About the Author: Dr Peter Levin, lives in Penzance. He taught social policy at the London School of Economics for 25 years, books include Making Social Policy: The Mechanisms of Government and Politics and How to Investigate Them and the best-selling Student-Friendly Guides (including Write Great Essays! and Excellent Dissertations!), all published by Open University Press.
Comment & Opinion
Work on the Sustainability and Transformation Plan for health and social care in Cornwall and the Isles of Scilly, now rebranded as Shaping Our Future, has reached a critical stage.
We risk being gulled into earnest round-table discussions under the guise of ‘engagement’ while an organizational bulldozer lightly camouflaged with poor quality information lumbers towards us. Community hospitals are under threat and it appears that decisions may be being taken on scrappy information and limited understanding.
In July half-a-dozen ‘local area workshops’ were held across Cornwall. They brought together people from three groups: people who work in the health and social care services, people who work for voluntary bodies (the ‘third sector’) in delivering those services, and people who have recently received support from these services, or their full-time carers. The term ‘co-production’ is sometimes used as shorthand for working-together endeavours of this kind.
So patients and carers have sat round a table with service providers and members of voluntary organizations, and (as I have witnessed) some worthwhile exchanges have taken place. At the time of writing this, we wait to see what written records emerge from these exchanges and how frankly they reflect them. And, importantly, what can be built on them.
At each local area workshop, an information pack was handed out. It included a section on ‘The case for change’, and here we find four snippets of quantitative data on hospital services (p.5):
(1) ‘Around 60 people each day are staying in acute hospital beds in Cornwall and they don’t need to be there.’
This statement could be extremely misleading, because it does not necessarily follow that people who no longer need acute treatment are fit to go home, although this seems to be the conclusion we are intended to draw. It may be that many of these people are awaiting transfer to a community hospital. Evidently the Royal Cornwall Hospitals Trust does not collect data on the fitness of patients for a particular destination. It exists within its own ‘silo’, not looking beyond its own boundaries, so we are given this number out of context. Also we aren’t told what date or period the figure of 60 people refers to: it is a snapshot taken at an unspecified time.
(2) ‘35% of community hospital bed days are being used by people who are fit to leave.’
Similarly, we are not told what destinations the people in community hospital beds who are judged ‘fit to leave’ are fit to go to, or on what date or over which period this percentage figure was gathered.
(3) ‘83% of admissions to community hospitals are from acute services compared to 42% nationally.’
While this statement does recognise the connection between acute and community hospitals, and it does provide a national comparison (though we aren’t told whether ‘national’ denotes England, Great Britain or the UK), we could draw quite different inferences from it.
We could infer that community hospitals are coming under greater pressure in Cornwall than elsewhere to take patients who have been discharged following acute treatment, and conclude from this that Cornwall needs more community hospital beds or more provision in care homes and/or people’s own homes.
Or we could infer that among the ‘national’ population there is a need for care that is different from ‘step-down’ (rehabilitation) from acute treatment, and that in other parts of the country this need is being met by community hospitals, whereas in Cornwall the community hospitals are close to being monopolized by patients moving out of the acute hospital at Treliske.
Maybe part of the pressure that we know is experienced by the Emergency Department at Treliske comes from patients who, elsewhere, would be admitted directly into a community hospital. Again, we could conclude that Cornwall needs more community hospital beds.
(4) ‘62% of hospital bed days are occupied by people over 65 years old.
It is impossible to draw any sensible conclusion at all from this piece of information. We are given nothing to compare it with. We aren’t told whether this figure applies to Cornwall & IoS only or to a larger area, and when, or whether the proportion has increased over recent years. 65 years was formerly the state pension age in the UK for men. For women state pension age was formerly 60. At present those ages are in the process of being both raised and equalized, so the very benchmark of 65 years seems entirely arbitrary.
As we see, the information presented in the information pack to justify reorganizing our hospitals – a mere four statistics – is of extremely poor quality. It is scanty and arbitrary. It is silo-dominated, and indeed it could be taken to imply that managers do not care where discharged patients go so long as they vacate their beds. The fact that acute hospitals count numbers of patients while community hospitals count percentages (another silo effect) makes it very difficult to compare the stress that they are under.
Moreover, the information presented is in the form of snapshots. These represent situations at particular points in time or over particular periods. We are not told at what particular points in time, or over what particular periods, the data were collected. This is not good professional practice. And such truncated information ignores dynamics, how situations change over time, and – importantly – it largely ignores processes that link organizations together, such as the movements of patients through the health and social care system. Failing to state the sources of data or the relevant dates or periods it applies to is an unprofessional way of managing and presenting information.
