recent article in The New England Journal of Medicine describes UK General Practice as" The Jewel in the Crown" and concludes "In 10 years' time, General Practice in England may look very different from how it looks today, but it would be a disaster if the assets that General Practice has historically brought to the NHS are carelessly lost in the name of reform."
http://www.nejm.org/doi/full/10.1056/NEJMp1411429

It would be a matter of great regret if there was to be a loss of continuity of care making it much less likely that the patient will see a personal physician whom they know and trust, who has overall responsibility for their care and has a long term relationship with them, who is aware of their past history and may have insight into their psychosocial circumstances and who provides care for them close to home.

General Practice is making a leap in the dark – “New Models of Working Risk Throwing the Baby out with the Bathwater” -
BMJ 2016;355:i5698 doi: 10.1136/bmj.i5698 (Published 28 October 2016)
Martin Marshall professor of healthcare improvement 1, Denis Pereira Gray emeritus professor 2 1Department of Primary Care and Population Health, UCL Sir Ludwig Guttman Centre, London E20 1AS, UK; 2University of Exeter, Exeter, UK

We know that health systems with a strong focus on General Practice deliver better outcomes at lower cost than those that are more specialist oriented. Starfield and others have shown that effective General Practice is associated with better outcomes (including life expectancy, early detection of cancer, and reduced deaths from cardiovascular disease), better system performance (including fewer hospital admissions, lower cost, and reduced health inequalities), and better patient experience (including high rates of satisfaction and trust).4 5 The evidence, although observational, seems consistent over time and across different health systems.

What are the likely mechanisms by which General Practice achieves such important outcomes?

1.       it provides accessible care to all communities, including those with the greatest need and the greatest scope for improvement.

2.       given that a large proportion of health is socially determined, the “whole person” orientation of General Practice care is more likely to be effective than the disease orientation of most medical specialties.

3.       in dealing with uncertainty and managing risk, General Practice reduces the likelihood, consequences, and the costs of overmedicalisation.

4.       while specialists are generally better at adhering to single disease guidelines, generalists are more effective at dealing with the growing epidemic of multimorbidity.

5.       general practice care is more likely to focus on prevention and on enabling patients to look after their own health.

A commitment to continuity of care and general practitioners’ sense of responsibility for individual patients underpins these mechanisms.

Do GPS Support STPs?

NHS Kernow claim that health professionals are overwhelmingly in favour of proposed STP changes. A survey of BMA members reported in the Guardian regarding STPs found that around two-thirds said they had not been consulted and a third had never heard of the STPs. Only 14% firmly supported their introduction with 64% undecided and the rest against. Those who must deliver these changes may not be not much better informed than the rest of us.

Appendix C - Pathways of Care

 

This section raises more questions than it answers. Our major conclusion is that is that we are presented with much too little information to accept or reject the general direction.  It contains some very welcome proposals, particularly the view that mental health must be given as much attention as other parts of the NHS; the recognition that people with mental illness and those with learning disabilities tend to die at a young age and the realisation that all health services have a responsibility to make sure this improves. The proposals to streamline out-patient services are also welcome - as long as this can be shown to improve outcomes for patients as well as saving money. We are concerned that the document contains so little detail about how the proposals would be funded, how they would be staffed and which parts of the service might have to disappear to fund other developments. We are concerned that using pathways to move care away from hospital increases the pressure on primary care services, and on GPs in particular. We are also concerned that some of the proposals appear to be taking provision out of the public sector altogether.

 If we have understood this very abbreviated and optimistic document correctly it proposes reducing the amount of routine out-patient appointments in order to free up time for more urgent appointments. It argues that some of what currently happens in an out-patient visit could be managed by the GP or with self-care by the patient or is not needed at all.

Unnecessary visits waste the time of patients as well as the NHS and to the extent that pathways can be used to prevent this, we welcome them, but want to see the evidence.  Have local GPs been fully involved in drawing up this section? It does seem to imply substantial extra work in a part of the NHS that is already overstretched. GPs are both the first point of contact for most patients and provide regular medical care to most people with long term health problems. Their active co-operation is essential if pathways are to work. Is GP involvement needed at every stage of each pathway? Shouldn’t it be possible for a person to move from one stage to another of the pathway without needing to return to the GP for re-referral or investigations?

“Redesigning pathways of care is about identifying and following the best approach to treat or manage specific conditions based on the best available evidence” –

Will service pathways really respond to each patient’s particular needs or will they become a series of tick boxes, where people whose illnesses do not fit the model no longer qualify for particular services?

