In this section, you can find out what action Healthwatch Cornwall has taken in response to feedback received. Alternatively, read about our ongoing work on the Our Work page.
Commissioners and providers that support Royal Cornwall Hospital Treliske’s Emergency Department (ED) have responded to our 12-hours in the ED report as below:
On Tuesday, May 31, 2016, Healthwatch Cornwall (HC) conducted a study of patient flow by surveying patients and people accompanying them in the Emergency Department (ED) at the Royal Cornwall Hospital (RCH). The purpose of this study was to try to pick up information that might not be currently captured and feed it into the groups attempting to improve patient flow.
The full report can be read on the Our Reports page.
Healthwatch Cornwall decided that further clarification was needed on the findings and worked with NHS Kernow, Cornwall Partnership Foundation Trust (CFT) and Royal Cornwall Hospitals Trust.
The questions asked and responses are below:
Q1. Why are so many patients attending the ED after accessing more than one service prior to doing so – could that number be reduced and how?
NHS Kernow response:–
Notwithstanding the limitations of the survey which was based on the responses gathered from 78 people on one day, the findings in the report echo other sources of feedback to NHS Kernow (CCG) that many patients try hard to seek out alternatives but often find that “all roads lead to the Emergency Department”.
Given the complexity of the out of hospital urgent care service, the reasons for this will be multiple and variable on different days and at different times. The CCG has established a ‘Demand Management Workstream’ reporting to the A&E Delivery Board to deliver an objective to increase the number of attractive and viable alternatives to the ED recognising that there are several opportunities to reduce the “failure demand” that sees people referred on to the ED unnecessarily. It includes the following projects:
- MIDOS Roll Out – an online directory (app) of service for use by Healthcare Professionals and, in time, the public
- MIU Resilience
- Minor Ailments and Emergency Supply Services
- 111 and Out of Hours Service Redesign
- Reducing 999 Conveyances
The Demand Management Group is represented by operational and clinical leads from across the urgent care system, including primary care.
Q2: Should patients who need an X-ray be admitted via the ED (as opposed to another area)?
Not all patients requiring an X-ray will need to be seen in the emergency department. Some patients are referred directly for clinical imaging by other healthcare providers, who will not require to be assessed, treated or admitted by the ED team.
Other patients with acute injuries or more pressing clinical conditions should be seen by the ED team to assess the extent of the acute injuries or clinical conditions.
Following assessment some of these patients may require some clinical imaging to be carried out and will either be discharged home from the ED or admitted into hospital under the care of other specialty teams for further treatment.
The ED is established to assess and treat patients in the acute phase of injuries and clinical conditions and signpost patients to other specialty teams as appropriate following initial assessments and investigations.
Q3. Do MIUs fulfil their purpose if they can neither be open during the busiest times for the ED nor treat suspected fractures or breaks?
We have reviewed the report to understand the exact issues that occurred on the day of the Healthwatch Cornwall review.
- On that day all MIUs were open for their full commissioned hours (8am – 10pm) except Helston which closed at 5pm rather than 8pm due to unexpected staff sickness. It is anticipated that the work on the Urgent and Emergency care priority of the STP will include a review of the current services.
- All RCH-facing MIUs have X-ray facilities except Helston who refer their patients to Camborne and Redruth Community Hospital (CRCH) for X-ray. X-ray services in the community hospitals are provided by RCHT and run from 9am to 5pm Monday to Friday with extended hours in CRCH and are supported by protocols around the type of X-ray that can be undertaken.
In order to fully assess suspected fractures X-ray facilities are crucial. The report contains a patient comment related to Falmouth X-ray being unable to take facial views. MIUs are able to refer for upper and lower limb X-rays only and not facial views.
This will also form part of the work undertaken by the STP priority group.
Q4. Can medical issues affecting tourists be dealt with in a better way/outside of the ED?
NHS Kernow response:–
The work of the Demand Management working group is designed to reduce all ED attendances from people in Cornwall, including residents and those visiting the area. Targeted communications are already issued every year to areas where visitors are likely to go, including service stations, campsites and other tourist destinations. There is always room for improvement and we will continue to expand and refine our communications every year.
