Please can you confirm the commissioning arrangements for earwax removal in GP practices in Cornwall? We understand that the NICE guidance recommends earwax removal by micro suction or electronic ear irrigation rather than traditional syringing; but we have been advised that not all practices have the equipment and deliver these services. What are you doing to ensure that earwax removal remains an NHS-funded service for the many patients in Cornwall who require this treatment at their local practice?
GPs across Cornwall and the Isles of Scilly have historically provided ear wax removal via ear irrigation, sometimes called syringing by mistake. None of our practices perform manual syringing as it is contraindicated and only a handful have ever provided microsuction.
In terms of commissioning arrangements it is not explicit in the national GP contract that GPs need to provide this to their practice population. Early in the year we identified that 48 practices were still providing some sort of a wax removal services, but as this is classed as an ‘aerosol inducing procedure’, many more are now not performing because of the associated COVID-19 risk.
Feedback has suggested that people with earwax tend to seek treatment in the form of a procedure. For example ear irrigation or microsuction. Having not given sufficient enough time for first line treatment with ear softeners. Wax softeners take anywhere between 4 to 6 weeks to work. We have therefore been working with the ENT consultants and GP leads to finalise a patient/GP information leaflet that gives consistent information to patients about treatment with softeners. The majority of people with ear wax removal should never need a procedure to remove it.
In regards to the supplementary question raised about the secondary care service, NHS Kernow commissions the Royal Cornwall Hospitals NHS Trust (RCHT) to provide an aural care service within the ear, nose and throat (ENT) speciality. This nurse led service is not only designed to see people needing complex ear wax removal via microsuction but supports our ENT consultants by seeing people with ear conditions such as active infection and disease which often cause significant complications such as infection in and around the brain, dizziness and permanent irreversible hearing loss if not managed regularly.
To ensure that we utilise this resource appropriately, there is a longstanding agreement in place that certain criteria must be met for referrals to be accepted in to the service. Read the current commissioning policy criteria for troublesome ear wax.
Some people may only need to attend 1 appointment for microsuction but others may have a number of appointments over a longer period of time. A clinical assessment on when a person can be discharged is applied to all patients based on criteria set by the ENT department. Whilst an average appointment timeslot for aural care is about 15 minutes per patient, there are currently around 2000 awaiting a follow up appointment within the aural care department.
Some patients have been contacted recently to advise that they no longer need to be seen by the aural care team. This is because the department is currently reviewing their waiting list/follow up lists and applying discharge criteria. Such reviews are essential in light of the recent events of COVID-19 which means that social distancing measures reduce the number of appointments available in clinic and therefore the amount of people that can be treated. NHS Kernow is fully supportive of RCHT conducting these clinically led reviews and applying the access and discharge criteria that has been previously agreed.
NHS Kernow and RCHT would like to reassure everyone that every person who has been discharged has had a clinical evaluation of their medical records against the clinical criteria for discharge. Each individual has been given detailed advice on self- management of their condition from home without the need to attend for a further hospital appointment.
NHS Kernow confirms that this is not a withdrawal of a service nor is it based upon any financial cut backs. It is however paramount if we are going to have enough resource across Cornwall and the Isles of Scilly in treating those with the most pressing clinical need. If a patient’s condition changes and they subsequently meet the access criteria for the service, they can be re-referred by their GP.
Could the Governing Body please advise their concerns about the future supply and cost of medicines and medical equipment following Brexit and how these can be addressed generally and particularly within Cornwall? This is a particular concern given the well-publicised problems arising from the Government’s insistence on nationally organised COVID pillar 2 testing rather than local NHS and public health organisation.
Governing Body concerns about the future supply and cost of medicines and medical equipment following Brexit would include:
How these can be addressed generally and particularly within Cornwall?
More generally the medicines optimisation team, has supported during COVID and continues to support the provision of information and advice on how to manage an interruption in supply.
DHSC has also indicated that it will continue to ask healthcare providers to avoid local stockpiling over and above business as usual ahead of 31 December as it is unnecessary and could cause shortages in other areas. This includes advising patients that they do not need to stockpile medicines either
How will NHS Kernow ensure that the mental health budget is protected in the event of a merger between Royal Cornwall Hospitals NHS Trust (RCHT) and Cornwall Partnership NHS Foundation Trust (CFT)?
The Cornwall and Isle of Scilly Health and Care Partnership maintains it commitment to parity of esteem between physical and mental health service provision and the strategic intentions set out in the adult mental health strategy: Futures in Mind. We are also committed to meeting the annual Mental Health Investment Standard (MHIS) to ensure that service development and transformation keeps pace with national expectation and meets the needs of the local population.
