West Country Chronicle: Inside Cornwall’s care capacity row

Tensions are running high in Cornwall, where some of the worst emergency care performance in the NHS — very possibly the worst — is currently found.

HSJ has previously written about the normalisation of two-day waits in Royal Cornwall Hospital’s emergency department, while ambulance response times have spiralled above three hours for patients with suspected strokes and heart attacks.

Now the West Country Chronicle can reveal more details of how the problems are causing strains on crucial relationships across the troubled integrated care system.

‘Proxy care home facility’

Shortly after Cornwall’s integrated care board became statutory in July, ICB chiefs received a letter from Royal Cornwall Hospitals Trust chief executive Steve Williamson and chair Mairi McLean.

In the letter, obtained by the Chronicle through Freedom of Information law, Mr Williamson set out how problems discharging patients was causing the emergency care problems at the front of the hospital.

With the trust’s number of delayed discharges having grown to more than 100 (around a sixth of the hospital’s bed base), Mr Williamson warned “parts of the hospital are now operating as a proxy aged care home or domiciliary care facility”.

Taken together with the discharge problems at Cornwall Partnership Foundation Trust (the county’s community and mental health provider) – where up to 40 per cent of patients have been stuck waiting for onward care – Mr Williamson concluded the social care shortages were having a “devastating impact” on ambulance response times, emergency department waiting times, and “increasingly on our emergency and urgent clinical services”.

It was clear from trust data, Mr Willamson wrote, that ambulance response times have deteriorated “directly in line” with the increase in social care residents or other delayed discharge patients who are occupying acute hospital beds.

The number of hospital patients staying longer than seven and 21 days (“stranded and super-stranded respectively”) was also growing proportionately to the increasing numbers of delayed discharges, the letter said.

In summary, the message from the trust was clear: the system needs to resolve the onward care capacity problems in order for RCHT’s emergency care problems to ease.

Where’s the money gone?

However, the trust did not stop there in its letter to the ICB. Mr Williamson also raised concern about a £33m allocation made by the ICB’s predecessor (Kernow Clinical Commissioning Group) to Cornwall Council through the Better Care Fund.

Mr Williamson claimed this funding had been allocated to the council to tackle the social care crisis, but he said “the position with delayed discharges continues to deteriorate and it is not clear how this very significant additional resource has been allocated”.

He called for “clarity, transparency and regular reporting” on the funding to “ensure it is deployed in the most impactful way to urgently create community capacity to address this discharge challenge”.

The message again was clear: what has the council and ICB achieved with this allocation?

The trust ended its letter with a plea for funding to open another 50 beds this winter if the existing funding – including the council’s £33m – did not result in significant reductions of delayed discharges.

The reason Cornwall’s social care situation and handover delays are quite so bad is not absolutely clear, but it is of course at the end of the UK’s most substantial peninsula, with very particular workforce and economic problems, and little scope for “mutual aid” from neighbours.

Read our minutes

If the trust was hoping for a detailed response from the ICB following its four-page correspondence, its hopes were quickly dashed.

ICB chief executive Kate Shields (who joined the ICB directly from RCHT, in unusual circumstances) and chair John Govett sent back a letter which consisted of just three sentences.

In its very short response to the trust (also obtained by the Chronicle via FOI), the ICB said the minutes of its latest board meeting would “reflect the discussion we had and the significant work taking place across Cornwall to address high levels of demand on the urgent and emergency care pathway in Cornwall and in particular, our high level of ambulance holds”.

“As you will both be aware, our entire ICB is determined to make the difference we need to, to keep our people safe”, the letter said.

The Chronicle checked the relevant minutes of the meeting in question, and found it mainly comprised “confirmation that plans…are being developed” and “all partners are committed to working together”.

In an apparent slap on the wrist for the trust, the minutes recorded some ICB non-executives suggesting “these types of issues could be better dealt with by discussions at ICB board meetings in the first instance”, inferring this was preferable to receiving an angry letter.

The Chronicle approached the ICB to ask what assessment it had made of whether the £33m funding had been well spent and what it was doing to help with the social care capacity, but received no reply.

In a similarly miniscule response to us, the ICB merely said: “As elsewhere in the country our demand and capacity plans are currently being formulated, taking into consideration acute beds, recruitment and capacity issues to help improve patient flow.”

RCHT did not comment when the Chronicle asked if it had received a satisfactory response from the ICB. Cornwall Council did reply (see box below) and said the bulk of the funding had supported increasing the hourly rate pay for care workers, increased care package provision, more homecare and more community equipment.

ICB chief departs after three months

The above story paints a picture of a health system where there are different opinions at senior level over who can do what to help the overall problems.

One thing is certain: the Cornish ICS is an extremely challenged health system and represents one of the toughest turnaround tasks in the NHS right now. In terms of discharge and emergency care, probably the most.

Just ask Helen Skinner. She was appointed as the ICB’s chief medical director in July and was given the senior responsible officer role for emergency care after joining the organisation from New Zealand.

Three months later, Dr Skinner has quit already. An ICB spokeswoman told the Chronicle she was leaving to “pursue different challenges within the UK health and care sector”.

Her departure leaves a large hole in the ICB’s new leadership team, and with Cornwall’s historic problems in attracting good leaders to its NHS – the timing could not be worse as the system braces for what could be the toughest winter yet.