Q5. Are other services being over cautious when telling patients to come to the ED for observation?
NHS Kernow response:–
A definition of ‘other services’ and a detailed clinical audit would be required to answer this question. However, as a general principle we know that when patients speak to experienced clinicians in any service, either on the phone or in person, they are less likely to be referred on to EDs. This is the rationale behind new targets being set of the A&E Delivery Board. For example, to increase the number of 111 calls that are referred on to a 111 Clinician.
Q6. Is the ED the most appropriate place for patients to come if another medical professional thinks they need a second opinion?
NHS Kernow response:–
A definition of ‘another medical professional’ and a clinical audit would be required to answer this question fully. Some services such as MIUs have protocols in place stating when patients should be referred on to the ED. We are aware that some professionals are not aware of all the alternatives to the ED and that is where we see innovations like the MIDOS app making a difference because this will allow healthcare professionals to quickly identify local alternatives for given conditions.
Q7. Why are patients who are referred to the ED by other services waiting in the general waiting area when there is an ambulatory care area waiting area with a lot of unused space?
Patients referred by other health care providers to the ED for treatment and review will use the ED waiting area. The ambulatory emergency care waiting area is for those ambulatory patients referred to and accepted on the medical take by the acute physicians/acute GP service. The ED does at times transfer patients to ambulatory care if clinically appropriate.
Q8. Why does there seem to be a relative high number of people from Camborne Redruth?
We have reviewed the report to understand the exact issues that occurred on the day of the Healthwatch Cornwall review.
According to the report (p.12) six patients had been referred to RCH ED by CRCH MIU. On review of the attendance data it shows that of the 60 patients seen and treated in CRCH MIU during that 12-hour period only two were referred on to the ED. On both occasions this was because their illness/injury was potentially life-threatening. On that day the GP service did finish at 5pm, but analysis of the attendances by experienced clinicians clearly demonstrates the two referrals to ED were highly appropriate and the care needed could not be safely delivered in the community.
The data shows that CRCH see a higher proportion of people in the MIU and their conveyance rates are low compared to the numbers of people treated.
On this day the RCH-facing MIUs (Helston/CRCH/Falmouth/Bodmin/St Austell/Newquay) saw a total of 241 patients between them. The referral rate to ED from each of these mirrors that of CRCHs.
From the data MIUs play a significant part in the treatment of patients seeking emergency care and substantially reduced the pressure on RCH ED. There is always further work that can be undertaken and the service will look to work with system partners to address any issues and plan a cycle of continuous improvement.
Q9. Can the environment in the main waiting room be changed to improve the mood of the patients and those waiting with them?
We have invested in new seating and the reception area has been decorated. The area has two toilets, three vending machines and two televisions for patient use. At the present time there is no additional Trust funding allocated to further improvements. However, we would welcome input from patient groups or their representatives to improve the patient experience in this area within existing funding arrangements.
You can read our press release on the News page too.
We are currently working to bring to a close our work relating to patient flow/emergency care and St Austell Healthcare.
Following the conclusion of our research into issues relating to St Austell Healthcare we offered to produce a short information film about our recommendations and subsequent improvements.
We also ran a survey at surveymonkey.co.uk/r/staustellhc to find out more.
In early April 2016, we spoke with the practice to find out their viewpoint. They informed us that the appointment system at the centre changed on April 1 and that now, after triage, appointments should be made within five days, with 180-200 appointments available each day.
The practice said it was also reviewing staffing at the urgent care hub (Polkyth) and will be recruiting to replace retiring GPs and cover hours where some GPs have reduced these.
SAH receives approx. 16,000 calls per month – which equates to half the registered patients calling – which they say is far above expected averages. They confirmed they have the recommended number of lines for their volume of patients. However, there have been repeated technical issues with the phones but the practice has said these are working well currently. There are 10 receptionists employed, 14-15 at peak times, with the average wait three to four minutes.
There is an additional landline for referral queries and for prescription enquiries.
Prescriptions are now mostly electronic and sent to pharmacy. Only 10-15% now are paper, although some controlled drugs have to be paper. Repeat requests are turned around within three days.