As a basis for taking decisions, information of this calibre is not fit for purpose and is likely to pull wool over the eyes of people who don’t have specialized knowledge. It is not the demonstrated outcome of careful research, and no serious reasoning from it is presented. So we may conclude that it is offered to support a case, to sell a message, the message seemingly being that Cornwall is over-supplied with community hospital beds and consequently some community hospitals should be closed.
At Transformation Board level there is no shortage of expressions of goodwill towards public engagement and co-production. But it may be that in some quarters this is seen as a useful manipulative tool, a means of ‘selling the message’ and ‘nobbling’ influential lay people so they won’t be obstructive when proposals are published. Tellingly, among the proposals for reorganizing the SOF enterprise there is no mention of a co-production delivery group. And the two engagement specialists who have been brought in from regional level have been given the absolute bare minimum of support staff. Judged on these criteria, within the SOF set-up engagement and co-production have a very low priority indeed.
The quality of the information packs on the subject of how the system works is so abysmally poor, although lavishly illustrated, that it could be taken to indicate either incompetence, i.e. a lack of appreciation of what data are significant and why, or, more sinisterly, an attempt to coerce the reader into conceding without quibble that a case has been made for change. A third possible explanation for these poor quality scraps of information on hospital services presented to the public in the information pack may simply be that they were deemed good enough for us. If that was so, it indicates an attitude of condescension, if not contempt, towards the public. This can only breed suspicion and contempt in return: not a healthy state of affairs for our society and no basis for genuine co-production
At the head of the Shaping Our Future (SOF) operation is the Transformation Board, which has 20-plus members, mainly appointed as representatives of various organizations. The key members are Kate Kennally (Chief Executive, Cornwall Council), who is in the chair; Kathy Byrne (Chief Executive, Royal Cornwall Hospitals NHS Trust); Phil Confue (Chief Executive, Cornwall Partnership Foundation NHS Trust); and Jackie Pendleton (Interim Chief Officer, Kernow Clinical Commissioning Group).
Until recently the Transformation Board met every month, but as from May 2017 it will meet only every two months. The papers that are presented to the Board are not published, and nor are the minutes of its meetings until they have been approved by the following meeting, so it can be the best part of four months before the public gets to know what was on the agenda and what was agreed. (The latest minutes currently available are those of the May 2017 meeting.) It appears, then, that the four leading members will have considerable autonomy.
At the May 2017 meeting of the Transformation Board it was reported, under the heading of ‘Communications and engagement strategy: co-production plan’, that ‘senior communication and engagement support had been secured … with a view to them taking over the strategic lead for this work’. This refers to the secondment to SOF of the current NHS Regional Head of Stakeholder Engagement and the Regional Head of Communications and Engagement Specialist Projects. The minutes also record that ‘[there] was full support from Transformation Board members for the co-production approach’. And Jackie Pendleton of KCCG is recorded as saying: ‘It is important to be able to give answers to questions raised in the first phase of events to show the public that we have listened and we will continue to listen.’
While we might take encouragement from this, other items recorded in the minutes of the May meeting are worrying. We learn that the leading Board members want to be a ‘first wave Accountable Care System’ and have put in an application to NHS England to that effect. And we learn that it was proposed to establish two ‘delivery groups’ (‘Model of Care’ and ‘System Reform’), and that the ‘Programme Board’ was to be renamed the ‘Portfolio Board’, ‘to reflect the scale and scope of work’. No mention is made of publishing the minutes of these bodies. In a nutshell, this is all about fashioning the organizational bulldozer.
The local area workshops have shown that when people talk about their experiences of health and social care services they are invariably telling a story. One of the great values of stories, along with their authenticity (the fact that they represent genuine experiences as recounted by the people who experienced them) is that they are dynamic. Unlike the information presented as snapshots in the information pack, they tell us what took place over a period of time and how the different parts of the system interacted with one another. It follows that those in charge of ‘engagement’ have the task of finding a way of taking these stories and using them, drawing lessons that can be fed into the planning process.
Within the Transformation Board, some transformation needs to take place. Halving the number of meetings, holding meetings in private, not publishing the agenda in advance and the minutes for several months after the meeting: these are characteristics of a body that is uncomfortable with transparency and shuns the light. It and the people working for it seem to be more concerned with securing power, autonomy and status than with doing a good job for the public they ostensibly serve. For starters, let us have more transparency and let us have a co-production delivery group.
7 Aug 2017