A RESPONSE from the UK Health and Social Care Secretary is due this week on what action will be taken to prevent future deaths linked to ambulance delays in Cornwall.
In November 2023, Cornwall’s senior coroners set out how a lack of provision in Adult Social Care was the underlying reason behind why ambulance response times were way beyond target and delays in handing patients over from ambulances to the emergency wards.
At the start of 2024, ambulance handover times at Derriford had been the worst in England for three weeks running, with those waiting to be admitted to Treliske in Truro experiencing the third worst delays in the country.
In their letter to Secretary of State Victoria Atkins, senior coroner Andrew Cox and assistant coroner Guy Davies also cited staff burnout and difficulty in recruiting to vacant positions in Treliske as factors having a knock-on effect to ambulance delays.
The coroners had prepared four ‘Preventing Future Deaths’ reports, each linked to a person in Cornwall who had died in the previous two years. Long ambulance response times and delays outside the hospital door were named as a contributing factor in their deaths. The patients had waited between 16 and 24 hours between calling 999 and being admitted to the emergency ward at Treliske.
Kenneth Heard, who suffered a major heart attack in July 2022, waited for an ambulance for more than 10 hours after a call to 999. The inquest report described how early treatment within two hours of a heart attack leads to a 95% survival rate, and found that it was ‘more likely than not that Kenneth would have survived had it not been for the ambulance delay’.
In a letter to MP Victoria Atkins, Mr Cox said that the circumstances around the deaths of Mr Heard, Patricia Steggles, Pauline Humphries and John Seagrove were not one-offs, but part of a long-standing situation.
“I wrote a Preventing Future Deaths report to your predecessor just over a year ago setting out details of four deaths that had arisen in similar circumstances. During the course of these inquests, the evidence has revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. It is my statutory duty to report to you.”
In his Preventing Future Deaths report, assistant coroner Guy Davies wrote: “The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.
“It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision.
“This means that wards are accommodating patients who would otherwise be discharged.”
In his stark and strongly-worded letter to the Health and Social Care Secretary, copied in to the ambulance trust and the Royal Cornwall Hospitals Trust, Mr Cox places the responsibility for improving the situation squarely with government.
“The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix,” he writes.
“They are too big for either the hospital trust or the ambulance trust to fix on their own. It is for you and your department to take the action that is required to resolve the issues and to prevent future patients in the area from dying avoidable deaths.”
The Secretary of State is due to formally respond to the coroner’s letter at the end of this week.
At the time of the reports, the Cornwall and Isles of Scilly Integrated Care System said that it was working hard to improve ambulance response times and delays at the emergency department “but acknowledged there was still more to do”.
The latest report on Cornwall’s health system performance was presented to the Integrated Care Board (NHS leaders in Cornwall) in mid December, and considered by Cornwall Councillors on the Health Scrutiny Committee last week.
At the time of publishing, Urgent and Emergency Care facilities had been “extremely challenged” and in OPEL 4 status for several days, (OPEL 4 meaning the system is under severe pressure, unable to deliver comprehensive care, and putting patient safety at risk).
The wider picture during 2023 set out in the report shows that Cornwall’s Urgent and Emergency Care (UEC) system is performing badly in comparison with others in the country. Ranked 36/42 in the country overall, Cornwall’s UEC was in the lowest quartile for five out of the six criteria used to measure how urgent and emergency care is faring.
“Recognising the very real risk of increased harm and mortality over the winter period,” the report states, “….[there is a] focus on keeping frail patients at home or in the community wherever safe and appropriate to do so, enhancing primary care services and care coordination services.”
A focus would be placed on enabling Health and Social Care professionals to work together better to manage the safe and timely discharge of patients from hospital, said the report, and enabling Community Assessment Treatment Units in Bodmin, Camborne and West Cornwall to meet the daily demands of frail and vulnerable patients, avoiding the need for them to go into an acute bed.
It was expected that the ambulance handover times and response times would improve significantly into the New Year as these interventions took positive effect, said the report.
For the population as a whole over the winter months, said the ICS, the focus for the health and care system would be on providing as much care as possible in people’s own homes or in the community, so that only those most acutely unwell or injured need to come to the main hospitals.
‘Virtual wards’, where people can be remotely monitored at home, community health hubs and putting additional resources into care and support packages would play an important role.
Residents could help too, said the ICS, by “considering carefully which services were most appropriate for their needs, and making use where possible of self-care, pharmacies, or minor injury units”.
Funding totalling £50-million was invested in 2023 in new ambulance hubs and discharge lounges — facilities which the government says will cut emergency and urgent waiting times for thousands of people in the country.
The six ambulance hubs will ‘cut out unnecessary delays’ getting emergency vehicles back on the road more quickly, it says.
Meanwhile 42 new discharge lounges will free up hospital beds, providing a comfortable environment for patients about to return home.
In Plymouth, the University Hospitals NHS Trust received £3-million to purchase the Clearbrook Manor Nursing Home to be used for out of hospital care. Mount Gould Hospital received £5-million to open two new discharge wards for people with complex needs.