They told us there are new clinics; ophthalmology starting mid April 2016 and stable glaucoma and macular degeneration for two days a week at Wheal Northey.
A number of support groups such as diabetes, long-term conditions, mental health and communication are also run out of SAH.
The practice also said that a number of people per month are not attending appointments (Did Not Attend – DNA), and that in February 2016 there were 750 DNAs. They urge people to cancel appointments if they cannot attend. A text reminder system has been introduced for adults who have provided their mobile number and these people can cancel by text.
Visit staustellhealthcare.co.uk for more information.
Healthwatch Cornwall’s Chief Executive Debbie Pritchard said: “We are aware of how hard everyone at the practice is working, and the improvements and changes being made to rectify issues.
“As a publicly accountable body, Healthwatch Cornwall has a duty to respond to concerns brought to our attention and hope this new survey will help inform the delivery of services.”
Our survey closed on April 22. As of April 12, more than 170 responses had been made via SurveyMonkey alone.
We have also queried NHS Kernow’s decision to end funding for gluten free food on prescription following a number of comments received from worried Coeliacs. Our questions, and NHS Kernow’s response, is below:
How was the public online consultation for this proposal publicised?
The public engagement was advertised using the following methods:
• The consultation document was published on NHS Kernow’s website. From 28 June to 12 August, there were 658 unique page views of the gluten free consultation web page, of which 191 page views were from Facebook and 52 page views were from Twitter.
• A carousel slide was created for the home page of NHS Kernow’s website, which allowed people to click straight to the consultation document. for the duration of the consultation. This was available from 28 June to 13 August.
• A press release was issued to the local media, which generated significant media coverage, including BBC Radio Cornwall and the West Briton; Western Morning News; Cornishman and Cornish Guardian, as well as their online editions.
• A press release was also published on NHS Kernow’s website, which generated 51 unique page views from 28 June to 13 August 2016.
• A link to the consultation was promoted on Facebook and Twitter, which generated 191 page views from Facebook and 52 page views from Twitter:
• A range of statutory sector and voluntary sector stakeholders were directly notified of the engagement, with a request that they use their own networks to cascade news about the public engagement. Healthwatch Cornwall and Healthwatch Isles of Scilly were both included in this – (Healthwatch Cornwall promoted the survey in its June newsletter).
• Coeliac UK were notified, and we understand that they kindly notified their Cornwall members of the engagement
• Community pharmacists actively encouraged patients to participate in the consultation and complete the survey.
How many people responded?
607 responses were received, comprising:
• 555 online surveys completed
• 41 hard copy surveys returned
• 6 letters received
• 3 telephone calls
• 2 emails
This paragraph is from Coeliac UK’s website. Is the statement correct?
“While the CCG have made this decision, we would like to stress that the final decision about what to prescribe lies with your GP. We would therefore encourage you to have a discussion with your GP about gluten-free food on prescription if you are concerned about the impact this may have on you.”
The statement is correct, and NHS Kernow has today (November 29) written to GPs to ensure that there is clarity on this point. What NHS Kernow can and will do is strongly support GPs discussion with patients on alternative diets and purchasing in supermarkets etc. We have produced a patient leaflet that provides useful information for people with coeliacs disease. This leaflet is available both online for GPs and patients to download and printed copies will also be available:
If so, can you please explain which commissioning organisation would fund the prescriptions in question?
It has long been recognised that the most difficult judgements in relation to gluten free food would concern patients with a confirmed diagnosis of coeliac disease or dermatitis herpetiformis. GPs may be assured that the CCG will support them in whatever decisions they have to make in this regard but, if a GP did write a prescription it would come out of the NHS Kernow prescribing budget.
In order to ensure GPs have all the relevant information to hand, we have however agreed with Coeliac UK to direct prescribers’ attention to the organisation’s guidelines published on its national website so these may be considered alongside this CCG’s policy. A link is provided below:
As a membership organisation, NHS Kernow will always continue to support GPs who seek to enact its decisions in good faith and in the best interests of patients.
Also, is this the case for both new and recurrent prescriptions and if only for one, which?
This would be the case for both new and recurrent prescriptions.
