A pilot urgent care model for Cornwall has fired the enthusiasm of providers while raising questions including start-up funding
Issue: The NHS in Cornwall has been searching for ways to deliver care closer to people’s homes, despite the fact the county’s population of 500,0000 is sparsely spread over 1,376 square miles. A pilot urgent care model for delivering care, which involves an expansion of elective services, was launched at the previously underused West Cornwall Hospital in June. It is hoped the model can be replicated to varying degrees at other Cornish community hospitals.
Context: The national direction of travel for acute services is often greater centralisation but going down this road in Cornwall would leave patients in parts of the county facing round trips of 70 miles to its main hospital in Truro. Royal Cornwall Hospital Trust is also keen to expand or win back market share and providing care closer to home could be a way to do that.
Outcome: Discussions are still at an early stage but there is a lot of enthusiasm, particularly from the provider side. However, there is a suggestion that changes to the tariff might be needed to make the model affordable. It is also believed that funding for start-up costs may not be forthcoming.
Geography and population
Cornwall has become synonymous with the difficulties of providing cost-effective healthcare to a rural population.
The county has a population density of 151 people per square kilometer; this compares to 528 in North Somerset and 4,026 in Bristol. England’s median population density by district is 564.
However, even this does not fully illustrate the county’s size and remoteness. According to NHS Cornwall and Isles of Scilly’s quality handover document,the county has the lowest population density in the South West, with almost half of people living in settlements of less than 3,000 and its largest town houses a population of just 22,700.
The population is ageing, with a greater proportion of people over 50 and with a higher life expectancy than the average in England and Wales. This challenge of the geography is added to by the requirement to provide urgent and emergency care for the 300,000 tourists in Cornwall at any one time during the summer months.
Travel time to Royal Cornwall Hospital Trust’s main site in Truro or Plymouth Hospitals Trust’s Derriford Hospital.
Source: A healthy Future for Cornwall and the Isles of Scilly
The case for change
Following its creation in 2006, the board of NHS Cornwall and Isles of Scilly launched a strategic review of healthcare services in the county. This led to the publication of A Healthy Future for Cornwall and the Isles of Scilly in 2007. In line with national policy, the review concluded care should move closer to home.
One of the immediate priorities identified by the review was the development of a local emergency care model. Three years later this was still a pressing ambition in the strategy update covering 2009 to 2014. One year further on, GPs and patient groups in the west of the county still had serious concerns about the safety of the emergency department at West Cornwall hospital, senior figures in the county report.
The county is served by Royal Cornwall Hospitals Trust, which has three sites: the 750-bed Treliske Hospital in Truro, the main site; St Michael’s Hospital in Hayle, specialising in orthopaedic and breast surgery; and West Cornwall Hospital in Penzance.
Until recently, West Cornwall Hospital was seen as a struggling site that was steadily losing services due to efficiency drives, recruitment problems and centralisation. However, in the last six months it has undergone something of a turnaround, including the introduction of a new model of 24-hour doctor-led urgent care provision.
There is a belief in Cornwall that this “sub-acute” model could provide a blueprint for improving the range of services available at some of the county’s 13 other community hospitals, taking care closer to home in the process.
The community hospitals are run by Peninsula Community Health, a social enterprise created under the Transforming Ccommunity Services programme just over a year ago.
Location of acute and community hospitals in Cornwall
Source: A Healthy Future for Cornwall and the Isles of Scilly
The West Cornwall model
The future of West Cornwall Hospital has been a source of local controversy for at least 20 years, with much of the local population convinced Royal Cornwall and the commissioners wanted to close it down. During the 1990s there were protests against plans to shut the maternity unit and children’s wards, while in 2006 27,000 people marched through the town of Hayle to show their concern the hospital was being downgraded.
In 2011 the temporary closure of a medical ward sparked local uproar with the Hands off Our Hospital campaign, leading to an event in which thousands of local people held hands around the hospital.
West Cornwall Hospital is based in Penzance, 25 miles and a 40 minute drive from Royal Cornwall’s main site in Truro. Over the past 20 years it has lost services including its children’s ward, maternity services, high dependency unit and 24 hour pathology services.
It did have, so the local joke goes, one of the only two remaining “casualty” departments in England – the other one being on BBC hospital drama Holby City. Royal Cornwall struggled for years to staff the department with doctors in the face of a national shortage of emergency medicine doctors.
As a result, the ambulance service regularly bypassed the hospital as staff never knew whether there would be a doctor on duty.
The lack of medical cover led to other inefficiencies, according to Matthew Boulter, a local GP who was heavily involved in creating the model at West Cornwall and is now clinical lead of the hospital’s urgent care centre project.