At Derriford Hospital, the Accident and Emergency Department is to be significantly expanded and upgraded — this will be the first phase of a ten-year plan of improvements to health facilities at the hospital and in the city.
The new-build element will contain new emergency department facilities, a Same-day Emergency Care facility (SDEC), imaging facilities, interventional radiology, training facilities, staff rest and welfare, and emergency surgery theatres.
But what about Adult Social Care?
The National Audit Office — the UK’s public spending watchdog — has said that the government’s plans for reform of the Adult Social Care Sector are in ‘disarray’ with a budget of £1.7-billion pledged in 2021 now cut by more than half.
Key changes, including plans to develop the workforce, have been scaled back. Currently, around 10 per cent of social care vacancies in the country remain unfilled.
One in six local authorities expect demand for adult social care to exceed capacity this winter, said the National Audit Office (NAO), and as of March 2023, around 82, 00 people were waiting more than six months for a care assessment — nearly double what this was at the end of 2021.
In response to the NAO’s comments, the Department for Health and Social Care said that it had made £570-million available to help local authorities improve adult social care provision, in particular by boosting the workforce.
In Cornwall, says councillor Colin Martin, Adult Social Care is a ‘bottomless pit’ into which money from other parts of the local authority’s budget is repeatedly siphoned to address crises.
Cllr Martin is Cornwall councillor for Lostwithiel and Lanreath, leader of the Lib Dems on the council, and sits on the local authority’s Health Scrutiny Committee.
On the day we spoke to him about the ambulance delays, Cllr Martin had been at Treliske where there had been 18 ambulances queuing outside the hospital, with 80 patients in the emergency department — a not untypical scene.
He believes the answer has to lie not in short term emergency fixes, but in longer term investment in preventative care.
“Ambulance delays is a story that people hear about in the news all the time. People might tend to say this is just a national problem, and that Cornwall isn’t any worse than anywhere else. But while the national situation is dire, Cornwall has got a significantly worse problem than other areas.”
The extreme pressures in adult social care have a knock-on effect to available ward space in hospitals and on to ambulance handover times. Contributing to Cornwall’s unique situation is that the county has a relatively older population.
There are problems recruiting and retaining staff in adult social care in Cornwall, and this has been exacerbated by the cost of living increases and the ability of the retail sector to offer higher wages, he argues.
The Lib Dems say they would introduce a minimum social care wage of £2 per hour above the national living wage of £10.42, in order to help address the staffing gap and the resultant pressure on the NHS.
For Cllr Martin, longer term investment is needed within a truly integrated care system.
The ICS, launched in 2022, still has a way to go before it is truly providing the ‘seamless service across health and social care’ that has been promised, he says — but he adds that the system is more joined up than it was.
“The system itself is joined up but it’s the relationships between leaders of organisations that matter most, more than the charts and diagrams.”
Health system leaders are under constant pressure to reduce ambulance waiting times but if people are focusing on the most visible end of the problem – the ambulance delays, then that’s taking their attention away from the underlying causes, Cllr Martin feels.
“The analogy is that the boat is sinking but the person who’s fixing the leak keeps having to stop what they’re doing to explain to the captain why the crew is experiencing a bucket shortage!”
“We don’t need more ambulances; we need to help people get out of hospital more easily, and to prevent people from going into hospital in the first place.”
Money spent in health can broadly be split into five categories: preventative, early intervention, cure, management and crisis.
“I feel we should put a label on every £1 that is spent in the NHS and every time we put money into ‘crisis’ we should put a proportionate amount into preventative and early intervention. If you can find £200-million for easing winter pressures, then you can find money for the stuff at the other end of the scale. We know that money spent on prevention and early intervention saves money five, ten, twenty times over later on. But whenever the government provides extra cash, they insist that is spent on tackling today’s crisis rather than preventing tomorrow’s.”
Many illnesses and conditions that lead to hospital admissions, such as breathing and circulation related conditions, can be prevented or managed early with lifestyle changes and exercise.
Social prescribing is part of the integrated care system approach whereby beneficial activities in the community can be prescribed to a patient. But how money is allocated is the issue.
“At the moment a £50 inhaler can be obtained on the NHS, but if a social prescriber suggests that a person would benefit from say a weekly walking football group, there is no money to pay for this — either to give to the patient or to the organisation running the group.”
One key issue which must be grappled with in order to see these problem resolved, says Cllr Martin, is the way in which the finances are run and how decisions are made on spending. We have an integrated care system but the system itself has no budget of its own — Cornwall’s health system and the local authority each have their budgets which are set and organised separately. While social care comes from Council Tax, the health part comes from the government.
The problems are compounded by the debt which Cornwall’s NHS carries — the government has promised to cancel some of this debt if local managers cut current spending.
“Local leaders are being coerced into making short-sighted cuts to give the Government a positive pre-election headline.
“Nationally we hear that there are record amounts of spending in the NHS but outcomes are getting worse, so just spending money isn’t working, we need to think about where that money is being spent.”