We hope this provides some clarity for those people who contacted us about their concerns and provides detail for anyone newly diagnosed. If you wish to comment further, please complete a Have Your Say feedback form or call 0800 0381 281.
St Austell Healthcare (SAH)
Following our report looking at patient feedback relating to SAH, the practice has responded to our eight recommendations. Read the full report at: healthwatchcornwall.co.uk/our-work/our-reports/
You can download SAH’s response here:
St Austell Healthcare responds to Healthwatch Cornwall recommendations
We will now review the response as part of our ongoing work with SAH.
NHS Kernow has told us that the orthotic back office service (appointments, referrals, orders etc.) has transferred from Disability Cornwall to Steepers from May 3.
Carol Clark, NHS Kernow’s Engagement and Inclusion Lead said: “This is an operational move only and will not detrimentally affect the service provided to patients. Our intention is in fact that it will improve the service as the communication between the Leeds factory and the Cornwall orthotic service should be much more effective once they are part of the same organisation.”
Healthwatch Cornwall has received a reply to our End-of-Life Care Report sent to commissioners after our A Good Death Conference in January 2016.
The response sets out how the sector is acting on our recommendations and progressing with collaborative working, to better provide a seamless service and information at what can be a very difficult time for patients and family.
An End-of-Life Strategy Group is being assembled to hold its first meeting in May, under the clinical lead Tamsyn Anderson. We have been invited to attend this group, which will help in monitoring and reporting on progress made.
Dr Matt Boulter is leading on a whole system IT project, starting with a single care plan, which was a clear message from the conference. NHS Kernow is bidding for funds to support a web-based IT package that will be accessible to all parties, including patients. This system should also be able to improve registration of death, which is currently causing some frustration for care providers.
In the meantime clinicians are reviewing the Treatment Escalation plans (TEPS) to adopt these across the whole system, instead of having a variety of different care plans.
An audit is being undertaken to consider demand for 24-hour nursing across the system and in the end-of-life pathway. We are told that different working arrangements with the new consortium that has taken over community services should facilitate this and that this consortium is prioritising end-of-life care.
Healthwatch Cornwall has been asked to support the further development of a Charter and work with public health on advanced end-of-life planning awareness raising.
Healthwatch Cornwall heard from patients experiencing difficulties with the county’s orthotic service. You can read the report and other information on the You Said – We Did 2015 page.
NHS Kernow has now responded to our recommendations. The clinical commissioning group acknowledge a number of issues had blighted the service but these were all be dealt with and the director of commissioning is confident of good long-term solutions.
They highlighted that a larger than expected waiting list and staff capacity had impacted on the service since 2014 when changes in administration were made. They confirmed that repairs should not take more than a few weeks but replacement equipment is contracted out to a third party for manufacturing and this process therefore takes longer. The service can only provide equipment from approved suppliers but it has introduced key performance indicators to monitor delivery times. NHS Kernow also stated that existing patients would not need a clinical referral for ongoing care and, to help manage patient expectations, it provided an update on the orthotics service to all GPs via its GP newsletter in January 2016. It also informed us that it uses the term ‘trial fit’ so people have time to make sure the equipment is suitable, comfortable and meets their needs.
In relation to new NHS England service specification model for orthotics, NHS Kernow pointed out it had concerns relating to the expectation to deliver within 25 working days, or five weeks, rather than the standard 18; that workshops are made available on-site; that the range of orthotics provided is increased to included stock items; and that the service can be extended to provide lycra garments, which could have a substantial financial impact without any clear clinical evidence of efficacy.
Drilling down, NHS Kernow said the new NHS England specification model contains referral to assessment times within 15 working days of referral, but it offers an assessment within 10 working days for urgent cases and 30 working days for non-urgent.
It said to achieve fitting times within 10 working days after the order being placed for 90% of the equipment (as the new specifications) would require significant investment to “incentivise the provider to deliver within this time”. NHS Kernow confirm that this is unlikely to be approved locally as nationally the orthotic service is only required to deliver within the 18 week Referral to Treatment pathway.
