Health services in Cornwall are “under extreme pressure” and patients are “at risk” despite the best efforts of hard-working staff, a new report has found.
The Care Quality Commission carried out inspections at short notice of Cornwall’s integrated care system, including both emergency care services and minor injury units.
This included an unannounced inspection of the Royal Cornwall Hospital’s A&E department and its medical care services, including of older people.
Inspectors found risk assessments were carried out as quickly as possible, infection control was good, and staff treated patients with compassion and kindness, but there were challenges in urgent and emergency care, where there were long waits, delays in treatment and a high turnover of staff, and in medical care patients were sometimes moved multiple times and morale was low for some staff, due to “the immense and unrelenting pressures which had been ongoing for a number of years” and a belief from some that new senior leaders did not visit the medical areas impacted by demand sooner.
What did the report find overall?
- The health and care system is “under extreme pressure and struggling to meet people’s needs in a safe and timely way.” Inspectors identified a “high level of risk to people’s health” when trying to access urgent and emergency care in Cornwall.
- Significant delays to people’s treatment across primary care, urgent care, 999 and acute services, which put people at risk of harm. Staff reported feeling very tired due to the on-going pressures, which were exacerbated by high levels of staff sickness and staff leaving health and social care. All sectors were struggling to recruit to vacant posts.
- GP practices reported concerns about the availability of urgent and emergency responses, often resulting in significant delays in 999 responses for patients who were seriously unwell and GPs needing to provide emergency treatment or extended care whilst waiting for an ambulance. GPs also reported a lack of capacity in mental health services and a shortage of district nurses in Cornwall.
- A lack of dental and mental health support, which presented “significant challenges” to the NHS111 service. It was found that while NHS111 performance was below national targets it was better than other areas in England.
- When urgent treatment centres and minor injury units faced staffing issues, some units would be closed, with patients diverted to the nearest alternative. However, inspectors found this carried a potential risk of increased waiting times in other minor injury units and of more people attending emergency departments to access treatment.
- Due to the increased pressures, some patients were treated at urgent care centres who were acutely unwell, or who required dental or mental health care not available. Staff were said to treat those patients to the best of their ability, but patients were not always receiving the right care in the right place.
- Delays in ambulance response times in Cornwall were described as “extremely concerning” and posing a “high level of risk to patient safety”. Ambulance handover delays at hospitals in the region were some of the highest recorded in England. This resulted in people being treated in the ambulances outside of the hospital, as well as a significant reduction in the number of ambulances available to respond to 999 calls. At the time of the inspection, the ambulance service in Cornwall escalated safety concerns to NHS England and NHS Improvement.
- Staff working in the ambulance service reported “being bounced back and forth” between services and resorting to the emergency department as they were unable to get their patient accepted.
- Hospital wards were being adapted frequently, 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 remained in the hospital, impacting on the care delivered to other patients.
- Delays in handovers from ambulance crews, prolonged waits and overcrowding in the emergency department due to the lack of bed capacity meant that treatment was not always provided “in a timely way” due to overcrowding, staffing issues and additional pressure on those working in the department
Inspectors found that community assessment and treatment units set up to help fewer people being admitted into Cornwall’s acute hospitals, and provide quicker care, were full and unable to admit patients, with discharges delayed due to a lack of onward care in the community.
Community nursing teams had also been recently established, but at the time of the inspections it was in its early stages and so its effect could not be assessed.
Staff shortages in social care across Cornwall, especially for nursing staff, are some of the highest seen in England, the report found.
A care hotel providing very short-term care for people with very low levels of care needs was found to be working well for those who meet the criteria, although this was a relatively small number of people.
The report said: “Without significant improvement in patient flow and better collaborative working between health and social care, it is unlikely that patient safety and performance across urgent and emergency care will improve.
“Whilst we have seen some pilots and community services adapted to meet changes in demand, additional focus on health promotion and preventative healthcare is needed to support people to manage their own health needs.
“People trying to access urgent and emergency care in Cornwall experience significant challenges and delays and do not always receive timely, appropriate care to meet their needs and people are at increased risk of harm.”
Minor Injury Units
As part of their reports, inspectors also visited six of Cornwall’s ten minor injury units – Camborne and Redruth, Helston, Liskeard, St Austell, Bodmin and Newquay – and spoke with 42 members of staff, 25 patients and one carer, and looking at 45 patient records.
Staff were found to be well trained, triaged patients within national target times, provided good care and treatment, with the service found to have enough nursing and support staff to keep patients safe.
The minor injury units were found to occasionally stay open past their commissioned hours in order to support an increase of patients within the system.
Andrew George, chair of the campaign group Save our NHS Cornwall and a member of Cornwall’s Health Scrutiny Committee, said it was important not to put blame on the “hard-working and over-stretched staff.”
He said: “What our NHS needs is proper workforce planning, mandated safe staffing levels, proper budgeting and, above all, honesty.”
Cherilyn Mackrory, MP for Truro and Falmouth, whose constituency covers Cornwall’s main hospital, put it down to the after-effects of the pandemic.
She said: “While we have had historical pressures to our NHS services in Cornwall caused by things such as our rural nature, our services have been stretched like never before due to the unprecedented nature of the recent Covid-19 pandemic and the adaptations that needed to be made in order to get through it.
“The report does contain many elements which I recognise, having been contacted by many Truro and Falmouth residents with similar concerns in recent months. That being said, working closely with local NHS organisations, particularly RCH Treliske, Cornwall Council and care providers, I know that they are already starting to put in place the measures needed to improve in the areas that need improving.
“I also note that the dedication and hard work of the staff, working in exceptionally challenging circumstances, has been singled out and recognised and I would certainly extend my own appreciation to them, as well as a promise that myself, Cornwall MP colleagues and Cornwall Council will be continuing to do all we can to ensure that the service is improved for staff and users alike.”
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 one 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.”