NHS Kernow shall be consulted on RCHT and CFT’s planned integration as part of the strategic and full business case process which shall be managed by NHS England and NHS Improvement (NHSEI). As part of this process, we expect NHSEI will also seek assurance of both organisations continued commitment to national MHIS expectations.
It has been reported that the Government has now written off all NHS bodies debts. However, the position is far from clear since it was subsequently reported that these debts have been transferred into public dividend capital which would seemingly involve higher interest charges. Could you please clarify the position and the implications for the CCG and NHS providers in Cornwall? Could you also please advise if there have been any statements or actions which would help avoid future accumulation of such debts?
The Government’s announcement on 2 April was about historic debts and loans held by NHS providers, rather than commissioners like CCGs. You are right that this debt is being converted in public dividend capital (‘PDC’) instead, a sort of equity in a provider trust balance sheet, which also attracts a payment back to the government each year related to 3.5% of the net value of the trust (but unlike a loan, PDC doesn’t need to be repaid over time). This change does remove the uncertainty that has affected trusts in the past because of the regular cycle of having to rearrange the loans, which often came with changes in interest structures and loan terms each time. When this idea of changing the historic loans to PDC was first put forward during operational planning for 2020/21, there was a concern that the 3.5% rate on the public dividend capital payments could end up leaving some trusts worse off than repaying loans which had lower rates (although it is important to know that they are not calculated in exactly the same way), however, as part of the new announcement the government has been made clear that no provider’s bottom line position will be adversely affected by the change.
Note: It is worth knowing that the second national statement quotes the following draft figures for Royal Cornwall Hospitals NHS Trust (RCHT), University Hospitals Plymouth NHS Trust (UHP) and North Devon Health Care Trust (NDHCT):
In terms of the CCG’s historic deficit, we are awaiting further information to see if there will be revised arrangements for handling this. During the operational planning round, there was a proposal to write-off approximately 50% of this for most CCGs, with plan to be agreed for repayment of the balance. With the change in focus towards the important work of ensuring the NHS is to address the coronavirus pandemic, the Planning process has been suspended, so we will need to wait for further details on how this might be handled in future. It is important to remember that the CCG deficit does not bear interest like the trust loans did.
You asked about actions that might avoid such debts in future. Notwithstanding the current shift to doing whatever is necessary to meet the challenge of the COVID-19 for the people of Cornwall and the Isles of Scilly, in the background it remains as important as ever for the local NHS to get back to living within its means each and every year. That remains a significant challenge given the priorities we all wish to address, but we continue to work together across the whole system to get back towards financial balance, and avoid any further accumulation of debts , and the complications that come with that problem. Financial planning for the future will be an important part of our work when we come out of the COVID-19 response in due course, when we develop the NHS of the future, here in Cornwall.
There is no reference to the Isles of Scilly Council in the AO paper. Is this due to the council not being supportive of the role or if had they not been involved in the process?
Dr Chorlton confirmed that the Isles of Scilly (IoS) Council were part of early discussions on strategic commissioning and had been consulted and involved. The IoS Council would be part of the assurance panel and ongoing evaluation of proof of concept. However due to their separate authority with a specific role on the Isles of Scilly, the council opted not to be a part of the process indicating that, from a director of public health perspective, the AO role could link across to the island as they have a separate adult social care. Mrs Pendleton highlighted that a risk may be that this process may marginalise the IoS Council, and even though they were not formally part of the process, it was imperative that they continued to be consulted.
How does the new strategic AO role fit in with the recently announced Cornwall Council arm for adult social care?
Mrs Charlesworth-May advised that Cornwall Council (CC) had set up a new Corcare homes company which would sit in a discrete reporting Council cost code, under the highways organisation. Historically, Cormac Ltd had delivered a suite of services which were not picked up by other companies and this existing suit of services would now be covered by the new care homes company.
In terms of finance, will the year-end deficit would be rolled over?
Mrs Bryan informed that there had been recent changes to the way clinical commissioning group monies are managed and the new financial year would have a new budget allocation. The historical deficit of £27 million would need to be repaid at a point in time in the future however this would not be included in the new budget allocation for 2020/21 financial year. Mrs Bryan confirmed that the accumulated debt would always be stated in the financial reports.
Why are north Devon figures were not reported within the acute hospital activity of the month 10 finance report and commented that there was an identified gap of £52 million?
