NHS Leadership Academy Digital Team

Glenvern – The simulated health and care economy

Map

1. Population

The county of Glenvern has a population of 850,000, a 17% increase over the past five years. The main county town is Middleton. The areas to the north, west and south of Middleton are quite rural with affluent market towns. There are many young families in these areas and in Upton, there has been a significant increase in the number of young families moving there in recent years. Two years ago, a large American app developer opened its UK headquarters between Upton and Middleton, and the increase in population as a result has been significant. Expansion of the local infrastructure and services have not developed at the same rate.

Glenvern has a disproportionate number of older people (over 65s) compared with other counties, with significant concentrations in the coastal towns of Seaport and Eastvern. In Middleton, Eastvern, Ruffton and Seaport there are also localised pockets of high deprivation, each with one or two wards in the most deprived 10% of wards nationally. This deprivation manifests itself in high unemployment (especially among young people), anti-social behaviour, and alcohol and drug misuse. Ruffton and Seaport have seen high levels of immigration from elsewhere in Europe, although these numbers are expected to reduce in the coming years. Street homelessness is especially noticeable in the coastal areas.

2. Politics

The county has seven Members of Parliament. The constituencies are:

  • Upton and Westvern (Liberal Democrat)
  • Middleton Central (Labour)
  • Middleton Vale (Labour)
  • Lushton and Northvern (Conservative)
  • Seaport (Conservative)
  • Ruffton (Conservative)
  • Eastvern and Southvern (Conservative)

Glenvern has a two-tier local government structure, made up of Glenvern County Council, which deals with strategic services including social care and public health for adults and children; and six district councils, whose remit covers housing and planning amongst other things.

Glenvern County Council has been Conservative for many years, but with a very small majority since the last election. The next County Council elections, during which the whole council is elected together, take place in in three years’ time.

The six district councils are coterminous with the Parliamentary constituencies (Middleton Central and Vale constituencies share one district council area). The next District Council elections (whole councils) take place in four years’ time.

The county’s Health and Well-being Board (hosted by the County Council) has taken somewhat of a back seat since the inception of the Sustainability and Transformation Partnership. Members of the Board include: the Leader of the County Council, Cabinet Members and Directors for Adult Social Care and Children; Director of Public Health, Chair of HealthWatch, NHS England/Improvement Regional Director, the Clinical Commissioning Groups’ Joint Chair and Accountable Officer and a representative from the third/ voluntary sector. There are also two representatives from the District Councils on the Board (both elected Councillors). The main agreed priority for the Board has been to address the issue of long-term conditions. Glenvern is working towards integration. Not all of the boundaries are co-terminus.

3. Health and social care organisations

The main organisations providing and commissioning services in Glenvern are:

Glenvern County Council

The council is under serious financial pressure to stay in balance. It projects it will need to cut net revenue expenditure by 25% in the next three years, and 10% in the next year alone.

Clinical Commissioning Groups (CCGs)

There are two CCGs in Glenvern – Southvern and Northvern – however, they are working towards a merger and they now have one Governing Body including a shared Chair, Accountable Officer and Chief Finance Officer.

Southvern CCG is larger organisation representing 567,000 patients and covers four district councils and five parliamentary constituencies to the east, centre and south of the county. There is a low level of clinical engagement – clinical leaders have been in place for a long time, they are not driving change and they are not seen as innovators.

Northvern CCG is smaller representing 283,000 patients and covers two district council/parliamentary constituencies in the north and west of the county. There is a high level of clinical engagement in terms of widespread involvement of clinicians in decision making and codesigning new care pathways.

Seaport Royal Infirmary NHS Trust

Financially challenged and smaller in size to Middleton, Seaport Royal Infirmary Trust is being held back by its Private Finance Initiative (PFI) debt issue. It has been at risk of being unable to make its repayments and has received emergency funding from the Department of Health over the past two years to protect patient services. It has not had a stable leadership team for several years and this issue was raised at its last Care Quality Commission (CQC) inspection last year, despite which, most of its domains were rated as ‘Good’.

Middleton General Hospital NHS Foundation Trust

Middleton provides a wide range of elective, emergency, and specialist services for the whole community. It enjoys a good reputation. On its last CQC inspection two years ago, it met all the CQC Standards except for staffing, where improvements were required, and which continue to challenge the Trust.

Channel Mental Health NHS Foundation Trust

Channel has a national reputation as being a beacon of good practice amongst mental health trusts, with its staff having picked up several individual and team awards over the last five years. CQC rate the Trust as Good, with Outstanding features.

Glenvern Community Health Trust

A stand-alone Community Health Trust and an aspirant Foundation Trust which runs, amongst other things: four community hospitals at Eastvern (12 beds); Westvern (30 beds); Lushton (10 beds); and Seaport (12 beds). Local people view all these community hospitals as cherished assets.

NHS England / NHS Improvement

Glenvern is part of the NHS England/NHS Improvement Central region. They are involved in healthcare commissioning and delivery and provide professional leadership on finance, nursing, medical, specialised commissioning, patients and information, human resources, organisational development, assurance and delivery. Regional teams work closely with organisations such as CCGs, local authorities, health and wellbeing boards as well as GP practices.

