Chapter 8: Health and social care (Martin Vye)
SDG Target 3.4: Reduce premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being
SDG Target 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
The state of acute care
Acute hospital care in Canterbury is in a state of crisis. In 2018 the Kent and Canterbury Hospital was rated by the inspecting authority as ‘Requiring Improvement’ for the safety, effectiveness, and leadership of its services. At the same time, the East Kent Hospitals University Foundation Trust, which runs the Kent and Canterbury as well as the William Harvey and Queen Elizabeth the Queen Mother Hospitals, and the Canterbury and Coastal Commissioning Group, the GP-led organization which commissions hospital services from the Trust, have in the same year been judged to be in need of urgent improvement because they are both running a substantial deficit in their budgets. This could make hospital services worse: the focus is likely to be on financial recovery, rather than improving clinical performance. The reputation of East Kent hospitals will decline, making it more difficult to recruit the high-quality staff the services urgently need. Already, in the winter of 2017/18, waiting times in the Accident and Emergency units of the William Harvey and the QEQM (which serve Canterbury) rose to unprecedented and unacceptable levels, with an accompanying increase in hours spent by ambulance crews waiting to hand over patients. In 2017/18 75.1% of patients appearing at Accident and Emergency were admitted, transferred or discharged within four hours, against the target of 90%. In addition, there has been significant under-achievement of the NHS national standard for waiting times for cancer treatment. The ambulance service itself has been under great pressure. In 2017/18 the target was to achieve a 90% response rate to life-threatening calls within 15 minutes: the actual performance was 44.7%.
Key health facts for Canterbury
- Both elective and emergency admissions to hospital due to diabetes have increased year on year since 2006/7.
- Overall Canterbury and Coastal CCG (CCCG) had a child admission for mental health rate of 91.1 per 100,000, as against 87.4 per 100,000 for the whole of England.
- Northgate has the highest rate in the district of contact for children and young people with mental health services.
- The rate of admissions to hospital for self-harm for the same CCCG was 261.3 per 100,000, as against 191.4 per 100,000 for the whole of England.
- A survey of Canterbury Foodbank users showed that two-thirds of Food Bank users were disabled/had a long-term health condition.
- The rate of alcohol admissions to hospital for under-18s was 60.9 per 100,000 as against 36.6 per 100,000 for the whole of England.
(Sources: Canterbury District Community Profile/Canterbury and Coastal CCG Reports)
The future of hospital services
Fifteen years ago Canterbury was considered, along with Ashford and Margate, as a possible site for an all-inclusive hospital serving the whole of East Kent. The judgment of the NHS decision-makers was that: “The Kent and Canterbury is probably the best of the three locations for a single-site service for East Kent. However, the existing site would be grossly inadequate.” The K and C consists of an old 1930’s core, and then a sprawl of later additions, which make it inefficient and costly to run. In fact, fifteen years ago the decision was taken to continue providing acute services on the three sites, including at the K and C. However, between then and 2017 eleven services were transferred to Ashford and Margate. In April 2017 acute stroke services were removed from Canterbury, followed in June by cardiology and respiratory care. This was because the K and C, once a desired destination for high-quality clinical staff, could not provide a sufficient number of consultants to monitor the work of the junior doctors running the services. The partnership of NHS organisations and local authority social care in Kent and Medway are again preparing a plan to concentrate all acute services on one site. The offer by a developer of a site adjacent to the K and C, and the construction of the shell of a new 5-storey hospital building, has transformed the calculation of cost and the K and C has been included as one of the two options for the new all-inclusive hospital. This has been strengthened by the decision of both the University of Kent and Christ Church University to set up, in Canterbury, a brand-new medical school. However, if the William Harvey in Ashford is chosen above the Kent and Canterbury, then there is no clarity about which much-needed services will remain at our local level.
One of the reasons for overcrowding of local hospitals, and delays in treatment, is that patients who are ready to leave the acute service, but who will need ongoing social care, cannot be discharged because there is often no social care available for them at the time. The City Council estimates that by 2031 there will need to be an additional 180 bed spaces in care homes with nursing; and 530 bed spaces in care homes without nursing care. The care home sector is under pressure from 1) the minimum wage 2) reduced money in the county council’s budget for social care and 3) the uncertainty about continued recruitment of care staff from EU countries.
Primary (GP) care
Primary health care is provided by the following GP practices in Canterbury: the Canterbury Medical Practice, the Northgate Practice, the New Dover Road surgery, and the Canterbury Health Centre. In 2017 all were judged by the Care quality Commission as at least ‘Good’. The stated aim of the latest plan for primary and acute services in Kent and Medway is that all residents should be registered with a practice that can offer a wide range of services, which will reduce the pressure on hospitals. In Canterbury this plan is still in development .
One of the problems experienced by acute, hospital services is that their emergency and urgent care departments can be overcrowded with patients whose needs could and should be better met at a GP surgery. Sometimes this happens because the person concerned does not know what the GP practice can offer. Sometimes it is because experience or rumour tells them that they would have to wait longer for an appointment with a GP than they think is right. In order to prevent long waits for attention some GP practices employ paramedics who are available to make home visits.
