Watchdog says 'significant work' needed to reduce pressure on urgent care in Cornwall
The Care Quality Commission carried out a series of inspections in April
Last updated 27th May 2022
Health watchdog, the Care Quality Commission, has found that significant work is needed to alleviate extreme pressure on urgent and emergency care services across Cornwall and the Isles of Scilly.
The CQC carried out a series of coordinated inspections in April across the new Cornwall and Isles of Scilly Integrated Care System, which has replaced the Clinical Commissioning Group.
These inspections were conducted to understand how services respond to the challenges they face as individual providers, but that require a system wide response.
They are also intended to support ICSs to better understand the journey people experience when seeking urgent care and identify where they can make improvements.
The CQC found that although many of the services inspected are individually well-run and providing safe care and effective service to people, a lack of joined up communication across the system has resulted in people facing lengthy delays as they wait for assessment and treatment.
It has now called for closer working between the healthcare organisations who commission and deliver care across the county, to ensure people are able to access the right urgent and emergency care, in the right place, at the right time.
As part of its review of the Cornwall and Isles of Scilly Integrated Care System, CQC inspected over 24 individual services across the system, including urgent and emergency care and medical services run by Royal Cornwall Hospital NHS Trust and Cornwall Partnership NHS Foundation Trust.
What did the inspections find?
The Care Quality Commission says across the board inspectors found:
• There were significant delays to people’s treatment across GP care, urgent care, 999 and hospital services which put people at risk of harm.
• GP practices reported concerns about significant delays in 999 responses for patients who were seriously unwell, resulting in GPs needing to provide emergency treatment or extended care while waiting for an ambulance.
• GPs also reported a shortage of district nurses in Cornwall and a lack of availability in mental health services, which resulted in people’s needs not being suitably met.
• Other services were only available in specific geographical areas and during particular times, making it challenging for front line ambulance crews to know what services they could access and when. In addition, ambulance staff were not always allowed to make referrals to alternative services. The complexity of these pathways often resulted in patients being conveyed to the emergency department.
• Urgent care services were available in the community, including urgent treatment centres and minor illness and injury units and these services were promoted across Cornwall. These services adapted where possible to the change in pressures across the county. When services experienced staffing issues, some units would be closed.
• When a decision was made to close a minor injury unit (MIU) the trust diverted patients to the nearest alternative MIU and updated the systems directory of services to reflect this. However, this carried a potential risk of increased waiting times in other minor injury units and of more people attending emergency departments to access treatment. This had been highlighted on the trust’s risk register.
• Hospital wards were frequently being adapted to meet changes in demand and due to the impact of COVID-19. There was a significant number of people who were medically fit for discharge but remaining in the hospital impacting on the care delivered to other patients. The hospital had created additional space to accommodate patients who were fit for discharge but were awaiting care packages in the community; however, staff were stretched to care for these patients.
• A care hotel has been established in Cornwall providing very short-term care for people with very low levels of care needs; this is working well for those who meet the criteria for staying in the hotel, however this is a relatively small number of people.
What improvements are being recommended?
Amanda Williams, CQC’s director of integrated care, inequalities and improvement, said: "During the inspections of the Cornwall and Isles of Scilly Integrated Care System, we found that performance remained poor across Cornwall despite all stakeholders, including healthcare providers, commissioners, and the local authority being aware of the challenges.
"It was clear the majority of the services we inspected were trying to provide good care. However, there was lack of cross organisational working which meant the system was under extreme pressure and struggling to meet people’s needs in a safe and timely way. We found significant delays to people’s treatment across all services, putting them at risk of harm.
"People tried to start their journey in primary care. However, both people using services and ambulance service staff trying to arrange it for patients, found it difficult to access GPs, dentists and mental health services. These patients then ended up at urgent and emergency care services because they couldn’t get help elsewhere. Staff working in these services treated those patients to the best of their ability, but it meant patients weren’t always receiving the right care in the right place.
"Staff across the system have been left feeling exhausted due to increased pressures, which has led to high levels of staff sickness and staff resignations. All sectors are struggling to fill vacant posts especially in adult social care. Staff shortages in social care across Cornwall, especially for nursing staff, are some of the highest seen in England. This had a knock-on effect on the next part of people’s journey through the system as it resulted in long delays for people waiting to leave hospital. This delay caused overcrowding and prolonged waits in the emergency department because of a lack of available beds. It also meant ambulance crews were facing long waits to get their patients into the emergency department so they could get back on the road.
"The reasons for delayed discharge from hospital are complex, but discharge processes need to be improved. Without significant improvement in patient flow and better collaborative working between health and social care services, it’s unlikely that patient safety and performance across urgent and emergency care will improve.
"Much closer partnership working and more effective communication between the emergency department and other local urgent centre services is needed, to help improve people’s experience of accessing urgent and emergency care.
"To help facilitate this, we are in regular contact with the local services involved, and we look forward to seeing the resulting improvements".
What is the response from Cornwall's health bosses?
Speaking on behalf of Cornwall and Isles of Scilly’s integrated care system, Chief Executive Officer Kate Shields said: "As CQC has recognised, health and care staff working across our system have worked incredibly hard and under challenging circumstances during the past two years to make sure people get the care they need, when they need it.
"There has been high demand for primary and secondary care, mental health services and adult social care. Alongside this we have delivered our successful vaccination programme, and responded to the peak in COVID-19 infections which affected both patients and our staff, at the same time as our usual winter pressures.
"This placed unprecedented strain across our services, and together we have worked to stretch and expand our services to support those needing our care. The pressure is most clearly seen in longer waits for ambulances and for patients to be admitted to hospital.
"I am pleased that since CQC’s visit we have been able to come out of our critical incident, which we achieved by working as 1 system and will continue to do so over coming months.
"The CQC clearly recognises our biggest challenge as an integrated care system is creating a sustainable workforce, with a particular focus on encouraging people to work in domiciliary and adult social care to support those want to be in their own homes.
"It is so rewarding to be able to help people to maintain their independence in familiar surroundings and I would encourage anyone who is looking to start a career, for a change in direction, or the next step on their career ladder to visit our proud to care website to find out more about the varied, flexible and secure jobs we can offer".