Third, voluntary and charity sector

As in many places, Glenvern has a thriving third sector, which is made up of charities, voluntary organisations and social enterprises. They are commissioned to provide health and social care services by both the CCGs and Glenvern Council and are also key players in the development of services through the STP. The range of services that they offer is increasingly seen as a way of supporting the prevention and public health agenda, as well as to help ‘plug the gap’ in services left by tight finances and staffing issues in both statutory health and care services.

Other health and care organisations

Glenvern has a thriving Clinical Senate which is chaired Northern CCG’s Clinical Chair and a variety of Clinical Networks across the county.

There are a number of national private providers of healthcare, some of whose services have been commissioned for Glenvern’s NHS patients in the past. The arrival of a large app developer to the county has not only provided high skilled employment for the residents, but it has allowed for some interesting health and care projects to be identified.

There is one adult hospice in Westvern and a children’s and young people hospice near Ruffton, both providing support at the hospice and in the community for those needing palliative care, or care with life limiting conditions.

4. Glenvern’s positive features

Glenvern has been recognised previously as having a high performing health economy in reports from inspectorates and regulators. This extends beyond NHS and care services to private and third sector providers.

There have been excellent survival rates for the main forms of cancer (the Cancer Alliance has been a local success with highly engaged members), short inpatient waiting times for elective surgery, and above average day care surgery rates.

The Mental Health Trust has been recognised for its clinical and service excellence, for example as demonstrated by combining health services and housing related support for former mental health inpatients. They have been recognised for co-developing an improved children’s mental health pathway and for inclusion of patients and families in its development. This has been a key driver in those from outside the county coming to Glenvern for their treatment. However, the funding is now under threat and beds vacated due to improved pathways are still being used by patients with other morbidities raising a double funding issue.

There has been a long-standing section 75 agreement between Glenvern and Channel Mental Health Trust covering community mental health services and all Glenvern mental health social work staff are seconded to the Trust. The Trust have long argued for this agreement to go further and for staff to be TUPE transferred and the Council’s mental health Commissioning budget to be pooled. However, the Council has expressed concerns that Council social care funds are being used to cover health needs and there are early thoughts of withdrawing from the agreement.

As part of the work arising from the STP, the Council is working with the CCGs to look at now they could jointly develop an Integrated Care System. This will build upon the foundations set in the Better Care Fund of previous years but is unlikely to lead to major structural change. There are, however, positive discussions underway around exploring broader integration – particularly in respect of care for older people and those at the end of their lives.

5. Key health issues in Glenvern

  • Across all Glenvern’s health and care organisations, there is a growing workforce issue with the number of unfilled vacancies increasing and difficulties in attracting and retaining GPs. This issue has been highlighted by trades unions from across the county and the picture in Glenvern is similar to many other areas in England. There are concerns about retaining ‘low-skilled’ workers, particularly those involved in social care.
  • Accident & Emergency attendances and admissions have been rising, putting pressure on the system financially, operationally, and clinically. For the last two years, both Middleton and Seaport hospitals have failed to meet their target of dealing with 95% of A&E patients within four hours. A recent review has established that the acuity of emergency patients admitted is very high, i.e. these are ill patients who need specialist assessment and treatment. A significant number of the patients had multiple conditions and were admitted from nursing and residential homes. Both Trusts are part of a project to identify what changes might be most effective in improving the flow through their A&E units.
  • A review by the Royal College of Obstetrics and Gynaecology has found that there have been an increased number of unexplained and potentially preventable deaths of babies across both hospitals. Further work is currently on-going to better understand whether the configuration of maternity services, or staffing have played a part in this.
  • Seaport Royal Infirmary, built originally under a PFI scheme in the mid 2000s, has significant and on-going financial problems. As stated earlier, it has twice received emergency funding from the Department of Health and Social Care. A benchmarking report suggests there are relatively high unit costs for some specialities. The MP for the Seaport constituency has vehemently opposed any reduction in hospital beds to meet the financial shortfall.
  • There is an issue with duplication between the two acute trusts. Whilst they are only 20 miles apart, clinical services are replicated and are sub-scale, for example maternity, paediatrics and cardiothoracic surgery. Also, staff rostering for some specialties is presenting a real challenge at both acute hospitals.
  • There is disagreement between the organisations around significant numbers of delayed transfers of care from hospitals to the community. The disagreement is about who is responsible and what factors are causing the problem.

The local authority has seen a significant overspend on Adult Social Care in the past year. In addition to this the authority needs to save 25% over the next three years and Adult Social Care is going to have to contribute to this target.

The Council has faced continued budget overspends on care costs as a result of steadily increasing demand – across all client groups, but in particular learning disabilities. Whilst the Care Act introduced national eligibility criteria, this is open to local interpretation and recent service reductions have been introduced as part of the council’s cost reduction strategy. There is mounting discontent amongst advocacy and user-led organisations and it is anticipated that a legal challenge may be imminent on behalf of families of a group of service users whose services have been reduced.

  • The Council is committed to working towards more home-based care and reducing reliance on long-term care and has embraced a policy of reablement of its residents, particularly in their own homes.
  • Private residential care homes are running with little spare capacity (there are no Council run care homes in Glenvern). There have been no fee increases in the last four years and Glenvern County Council has been threatened with a Judicial Review over the lack of increase in fees.
  • In some areas, notably Eastvern, GPs have raised issues about poorer access to community services and through a campaign group have made representations to their CCG.