Mrs Bryan advised that once activity figures fell below a certain amount, with north Devon being the smallest, the detail is not included. Mrs Bryan confirmed that the report would include Devon, Exeter and any Cornish residents that attend elsewhere in the country for non-contracted activity. A list of contracts over a certain value is available on the NHS Kernow website. Mrs Bryan confirmed that this list included several hundred contracts for which analysis is included within the annual report.
Mrs Jones confirmed that NHS Kernow had received clear public health instructions and were following the national communications pathway. All communications were being released to the public nationally via NHS England, public health, disseminated via television, radio and social media outlets, and not updated locally to ensure uniformity of messaging. Members of the public are directed to seek advice from www.111.nhs.uk before calling 111 to assist with the volume of enquiries. Any changes to the current protocol would be under the directive of public health. Mrs Pendleton confirmed a national action plan had been released to support the developing situation.
What plans are in place around local issues of staffing which would be needed to supplement the national plan?
Mrs Charlesworth-May advised county wide planning rules would be initiated if that critical point was reached, which are tightly controlled and signed off at each level and a local workforce strategy would be included within this. Communications in that context would be closely managed, with national messages circulated locally alongside agreed local messages.
Concern has been expressed that the pressure to discharge patients more rapidly from our acute hospitals is leading to an increase in readmission rates which, if true, would seem to be counterproductive as well as distressing to patients and their families. What are the figures, over a period of time, please, for each of our acute providers?
Despite pressure on urgent and emergency care services, the rate of readmissions within 30 days has actually reduced over the past few months in all acute hospitals that serve our population (Royal Cornwall Hospital NHS Trust, Northern Devon Healthcare NHS Trust and University Hospitals Plymouth NHS Trust).
Traditionally a month of increased pressure on urgent and emergency care services, in December 2019 the readmission rate was lower than in November and lower when compared to December in the previous year in all 3 trusts. This is lower than the national average of 7.4%.
We can reassure you that this is a quality and safety measure that is monitored on a monthly basis.
|Acute trust||Readmission rate within 30 days (December 2019)||Readmission rate within 30 days (November 2019)||Readmission rates within 30 days (December 2018)|
|Royal Cornwall Hospitals NHS Trust||5.50%||6.18%||7.3%|
|Northern Devon Healthcare NHS Trust||4.12%||6.46%||10.9%|
|University Hospitals Plymouth NHS Trust||4.53%||5.76%||5.8%|
Natalie Jones confirmed that colleagues are encouraged to raise any queries or concerns around discharge through the peer improvement tips for care and health (PITCH) system so that individual circumstances can be reviewed and anecdotal learning is applied. Natalie confirmed they would look into discharge and readmission processes at times of escalation and take a report to the quality and performance committee.
Dr White confirmed that GP practices are updated with discharge information daily and reported that practices are reviewing this information regularly. Melissa Mead advised that PITCH and GP awareness of the system was raised at the last joint primary care commissioning committee and a new communication was being prepared for release to GPs in different formats to relaunch the use of the system for those with less familiarity. Dr Garman confirmed that he had been using PITCH. He advised the system was user friendly and more thorough than previous system (STREAM).
I would be grateful to know where the funding for the Edward Hain, St Barnabus and Fowey community hospitals in Cornwall is going.
Both Edward Hain Hospital, St Ives and St Barnabas Hospital, Saltash remain open and are operating as community health facilities offering a range of services to their populations. In St Ives the hospital is offering re-ablement support in partnership with Age UK. In Saltash, the hospital is providing accommodation for a number of community and outpatient clinics which include speech and language therapy, podiatry, district and community nurses and the acute care at home service while their inpatient facilities are closed.
The only hospital which is closed in its entirety is Fowey which in the last year that it was open, provided very limited support to its community offering just 6 inpatient beds and treatment to less than 60 people with minor injuries.
We can confirm the contract value with Cornwall Partnership NHS Foundation Trust who run the community hospitals has not been reduced as a consequence of the temporary closures. Where issues such as these arise, the contract gives the Trust flexibility to redirect and redeploy resources (which includes staff) to alternative priorities as highlighted above.
We are undertaking a programme of community engagement in Fowey, Saltash and St Ives and surrounding communities to identify and agree with the local people the type of health and care services they need both now and in the future to inform the long-term role of these facilities.
What are the consequences for the NHS in Cornwall if RCHT (and/or CPFT) are unable to manage within their current allocation of funds?
The CCG is committed to, and is, working in close partnership with the 2 local trusts to ensure that safe and affordable healthcare services are provided to the residents of Cornwall. The health community operates, like other health communities, in a constrained financial environment and is on the path to financial recovery. As part of the 2019/20 financial plan the 2 trusts have agreed to funding levels that should enable them to deliver their plans however it is recognised that there is still a significant financial challenge to delivery of these.