And although part of NHS England’s new specification model, late and weekend opening times are unlikely to go ahead as current local service specification does not include this and, again, would require investment; on-site repairs are not possible as there are no orthotics workshops at any of the county’s clinical venues; temporary devices and stock items such as wrist splints etc. are not provided by the Cornwall orthotics service, which provides bespoke, specialist items only; and training ward staff is not applicable as the Cornwall service is a chronic community service and is not based in hospital.
NHS Kernow acknowledged that severe floods had badly affected the equipment factory in December 2015 and therefore the supply of orthoses were significantly affected. Approximately 400 people in Cornwall were directly affected and may have had to wait longer than expected for their orthoses. This will see a downturn in meeting the referral to treatment times after December 2015. There is a mitigation plan underway in Cornwall which includes a locum orthotist providing more clinic time for those people who need to be recast, extended existing clinics, the equipment provider sub-contracting out equipment supply where possible and the escalation of production in another factory. The CCG has written to all patients who may have been affected by this unfortunate event and many of these people are now booked in for follow up clinics.
Cardew closure – what we did
Since the news about the proposed closure of the Cardrew Health Centre became public earlier this year, Healthwatch Cornwall has received some feedback about patients facing difficulties finding a new GP.
As the Centre was one of our 12 Days of Christmas Stars, and was awarded a certificate for being one of our top three organisations to have received positive feedback during 2015, the plan to end its valuable contribution has saddened Healthwatch Cornwall.
Regardless of the future outcome it was reassuring to see that the Health and Social Care Scrutiny Committee evaluated the decision on Tuesday, April 2.
Healthwatch Cornwall was asked to provided examples of the feedback it has received so far to the Committee, which included comments collected at the centre on April 4.
The details of the Committee meeting can be found at democracy.cornwall.gov.uk
Healthwatch Cornwall attended and understands the Committee agreed it had enough information on this now and would leave it to NHS England to manage.
To read the Extraordinary Health and Adult Social Care Scrutiny Committee notes from March 11, visit:
To read a news story, visit:
Devolution decisions – your input
Healthwatch Cornwall supported Cornwall Council, the Council of the Isles of Scilly and NHS Kernow to gather feedback from the public to help develop a plan for the whole health and social care system, which is both clinically and financially sustainable.
Early in 2015, Healthwatch Cornwall was contacted by five people who reported a less than optimum experience when they needed to access either emergency or elected care services relating to spinal injuries at Royal Cornwall Hospital’s Trust. They reported feelings of vulnerability with current arrangements.
Their interest in raising these issues was to improve practice for other similarly affected individuals.
The main concerns were:
- Lack of awareness of Autonomic Dysreflexia (AD), which is a sudden and uncontrollable rise in blood pressure that can be caused by a number of factors including a full bowel, nutrition, pressure ulcers and which can be life threatening if intervention is not quick and competent. They cited the need for regular manual bowel evacuation to prevent the possibility of AD.
- Lack of consideration of care requirements for patients with spinal cord injury (SCI) specifically:
- The need for regular turning to prevent pressure sores
- Support required for transfer and for feeding/drinking while receiving secondary care
- Appropriate transport and means of transportation when attending or leaving hospital
- Tissue viability risk for SCI patients due to reduced mobility
- Lack of awareness of the advice that could be given by the Spinal Unit concerning the individual patient.
These concerns were reported to Royal Cornwall Hospital Trust in March 2015 and a meeting held in April. A number of improvements were agreed and Healthwatch Cornwall has now received formal communication from RCHT which sums these up.
In brief, a number of guides have been developed for staff specifically for SCI patients on Manual Handling, Autonomic Dysreflexia, Pressure Area Care, Venous Thromboembolism, Bowel Management, Bladder Management and Community Liaison. These will be available to staff online from mid-January 2016.
The Carer’s Policy has been revised and a Carer’s Passport introduced to extend permissions for carers to stay and care outside visiting times.
A list of staff who can offer specialist advice has been developed and is being added to and is available to staff.
Patients should now have SCI Passports giving detail of their specific requirements that RCHT are committed to supporting.
Read the full response below.
Healthwatch Cornwall would like to thank the individuals who raised these concerns with us and Frazer Underwood and Kathy Smith from RCHT who made this happen.