We would like to know much more about the evidence for each pathway the STP proposes to introduce.  Only those pathways that have been shown to be effective and that can be safely implemented in our rural area should be introduced. The draft business case helpfully distinguishes between changes that will save lives, those that will save emergency and elective hospital admissions and those that save prescribing costs.  Pathways can be a good way to reduce costs and attempt standardisation but the primary focus must always be the overall quality of the care the patient receives. We must not go the way of the Liverpool Care Pathway where it was concluded in the 2013 review “there was often too much pathway and too little care”. ¹

Will services be levelled up or planed down?   When the document talks of reducing the variability between practices in different parts of the county can we assume that in every case this will mean improving services? Or, if a patient is lucky enough to be with a GP who offers an exceptionally good service, for example for diabetes, might the service be down-graded to meet some notional national “bench mark”.  We want to be able to learn from the best practice, not to see standards fall.

We have looked at the Right Care pages but are still not certain what changes to existing Pathways are proposed. https://www.england.nhs.uk/wp-content/uploads/2015/12/nqb-oct15-5.pdf

“Technology is a growing part of improving care pathways, putting citizens in control of their treatment and their communication with care professionals. The digital age can also help us save money so that citizens can access specialist care online and don’t necessarily need to visit a doctor or nurse”

What services would make use of this? Using what technology?

20% of people in Cornwall have never been on line, according to the Inclusion Cornwall website. Probably many of those are the very older, frailer, disabled or socially isolated people the STP hopes to reach in this way. Mobile coverage is poor and Superfast Broadband is not universally available despite what BT might have us believe.

Allowing people to opt in to using technology is welcome.   Insisting patients use technology could put older people, disabled people or those experiencing poverty at a disadvantage.  There must be wide consultation involving those who are experts by their own experience of illness or disability on this matter.

“We are working with clinical experts to develop and standardise specific pathways of care and we want to involve patients to get the services right. Technology, innovation and citizen education will be central to our approach” 

 - who are these experts?  Do they include experts by experience? Do they include patients’ relatives? Are local GPs, District nurses, members of Community Mental and Learning Disability teams and specialists from RCHT involved? The Draft Outline Business case also refers to ‘system leaders’ ,’relevant stake holders’ and ‘enablers’. It is hard to be sure exactly who they mean in each case.  The STP represents a major change in the way services are run and will need the best local as well as national advice.

To what extent has the STP considered the needs of family members and neighbours who, it seems, will increasingly be called upon act as carers, often on an unpaid basis? They are also citizens and there are important equality issues here. Though many men can and do act as carers, service change that relies on self-care and family care will have a disproportionate effect on women who will feel constrained to give up work to pick up the care. Many family carers are themselves elderly.  Care pathways must be designed to minimise the negative impact on carers as well as patients. 

 “Specialised commissioning are engaging with providers to understand the opportunities for changes in service delivery. NHS England has stated their intention of working with Cornwall as one of two rural STPs to understand where and how we can link with neighbouring STPs ensuring a viable population footprint on which to plan future services.   Service reviews will be clinically led and involve all relevant stakeholders, including the strategic networks and operational delivery networks, in determining the best value option for the local population. 

We will work with ‘system leaders’ to build new models of care with other providers  such as operational networks, spoke and hub models or hospital chains with the ambition of bringing the best specialist services within reach of our population that are appropriately governed and resourced.”

KONP opposes increased privatisation of services. We are extremely concerned that it appears the STP is considering using providers whose first interest will necessarily be in securing profit for their shareholders rather than good to the wider public. The plan for these more specialist pathways is to focus on cancer services, child and adolescent mental health and dermatology, adopting national best practice to improve pathways of care. The use of ‘other providers’ and ‘hospital chains’ means you are seriously considering privatising services to some of our most vulnerable citizens.  We assume it is the specialist services, rather than the population, that you require to be appropriately governed and resourced. The experience of Winterbourne View and more recently Morleigh Care confirms us in the view that services for vulnerable people must be governed only for the good of those who use them, rather than for private profit. We also believe that it is very difficult to manage governance and safety issues in distant placements, especially in the private sector. We must emphasise that people detained under the Mental Health Act are uniquely vulnerable because they have not chosen to be in hospital at all. They are not in a position, as cancer patients may be, to make choices between providers or to balance the benefit of earlier or more specialised treatment against the distance from their homes and families. They are, quite literally, a captive population.