Both trusts are currently reporting that they are expecting to deliver their financial plans but it should be noted that the NHS Kernow is not planning to meet the required target deficit for the CCG. Whilst NHS England and NHS Improvement (the regulators) have not yet formally approved the CCG plan, they are supportive of the position and recognise that the system as a whole, are targeting a reasonable level of ambition.
The regulators, have recently come together under joint leadership with merged structures, and as such will be taking a more joined up approach to any emerging financial pressures in the system which may begin to indicate we are unable to deliver our collective financial plans. Legal directions and special measures remain an option for regulators in response. However, provided that they system are able to demonstrate that robust financial governance has been maintained, the response from regulators would be expected to be supportive, working with the Cornwall health and care system towards developing and delivering sustainable solutions.
Do members of NHS Kernow accept that Stratton MIU is busier than we have been led to believe and do they accept public concerns that proposed arrangements will leave
the local population isolated in terms of emergency medical care?
We understand the importance of having high quality services in the north and north east of Cornwall because of the long journey times to other health services including North Devon District Hospital and Treliske.
Our health and care system is working with communities to improve our urgent and emergency care system to ensure people get the right care in the right place, whenever they need it. Improving the ways people can get help for serious, but not life-threatening conditions, will make it easier for them, and also take pressure off our busy emergency departments, which should only be used for the most life-threatening of conditions like chest pain, stroke, serious trauma such as a road accident and major cuts, breaks and burns.
What people tell us is informing our plans to create a joined-up and improved health and care system, which works in partnership with our GPs, pharmacies, minor injury services and emergency departments.
We have consulted widely upon the optimal location of urgent treatment centres across the county with 1 of those chosen locations being at Bodmin, where the existing MIU will be enhanced to meet the national specification of an urgent treatment centre. We are aiming for this to be completed by December 2019.
The Bodmin Hospital site was chosen as an urgent treatment centre due to its close proximity to the A30, and because it has room on the site to expand in order to meet future need.
We evaluated the option of locating an urgent treatment centre in Stratton which, from a travel time perspective would make it a key site because it serves a large rural area. As a point of clarity, the PenCHORD modelling and analysis used to inform this decision did not recommend 5 to 9 urgent treatment centres in Cornwall. Rather, it concluded that mathematically between 5 and 9 urgent centres would be required to largely minimise average and maximum travel times.
Our collective evidence, which included other modelling and feedback from clinicians, showed that 3 urgent treatment centres was the optimum number and that there was neither sufficient clinical need nor would it be operationally feasible for more than 3 urgent treatment centres and to prioritise the site as an urgent treatment centre.
We do understand people’s concerns about the temporary overnight closure at Stratton Minor Injury Unit. The service remains open from 8am to 10pm every day when the unit is most in demand.
Cornwall Foundation NHS Partnership Trust has, unsuccessfully, tried to recruit clinical staff since January 2018, including a band 7 MIU sister/charge nurse, and a band 6 MIU practitioner. An interim MIU sister is in post and is shared between Stratton and Launceston hospitals, and 2 nurses have been recruited into developmental roles, but the team has not been able to recruit enough staff to re-open a night time service
We know from historic activity data collected by the service, that last year 9,436 people used the MIU and only 600 people used the service overnight. This is an average of 1.4 per night. Use of the unit from 10pm to 8am is consistent during the winter (October to April) and summer (May to November) months. There were 102 nights with no attendances. We are confident with the accuracy of this data.
We’re having constructive discussions with health and care partners in Stratton to develop a new model of urgent care provision which meets the community’s needs. The NHS, GPs, South Western Ambulance NHS Foundation Trust (SWASFT), community members and the hospital’s League of Friends are working together to understand the local issues and how they can support people in the community.
A multi-agency project group including local councillors and patient representatives has been established to review the model of care within the area. We will also establish a local patient participation focus group with the local PPGs and League of Friends. Council colleagues from Holsworthy will be asked to join the project group to understand the wider local context.
We believe the temporary change to the overnight service will have a minimal impact on safety. People can use other services at night, such as NHS 111, late-night pharmacies and 999 for life-threatening emergencies.
Anyone who has an urgent life-threatening condition, such as a suspected stroke, choking, chest pain, major blood loss, or loss of consciousness should call 999. An MIU is not the right place to be treated, and the temporary overnight closure of Stratton MIU would not change this advice. Anyone in the Bude area who needs emergency medical help will continue to receive this from either the emergency departments at Treliske in Truro, University Hospitals Plymouth or North Devon District Hospital in Barnstaple.