Patients would sometimes have to be sent by ambulance to Truro to be discharged because their condition meant the nurses at West Cornwall were not permitted to judge them fit for discharge. They would then be 35 miles away from home and often without transport.
‘All of a sudden we as a group of local GPs who had long-running concerns said we have the influence now, so let’s do it’
In light of these problems, local GPs got together with the emergency department lead from Treliske, representatives from South West Ambulance Service Foundation Trust and the lead sister from West Cornwall in 2011. A plan was developed to solve the staffing problem by using GPs with emergency medicine experience working alongside emergency medicine physicians from Treliske.
Because Royal Cornwall was already funded to provide 24-hour doctor cover at West Cornwall it was difficult for its leadership to say no when presented with the plan for a GP-supported service there.
The GPs are employed by the trust, with £200,000 funding from NHS Cornwall and Isles of Scilly to pay for their costs, although the PCT stresses this is not extra funding but using existing resources in a different way.
The urgent care centre is being piloted for a year. Ongoing funding arrangements are yet to be agreed although there is expectation locally that Kernow Clinical Commissioning Group will find a way to continue the service when it takes over commissioning responsibilities next April.
Dr Boulter says that alongside the involvement of Royal Cornwall chief executive Lezli Boswell, who “got it from the word go”, the introduction of clinical commissioning was vital to the turnaround of West Cornwall Hospital.
“All of a sudden we as a group of local GPs who had long-running concerns said we have the influence now, so let’s do it,” he said.
However, group members were aware that the introduction of GPs could be viewed as downgrading by a suspicious and well-informed community who had been campaigning for full accident and emergency services at the hospital for years.
They set about holding public meetings to explain the proposals and develop them using local feedback. Graham Webster, a leading local health campaigner with Health Initiative Cornwall and a former NHS manager, is emphatic in his support for the new and improved West Cornwall Hospital.
“Very poorly patients have to go to Truro; the community are accepting of that now,” he said.
The hospital relaunched in June with an urgent care centre replacing the casualty department on a one-year pilot. There are currently four GPs with experience in urgent and emergency care working at the centre on a part-time basis while continuing to practise locally.
Two doctors are on duty during the period between noon and 5pm and at least one at other times. The hospital is looking to recruit two or three more GPs on a part-time basis. Dr Boulter says the role is appealing to GPs who “tend to be more geographically fixed and are encouraged to have portfolio careers”.
Only low risk patients are currently admitted to the West Cornwall’s wards at weekends following concern from some consultants that it was a contravention of Royal College of Physicians guidelines for a consultant not to see patients within 24 hours of their admission. Work is being done on governance to address this with the ambition of admitting higher risk patients at weekends, too.
According to a presentation to Royal Cornwall’s September board meeting by Dr Boulter, the urgent care centre has so far seen between 1,500 and 2,000 patients a month, equivalent to around a quarter of emergency patients received by the trust.
The proportion of patients being sent to Truro by ambulance from the urgent care centre has fallen from 2.5 per cent to 0.5 per cent. Waiting times are around half those at Treliske, with an average total stay of 95 minutes compared to close to three hours at the main site.
As part of the expansion of the urgent care centre, a satellite of the acute GP service at Treliske was introduced at West Cornwall Hospital. Run by Peninsula Community Health, the service triages all GP referrals into hospital and identifies alternatives where possible to allow patients to stay in their own home. It also includes a GP-run clinic where patients can undergo diagnostic tests without the need for admission.
Claire Florey, a deputy divisional manager at Royal Cornwall, is leading the wider development of West Cornwall Hospital. She has been charged with introducing as many services as possible, provided they do not need critical care support and increasing activity.
The hospital also has two medical wards, a surgical ward, operating suite, dialysis, outpatient department, diagnostics and a treatment centre. Most of the surgery is day case, with only about 4 per cent of patients staying overnight. In July, 843 elective patients were treated at the hospital, the largest number in any month for the past three years and a 20 per cent increase on July 2011.
Space is being created at the hospital for the introduction of audiology services; an ambulatory gynaecology service is due to open this month and there are plans to increase the range of ophthalmology treatments available. The range of medical day treatments will be extended in a bid to offer some of the 700 patients with West Cornwall postcodes who have appointments in Truro treatment closer to home.
The community midwifery team has relocated from Bellair Clinic in Penzance and the working hours of West Cornwall’s CT scanner have been expanded.
Many of the services now offered at the hospital have been enabled by new technology – for example, blood tests in the past had to be sent to the main site but now can be done on-site with one machine.
The scope for expanding the scheme
There is enthusiasm from the provider side: Royal Cornwall Hospital Trust and Peninsula Community Health have set up an executive working party to look at where they can work together, including on improving the county’s community hospitals.