We note that CFT and NHS England are already in negotiation, indeed may already have made commitments, to the private Elysium Group (formerly Partnerships in Care and the Priory Hospitals) about secure beds for Cornish patients in a new private hospital near Wellington, Somerset. http://www.elysiumhealthcare.co.uk/locations/wellesley/ How does this fit in with the STP’s aspiration to reduce the use of out of area mental health beds and treat people closer to home?

 https://www.cornwall.gov.uk/media/22983857/taking-control-shaping-our-future.pdf

Cornwall and the Isles of Scilly: Sustainability and Transformation Plan. Draft Outline business case. 21^st October 2016 https://www.cornwall.gov.uk/media/22984634/cornwall-ios-stp-draft-outline-business-case.pdf  See especially pages 51- 57

RIGHT CARE https://www.england.nhs.uk/wp-content/uploads/2015/12/nqb-oct15-5.pdf

 

 

 

 

 

Appendix D - Mental Health

Why is mental health so important?

The pain of mental illness is no less real than the pain of other illnesses.

Mental health problems are disabling. They can prevent people from enjoying their lives, forming and sustaining relationships and from working. This harms them and the people they are close to.

Mental health problems are common, affecting most people at some time in their lives, either directly, or through a close family member. Most of these problems, however are relatively mild. Severe, long-term complex mental health problems are much rarer. 5% of people in Cornwall report long term mental health problems, this is more than the national average.

Mental health problems can be fatal. In Cornwall, we have high rates of suicide, self-harm, and intentional injuries. Though Cornwall’s suicide rate is higher, a lower proportion of Cornish suicides had been in touch with mental health services before they died, than would be seen nationally. 

People with mental health problems tend to die at a younger age than others. The average reduction in life expectancy in people with bipolar disorder is between nine and 20 years, while it is 10 to 20 years for schizophrenia, between nine and 24 years for drug and alcohol abuse, and around seven to 11 years for recurrent depression. People with learning disabilities also tend to die young.  On average about 20 years younger than the general population. Some of these early deaths are due to the poverty that goes with mental health problems and disability: people have worse housing and a poorer diet. Some is due to smoking drug and alcohol use, but there is also good evidence that people with these problems do not get a good service from the NHS for their other health problems. Some of the deaths would have been amenable to good treatment. So, preventing premature deaths is a matter for primary care and acute hospitals, not just Mental Health and learning disability services.

Mental Health services and services for people with learning disabilities have not been given an equivalent level of attention or funding in comparison with other parts of the NHS ² (http://www.rcpsych.ac.uk/policyandparliamentary/whatsnew/parityofesteem.aspx ). The mental health services we have now are only dealing with the most serious problems and at a very late stage.

Mental health services are staff and time intensive. Good mental health treatments require trust, respect, and the ability to develop long term relationships. How can that happen in Cornwall's overstretched services?

“Involving citizens in developing the best pathways of care is critical and we still have work to do before we can say more about proposed reforms” –

It is hard to disagree with this statement but we would like to know who will be consulted.

We believe that you must listen carefully both to experts by experience and to the staff who deliver primary care, community, mental health, and learning disability services.

How will the STP bring in experts by experience - the people who know about mental health problems and services because they have experienced them- to help design more effective, more reliable, more accessible services?  Small voluntary sector organisations that respect this expertise of people are one way of gaining the views of people with mental health needs. Why did KCCG cut grants to Pentreath, Nightlink, Carrick Mind, Restormel Mind, Penta Health and Wellbeing, Sea Sanctuary, Women’s Rape and Sexual Abuse Centre, and Cornwall Rape and Sexual Abuse Centre?

These are services whose work is recognised, for example by Inclusion Cornwall  http://inclusioncornwall.co.uk/what-is-inclusion/social-inclusion-2/health-and-inclusion/

 People at KONP’s recent conference told us how important these organisations are to them and pointed out that these bodies need support so that the group can still function when particular members are not well. This is a real issue in self-help organisations for people with mental health problems whose state of health can fluctuate.

 

Are staff being asked about proposed reforms?

 

Community Mental health services were drastically reformed recently and have developed into something that wasn't the suggested model. There was no consultation or involvement of affected staff, staffing levels have now reduced and recruitment is proving difficult. 

There is considerable expertise in services that would help the STP achieve its aims, for example existing Mental Health and Learning disability services operate liaison and in-reach to secondary care. Their experience would be helpful in working out how to reduce the number of people