While the headlines spotlight cri-ses at the sharp end of the NHS – such as the recent “critical incident” at Royal Cornwall Hospitals Trust – the county is now on the cusp of a deep-rooted and broad-reaching revolution in the way health and social care services are delivered and managed.
Instead of using a sticking plaster approach to patch things up when they go wrong, for the first time the county’s NHS bodies have joined forces with Cornwall and the Coun-cil of the Isles of Scilly, as well as a strong core of community and vol-untary organisations, to work togeth-er to create a sustainable model of services that will answer people’s health and care needs for the fore-seeable future.
Cornwall and the Isles of Scilly is developing a 10-year long-term health and wellbeing plan, as well as instigating more immediate practical changes over the next five years (as a local response to the Government’s Long Term Plan for the NHS) to give people the care, help and advice they need, where and when they want it.
Geographically, it’s a huge chal-lenge to create the ideal system in a peninsular county with a unique footprint that doubles its population in peak tourist season, coupled with an explosion of older people. The mainland is surrounded by sea on three sides and Scilly is a remote archipelago 28 miles offshore. There is just one acute hospital in the county serving the majority of peo-ple, lots of small towns and no large city.
Forty per cent of the population live in rural settlements with little public transport, and in terms of health and care back-up in a crisis there is nowhere else to look for assistance, except where the east of Cornwall borders with Devon.
The health of Cornwall and the isles of Scilly
Of the total current population of Cornwall and the Isles of Scilly of around 530,000:
- 85,000 are living well, requiring only ad hoc health or care support.
- 280,000 are at risk of future ill health and would benefit from targeted prevention advice.
- 135,000 are self-managing their long-term conditions well, with occasional support.
- 20,000 need some level of co-ordinated health and/or social care.
- 4,000 have more complex conditions needing more managed care and support.
- 4,000 are at the end of their lives and needing 24-hour support.
Nevertheless, there is a strong commitment and fresh energy being injected to make the integration plan work. It is not only about GPs, com-munity and mental health services, Royal Cornwall Hospitals Trust, community hospitals, the local councils’ social care, housing, chil-dren’s and public health teams, health watchdogs and the large and well-supported charitable and vol-untary sector, working collaborative-ly. The quest to create fully support-ive communities, committed to good health and wellbeing for all also extends through local schools, health clubs and businesses down to individuals.
The overall strategy – backed up by public health research and data – is keenly focused on cradle to grave physical and mental wellbeing – starting well in childhood, living well as an adult and ageing well as the years pass.
Historically, the emphasis has been on clinical intervention – with hospital care seen as a top priority – yet a key statistic shows that health care has only a 10% effect on people’s wellbeing and their likelihood of premature death.
- One in four people in Cornwall is now aged 65 or over.
- 62% of hospital bed days are occupied by that age group.
- A 47% increase in the number of people aged 75 to 84 was expected between 2015 and 2025.
- Each day around 60 people are staying in an acute hospital bed in Cornwall when they don’t need to be there.
- Around 35% of community hospital bed days are used by people who are fit to leave.
- Older people can lose 5% of their muscle strength for every day they spend in a hospital bed.
The biggest influence – 40% – is your own behaviour and lifestyle choices, such as how active you are and what you eat. Thirty per cent is down to your genes and any predisposition to diseases; 15% depends on your social circumstances and the place you live, and 5% is down to pollution or other environmental issues.
Helen Charlesworth-May, Corn-wall Council’s strategic director for adult social care and health says: “It’s a really exciting time locally and nationally. There is an understand-ing that being well is not just down to the NHS. There is a renewed interest in localities and communities. That means there are lots of people who are prepared to come together to build what we call a community-based model of care.
“People need to know that if they are not feeling well they don’t neces-sarily need to be in hospital. As the population ages, and with multiple long-term conditions – it was never going to be the case that hospital was the right place for people.”
One of the aims of the collabora-tive approach is not only to get peo-ple out of hospital and back home, or into appropriate community care with the right support, as soon as possible, it is to prevent them being admitted unnecessarily in the first place.
While confirming the promise to provide excellent and appropriate healthcare when someone does become ill, there will be a drive to show people the benefits of taking more responsibility for their own health, the prevention of common diseases, better self-management help – both face-to-face and online – and peer support for those with long-term conditions.
That is partly about changing peo-ple’s expectations about their health and care – simple things like accept-ing that:
- When it isn’t a life-threatening emergency, you could call 111 or visit the pharmacist for advice rather than going to A&E.
- There may not be any clinical benefit to having a post-op check-up with your hospital consultant if your recovery is proceeding as planned.
- If you carry on smoking, your lung condition won’t improve.
Another major challenge is for the different health and care providers to break down historical barriers, and try to work outside of traditional hierarchical structures, to offer help that is centred around each person as an individual, within their own local community. That also means members of the workforce building up stronger relationships beyond their closest colleagues and poten-tially learning new skills for chang-ing roles.