Bodmin, St Austell and Camborne and Redruth community hospitals in particular have been identified as potential sites to replicate all or some of the West Cornwall model. All three have minor injury units open between 8am and 10pm and X-ray provision between 9am and 5pm.
Dr Boulter warns that the introduction of the sub-acute model elsewhere in the county would involve the scaling up of services – something which would be difficult to fund in the current climate.
Royal Cornwall has invested £5m in West Cornwall Hospital in recent years to introduce facilities including the CT scanner, treatment centre and expanded renal unit, refurbished wards and point-of-care testing. It is unclear whether the level of capital would be available in the local health economy to provide the upgrade to services at the other community hospitals or fund the additional cost of medical cover.
However, providing more services at Bodmin Community Hospital, in the east of Cornwall, would fit with Royal Cornwall’s ambition set out in its annual plan to provide more services in the east of the county.
A paper to the Department of Health’s foundation trust application technical committee, obtained by HSJ under Freedom of Information legislation, reveals Royal Cornwall has lost market share in orthopaedics and ophthalmology and in response is planning to improve elective service design, reduce waiting times and target patients in the east of the county.
Clinics and testing services at Bodmin could attract patients who would otherwise go to Plymouth Hospitals Trust’s Derriford Hospital or Northern Devon Healthcare Trust rather than Treliske.
The move of ambulatory gynaecology services to West Cornwall, which is due to happen this month, will free up space at the main site which it is hoped can be used to expand orthopaedic capacity and win back some of the market share lost to independent providers including Ramsey Healthcare’s Duchy Hospital.
The model is also attractive to Royal Cornwall as an improved urgent care service at other community hospitals with a bigger medical presence would take pressure of accident and emergency in Treliske. The trust hit the four-hour target in August but failed it during the first quarter of 2012-13, something it blamed in part on the introduction of the NHS Pathways triage system at the out-of-hours GP provider Serco.
However, even if there is capital available to set up new services, there is also a consensus locally that a change in the tariff is required to make the model affordable.
Peninsular Community Healthcare chief executive Kevin Baber has started talking to GPs in the north of the county about the potential to expand services at Bodmin. He too sees the “economics” as the biggest obstacle and is unsure whether a 24-hour service could be sustained as it is at West Cornwall. It is also hoped the community hospitals can support further satellites to the acute GP service.
“It’s obviously better for patients but also it’s about avoiding unnecessary admissions. We are still working through how the money would follow the patient,” said Mr Baber. “We are really keen to try and use the community hospitals in a different way.”
Nick Bosanquet, professor of heath policy at Imperial College, chaired the strategic review back in 2007 and has recently revisited the county to see what has been done at West Cornwall. He is clear that the sub-acute model is what the strategic review group had in mind when its members talked about care closer to home. However, he is also clear it will take revision of the tariff to make it affordable.
It has been suggested in the absence of a change to the tariff an alternative would be for Kernow Clinical Commissioning Group to subsidise services through the savings made on reduced admissions. There is no doubt that commissioner support is essential if changes are to happen.
Kernow CCG serves a population of around 550,000 and plans to do all of its commissioning in house. It is in the first wave of CCGs to go through the authorisation process and has a locality-based model covering 10 separate areas which work alone and come together as appropriate. For example, the three western localities came together to lead the work on West Cornwall Hospital.
Dr Boulter is clear that the kind of “pressure relieving” facility would be welcomed by colleagues in the east of the county while Mr Baber reports a positive reception to proposals to upgrade services at Bodmin. Publicly commissioners say they have not identified specific hospitals yet and while they are keen to use the learning from West Cornwall Hospital there will not be a “one size fits all” approach.
The enthusiasm generated by the apparent success of West Cornwall Hospital is beyond doubt in Cornwall and beyond. Managers from the struggling Weston Area Health Trust in North Somerset are understood to have visited recently to look at how it operates. Patients like it, the community is happy and it is taking the strain off Treliske’s busy emergency department while delivering the NHS stated objective of bringing care closer to people’s homes.
However, whilst there is no doubt a lot that can be learned from West Cornwall’s revival the distinct challenges involved in upgrading services in a time of extreme financial constraint seems likely to make it a more challenging process.
It will require co-operation from the Department of Health, which is usually reluctant to make radical changes to the tariff, or a local agreement by the CCG to reinvest savings released by the service in a way to make it sustainable. However, this could make it less attractive to a CCG still finding its feet.
Bodmin will be the test case for whether what has been achieved at West Cornwall can be replicated elsewhere. With a sound evidence base and local champions it seems likely there will be some expansion of services on offer at Bodmin, particularly the popular acute GP service, but it is unlikely to offer such a wide range of services or open 24 hours.