If the GP surgery is not within walking distance, or if the person concerned has mobility problems, then there has to be a reliance on public transport, including taxis, or relatives or friends with cars, or voluntary organisations. This can inhibit access to GP services. On the Thanington estate, for example, residents are registered across town with the Northgate Practice, bus links are poor, and many families are without a car. This can lead to late diagnosis of serious conditions. There is evidence also that much needs to be done to ensure that people experiencing the need for urgent care understand how to access it speedily, and that the services which will either provide it, or signpost to it (NHS 111 Telephony and Clinical Assessment Service, GPS, ambulance service, pharmacists) work in a swift and integrated fashion.
In Canterbury services range from in-patient hospital care at St Martin’s Hospital to treatment and care in the community, whether provided by the NHS or by voluntary sector organisations, such as Umbrella. GPs are becoming generally more able to advise on, and refer to, the right treatment: their use of ‘social prescribing—referring people suffering from loneliness, and poor mental health to voluntary recreational and cultural organisations—is growing. However, the national shortage of psychiatrists, psychologists, and mental health nurses is evident here in Canterbury, as elsewhere in Kent.
This has resulted in a crisis in mental health services for children and young people. The need is great, and growing. The area covered by the Canterbury and Coastal Clinical Commissioning Group has for some years had the second highest percentage of all the Kent CCG areas of young people admitted to hospital for self-harm, and of children and young people referred to KCC’s Early Help Service for mental health treatment. It is estimated that in Kent 28,000 children and young people suffer from neurodevelopmental disorders, such as ADHD and autism—whereas the maximum caseload the service is supposed to handle is just over 11,000. The incidence of other disorders is causing similar overload problems. The North East London Hospital Foundation Trust, who have the local contract for provision of acute mental services for children and young people, readily concede that much work has to be done to identify the causes of this surge in incidence of mental health problems. In June 2018, the school examination month, there was a sharp upward spike in referrals for depression and anxiety. NELFT are also having to work to identify the treatments that really work. However, much more could be done to prevent emotional and mental problems from escalating into full-blown disorders. In Canterbury statutory agencies, voluntary sector organisations and schools are cooperating to train teachers, parents, foster carers, and youth workers in ‘mental health first aid.’ Misuse of alcohol is causing concern. The rate of alcohol admissions to hospitals in the Canterbury and Coastal CCG area for under-18s was 60.9 per 100,000 compared with 36.6 per 100,000 for the whole of England.
Ill-health hits some more than others
The overall figures for physical and mental health hide the stark difference in conditions of health in different neighbourhoods. Between 2013 and 2017 the incidence of premature mortality from cardiovascular conditions was over four times higher in Northgate Ward than in Barham Downs; for respiratory disease four times higher in Northgate than in the least deprived ward; while the rate of emergency hospital admissions for respiratory conditions for people aged between 20 and 64 was three times higher in Northgate than in the least deprived ward. Figures for death from cancer were significantly higher in Northgate and Barton wards than in the least deprived ward. Between 2012 and 2017 there were four times as many hospital admissions for mental health conditions from Northgate than from Blean Forest Ward. A survey of Canterbury Food Bank users has shown that two-thirds of these users were disabled and/or had a long-term health condition.
The health of residents of Canterbury as a whole would improve if we all ate less, with a balanced diet; took more exercise; refrained from smoking; used alcohol in moderation; and were able to avoid stress in our lives. In Canterbury District latest figures show 14,467 residents being treated for diabetes, up by 2 percent on the previous year. Earlier diagnosis, and access to treatment, would also make a big difference. However, the difference in incidence of ill-health between neighbourhoods justify a special effort to improve the health of our residents in the poorest areas of Canterbury. An important emphasis must be placed especially on persuading children and young people to take on a life-style that will help them to avoid debilitating illness, and to live longer; and on helping them to build in mental resilience.
- The waiting time from arrival of patients at Accident and Emergency to referral for treatment or discharge should be brought down to the national standard of 4 hours.
- The time from urgent referral to hospital to start of treatment for cancer should not exceed the national standard of 62 days.
- All residents should be made aware of the NHS 111 Telephony and Clinical Assessment Service; and if in need of Urgent Care be confident of swift referral to, and appropriate treatment by, an Urgent Care service that is fully integrated by 2025.
- All GP practices should check the accessibility of their surgeries to all people registered with them, and take steps to make sure that any impediments are overcome
- There should be a year-on-year reduction in inpatient admissions of young people for self-harm; and in Accident and Emergency attendances for deliberate self-harm.
- All staff in schools in Canterbury should be trained in Mental Health First-Aid by 2022.
- All schools in Canterbury should be judged at least good by OFSTED, in the next round of inspections, for their ability to promote emotional wellbeing and good mental health in their students
- A priority for the NHS should be the rapid and significant reduction in waiting times for children and young people from referral to treatment by the Children and Young People’s Mental Health Service, with an urgent review of the current target of ‘no longer than six months ‘ by 2022.
- The incidence of premature death for cardiovascular conditions, and for respiratory disease in areas with high levels of deprivation should be brought down to the level in the least deprived areas of Canterbury by 2031.
- The per 100,000 number of hospital admissions for mental health conditions in the most deprived areas of Canterbury should be brought down to the level of the least deprived areas by 2031.
- To combat the growing epidemic of Type 2 Diabetes the Canterbury and Coastal Clinical Commissioning Group, KCC Public Health, KCC Early Help, and schools should plan effectively to reduce childhood obesity in Canterbury; and CCGs should lead on a plan to reduce incidence of Type 2 Diabetes by 10% by 2030.