36. Cornwall and the Isles of Scilly
What concerns have been raised about your STP?
Health planners are trying to reduce NHS deficits and think about ways to re-organise care. However getting the large deficit under control could prevent facilities being developed that can cope with the health and care social needs of local people.
A review is under way of community hospitals and campaigners are concerned this could lead to a reduction in bed capacity or hospital closures.
The council has warned it will need to make savings from important NHS contracts including health visiting, school nursing, sexual health and drug and alcohol services.
The future of minor injury units is uncertain.
Cost-cutting a primary aim
- Longer waiting times for elective care
- Closure of wards and theatres
- Staffing cuts
- Ending funding for some treatments and prescriptions
- Delaying or avoiding funding newly approved treatments
A report in October 2017 by the CQC noted deaths in the county that were due to long waiting times and cancelled operations.
In October 2017, Kernow CCG put forward proposals to make changes to who received non-emergency patient transport services; the changes will affect patients receiving kidney dialysis.
To reduce its deficit Kernow CCG is trying to sell land and plans to cut its Telehealth service.
What are the proposed aims of the STP
- Elimination of a projected 2020/21 deficit of £264 million;
- To increase the focus on preventative care and self-care;
- Transformation of primary care;
- Development of integrated community hubs;
- Development of urgent care centres;
- Consolidation of back-office functions.
Like other areas this STP aims is to transfer services out of hospital and into the community. The concern is that cuts in hospital care will be made, helping to achieve savings, but without proper investment in community health services.
The STP does not contain exact details of how the aims are going to be achieved with the level of funding available.
The STP states that the 13 community hospitals in the area with a total capacity of 314 beds are not used effectively, not fit for purpose and are not sustainable. It also states that 35% of community hospital bed days are being used by people who are clinically fit to be discharged. The plan aims to reconfigure the community hospitals as "integrated community hubs."
A reduction in numbers of acute beds is discussed in the STP as a review: "Review of acute medicine beds to examine our overall requirement and distribution, including the impact of planned improvements to community based care for admission avoidance and step down and a subsequent review of required acute medical resources from all providers, including mental health support."
The STP outlines the development of integrated community care hubs, which focuses primarily on care of the elderly. The STP outlines that these hubs will "be one stop assessment centres for the frail elderly (replacing outpatient clinics), focusing on: comprehensive geriatric assessment; re-ablement and rehabilitation; prevention (co-opting third sector and community resource) and admission avoidance such as falls assessments."
The Integrated Community Hubs will be co-located with Urgent Care Centres to ensure workforce and financial viability, working in partnership with the acute trusts.
The STP plans for integration of care and health teams and notes that the development of an integrated single provider/commissioner model is possible.
The STP, contains an “ambitious” prevention plan, with areas including a domestic violence referral plan, improving immunisation uptake, a whole-system strategy to tackle childhood obesity, measures to identify patients engaging in harmful smoking and drinking, and a self-management and self-care programme. However, the report notes that £20 million will be needed to deliver these plans.
As well as a series of Urgent Care Centres across the region, the STP also outlines that the emergency care system will be reconfigured, with the commissioning of an integrated NHS 111 and out-of-hours service.
Changes across the area
In June 2017 the HSJ reported on discussions between NHS Improvement and NHS England on what certain high-spending CCG areas will be required to do to enable them to spend less money and remain within a budget (capped expenditure) known as a 'control total' for 2017/18. The 14 target capped expenditure areas include Cornwall. The measures under discussion include the following:
- Limiting the number of operations carried out by non-NHS providers so the funding stays within the NHS. Considerations differ between areas but include both limiting patients’ choice of providers, and reducing work which is outsourced by NHS trusts. In some cases it would require the NHS to find the capacity to carry out more operations.
- Systematically drawing out waiting times for planned care, including explicit consideration of breaching NHS constitution standards. Some plan to target delays at specialties/areas where waits are currently lower than average.
- Stopping NHS funding for some treatments, including extending limits on IVF, adding to lists of “low value” treatments, and seeking to delay or avoid funding some treatments newly approved by the National Institute of Health and Care Excellence.
- Closing wards and theatres and reducing staffing, while seeking to maintain enough emergency care capacity to deal with winter pressures.
- Closing or downgrading services, with some considering changes to flagship departments like emergency and maternity - though these would normally take too long to deliver savings this year.
- Selling estate and other “property related transactions”.
- Stopping prescriptions for some items, as suggested by NHS Clinical Commissioners earlier this year.
The commissioners in the area told the HSJ that they have been told to examine “difficult decisions” and “think the unthinkable”, including modelling changes which are normally avoided as they are too unpleasant, unpopular or controversial.
Cost-cutting across the area
Implementation of these cost-cutting measures could be difficult for Cornwall as it is already struggling. In June 2017, Kernow CCG produced a plan to save money that focused on a major downsizing of elective care, however this has not gone ahead due to its implications for patients. The CCG’s savings target this year is £29.6 million, which equals around 3.8% of its allocation.
In September 2017, according to board papers, Kernow CCG acknowledged that it had "no viable plan" to hit its control total for 2017/18 and closing the £17.7 million deficit.
In October 2017, Kernow CCG put forward proposals to make changes to who received non-emergency patient transport services; the changes will mean some patients receiving regular treatment, such as kidney dialysis, would have to make their own way to hospital. The changes were then put on hold due to an outcry by charities, including Kidney Care UK.
Kernow CCG has also tried to raise money via land sales; in October 2017, however, it was forced to suspend the sale of land in Launceston following a public outcry.
The land in question was left to the town and was covered by a covenant that any future development should be restricted to medical uses.
The Telehealth service in cornwall was due to be cut, but a user of the service, which allows the remote exchange of information between patients and doctors from patients’ own homes, took Kernow CCG to court. The court ruled that Kernow CCG had not consulted with the public on the closure of the service and had therefore acted illegally. The CCG has now had to begin a public consultation exercise.
In October 2017, the CQC recommended that the Royal Cornwall Hospitals NHS Trust be placed in special measures after they found services were failing across several departments, including surgery, maternity and cardiology. The report noted that too many people where waiting too long for surgery or treatment. There were cases where people died after waiting too long for heart treatment, while others were left to go blind before eye surgery was performed. There was also a significant number of operations cancelled, including for cancer patients.