The long-term plan is for all GP practices to act as local hubs for dif-ferent health and social care teams, supported by other practices as part of Primary Care Networks within a certain catchment area or locality. They would not only deliver the health and care people need when they are ill, they would also be places where people can come together to support each other in ways that will keep them healthy. And a one-stop-shop approach would combat peo-ple’s confusion over where to go for services.
“Integration is game changing. It is not about individual services belonging to any organisation, it’s about naturally forming communi-ties and services by organisations around a place,” explains Tryphaena Doyle, programme lead for integrat-ed community health services at NHS Kernow Clinical Commission-ing Group.
“We recognise that people don’t have just a medical, mental health or social care need. They need a multi-disciplinary team to work together.”
There’s also a commitment to rec-ognise the differences in each area and provide the right services in the place they are needed, rather than taking a blanket, one-size-fits-all approach.
And the big question health and care professionals are asking is changing from “What is the matter with you?” to “What matters to you?”.
“When you have that conversation it can lead to a very different pre-scription for what someone needs. Joining a local group like ‘knit and natter’ might have as much effect as medication if loneliness is the cause of someone’s depression,” adds Try-phaena.
There’s a growing opinion amongst professionals that the answer to people’s problems doesn’t always lie in a packet of pills and that being active and eating well are major influences of good health.
“If exercise were a pill it would be described as a miracle cure,” says Helen Charlesworth-May.
This premise is confirmed by Steve Brown, Cornwall Council’s deputy director of public health, who arrived from Devon County Council last October to re-energise the Health and Wellbeing Board and to produce a Health and Wellbeing Strategy, currently under review before general publication.
He says there’s a need to reframe the way we regard health and care overall.
“It is about thinking about the wellbeing of the person and asking questions about what does a good day look like for them,” he says.
“What determines whether you live a long and healthy life is not health care. We need to rebalance the wellbeing bit of health and well-being in order to improve the health of the population. The bulk of condi-tions we find are down to poverty and deprivation or lifestyle choices.”
The elements of wellbeing he cites are security, a place to live, a pur-pose in life and friends and family around you. Deprivation is a major issue. Around 35,000 households –12% of the population of Cornwall – live in the 20% most “deprived” com-munities in England.
Five behaviours that cause the county’s five major diseases:
- Physical inactivity
- Unhealthy eating and obesity
- Excess alcohol consumption
- Mental ill health, including lack of social connections
These are responsible for 75% of deaths and disabilities from:
- Heart disease and stroke
- Bone and joint conditions
- Mental health conditions
- Lung disease
“We know that depending on where you are born in Cornwall you can live a decade longer and in bet-ter health than someone else,” says Steve.
“It is really important that we talk about four-hour waits in the emer-gency department, but we have got kids who aren’t eating and people homeless on the streets. How can we shift that balance and get more of an equilibrium?
“And how do we shift from a medi-cal model of referring patients to ser-vices, which is something we have done for decades, to how we enable and connect people to assets that are permanent fixtures in our communi-ties?”
Dr Tamsyn Anderson, a GP at Newquay Health Centre as well as Director of Primary Care for the Cornwall Partnership NHS Founda-tion Trust and system clinical lead for Cornwall and the Isles of Scilly, has a broad overview from the coal face through to strategic planning.
“Lots of people’s issues are over-medicalised,” she says. “So much of our health is down to wellbeing, our social environment, how happy we are. You don’t get a lot of your happi-ness from going to the doctor’s sur-gery!
“We need to invest in our commu-nity services. As a statutory system we tend to prioritise the sickest in our environment. We need to move towards more prevention to engage with people and keep them well. We need to invest in local services to help people to stay well and happy.”
Mental health services locally have been operating a more integrated, community-based model for a long time, and community psychiatric nurses already work closely with Cornwall Council’s social care teams.
“You cannot address mental health without social care,” says Ellen Wilkinson, medical director at Cornwall Partnership NHS Founda-tion Trust. “This allows people to be treated while surrounded by friends and family and normal routines rather than taking them out of their everyday lives and putting them somewhere artificial, which has a whole series of problems associated with it.
“In some ways, mental health is at the leading edge of this kind of change. We have teams based up and down the county. Their respon-sibility is to keep that part of the pop-ulation mentally healthy. There are also specialist teams for things like perinatal, veterans and so on. Hospi-tal is for when those things have not worked. Some people will always need inpatient mental health care, but the goal is to manage people at home.”
She stresses the importance of integrating mental health care into the whole system, seeing and treat-ing people as a whole, rather than reacting to individual ailments or ill-nesses.
“People with physical health prob-lems will have a mental health reac-tion to those. People with long term physical conditions are more likely to have common mental health problems such as depression and anxiety. People also have medically unexplained physical health symp-toms that are manifestations of underlying stresses and anxieties,” says Ellen.
“People with mental health prob-lems – particularly more severe mental illness – have shorter lives, more physical illness and generally less access to health care. There is a 15-year gap in the life length of peo-ple with severe and enduring mental illness and it is not getting any better. It is caused by a whole range of health problems.”