The Croydon Healthwatcher Blog takes a current issues that has come up either through our research or in response to changes in services and discusses this with reference to wider sources.
It’s a great way getting to understand some of the challenges and how they might be responded to.
By Gordon Kay, Healthwatch Croydon Marketing Officer
Last month, we were contacted by a Croydon Grandmother who told us her story of what happened when her grandchild had a suspected fracture.
Being aware that the Purley GP Hub, would be the nearest and most relevant place to go, they went there. Previously, the Minor Injuries Unit was always nurse led and residents were told that this was the reason they could not access the x-ray facilities. Now the Hub was GP led, it followed that the xray facilities would now be accessible.
They waited for an hour and half before seeing a GP who suspected it may be fractured and suggested she go to Croydon University Hospital’s Urgent Care Centre as they could x-ray it. When the grandmother suggested there were x-ray facilities at Purley she was told that they were not available for this type of injury. So finally she went to East Surrey Hospitals A&E department and got the care for her granddaughter there, which meant another three- mile journey and more delay in getting treated.
Whatever people may feel about a service, nobody should have to wait over two hours in pain and have to see one specialist who then tells you to go somewhere else. Isn’t this the opposite of an integrated minor injuries service that is supposed to take the pressure of A&E?
This story raises two big issues one about buying of services that an x- ray facility exists that cannot be used and the other about poor signposting and communication of existing services.
Buying of services
We investigated further the pathway. Why is it that there are x-ray facilities at Purley GP Hub, but on this occasion they could not be used? Croydon Clinical Commissioning Group (CCG) told us that all GPs have the power to refer an x-ray at Purley but these are for injuries considered more serious, such as a chest injury.
We were advised that patients with injuries considered less serious should go to go directly to Croydon University Hospital. In short, while an x-ray facility exists it is only used in certain situations and there is no requirement to x-ray for suspected fractures at Purley.
To the public this is clearly a confusing proposition. The reason for this is that this was not an essential option in the recommissioning of urgent care services that concluded in 2016.
While the issue was discussed in the reprocurement process, the decision was taken that in order to meet the ‘right place, first time’ requirements for treatment, x-rays for minor injuries would be performed at the Urgent Care Centre at Croydon University Hospital.
The problem was that this has not been clearly or effectively communicated. Indeed Healthwatch Croydon only found this out after being sent a link by the CCG to a set of questions about the reprocurement process published deep within the CCG website.
Lack of effective signposting
As our research into GPs which is being published this week shows this is indicative of a system that is confusing the public. Indeed our research at hubs showed that whilst the majority of people we spoke to are happy with the quality of service provided, a clear majority were also unclear as to what was provided and where.
When hearing this grandmother’s account, we feel that she should at least have been informed at Purley Hospital on arrival that they did not deal with suspected fractures, and that it may be better for her and her granddaughter to go directly to Croydon University Hospital, rather than waiting for a GP assessment. A basic triage facility would have identified the potential injury and advised accordingly. It is an obvious assumption to make that a service with an x-ray unit, will conduct x-rays and if this isn’t always the case, then at a minimum the communication of this needs to be improved. This is even truer for Purley which used to have a minor injuries unit.
Croydon is not unique in these circumstances. Only last month, NHS England published guidance on what non-hospital based centres should be offering from 2019 see Urgent Treatment Centres – Principles and Standards July 2017.
On page 4 it talks about the public being confused by a mix of walk-in centres, minor injury units and urgent care centres, with a confusing variation in opening times and what diagnostics may be available. It is even refers to x-ray facilities but still refers to their use in some cases and later on page 8 at the recommendations makes only desirable plain x-ray facilities available, uses the number of people using the service as an deciding factor.
So what can be done?
Firstly, there needs to be better communication of the quickest, most effective pathway for people with different injuries and conditions to take when they arrive. This starts with effective triaging at GP hubs. By having trained professionals such as GP and nurses on the front desk, they can make swift assessments and decide whether you need to stay at the Hub or go somewhere else.
Secondly, a review of the demand for x-ray services needs to be made. The reason to make this decision was based on research by the CCG back in 2015. Well perhaps demand has changed, or maybe they need to look at cases for using the facilities when dealing with more vulnerable groups such as children.
Finally, much stronger and wider communications of which services are available where and how, which are easily accessible by phone call, mobile and print advertising, so that whatever age or background, a person genuinely gets to use to the ‘right place, first time’.
It is time to end this ‘snakes and ladders’ approach to an essential service, we should all be able to get care at the right place as swiftly as possible. After all, isn’t this what the reprocurement of urgent care services was all about?
By Gordon Kay, Healthwatch Croydon Marketing Officer, 6 July 2017
The concerns and needs of carers is usually an area long overlooked by policy-makers and NHS providers. While the focus is on those being cared for, carers sometimes get missed out in the system, as some of our reports on hospital discharge in 2016 suggested.
Did you know that according to Croydon Carers Information Centre, there are 33,000 carers in our borough? Yet it has one of the lowest carer Health Check take up rates of all London Boroughs with just over 1 in 20, 5.4% of the eligible population being offered a Health Check. The Croydon Carers Strategy 2011-2016, noted that while carers often neglect their own health and wellbeing, Black Minority Ethnic (BME) carers in particular faced additional difficulties of stereotyping and social inclusion.
The 2011 report Half a Million Voices noted that BME carers provide more care proportionally that White British carers, which puts them at greater risk of ill health, loss of paid employment and social exclusion. These are, of course the same issues as White carers, the difference is that they also have to deal with cultural barriers, stereotyping, language difficulties, which further enhances the exclusion. Some BME groups also suffer more exclusion that others with Bangladeshi and Pakistani carers particularly challenged.
At the local level, the London Borough of Croydon’s Carer Engagement 2017 report, which surveyed carers in the borough, had responses from 59% white carers and 24% BME, yet the population in Croydon is 54% BME, 46% white. The report proposed that future engagements should therefore seek responses from BME community to ensure better representation.
IRISS Insights, who specialise in enhancing the capacity and capability of the social services workforce, suggested in their report, Improving Support for BME Carers that there is little guidance concerning the needs of BME carers. Part of the issue is the difficulty in obtaining accurate information about the size and nature of the BME carer population. Census questions identifying BME carers have existed since 2001. This has made a difference, but underreporting is high, due to language barriers, concerns on immigration status, or a perceived suspicion of sharing data with the State.
Carers UK research suggest BME carers are more likely to struggle more financially, be more likely to be caring for a sick or disabled child aged 20-24 (which reflects long-term caring responsibilities) and be more likely to be caring for someone with a mental illness. As a result, carers have had restricted access to education, employment and, when in work, promotion.
Ethnicity data has improved significantly since the 2010 Ethnicity Act made a legal requirement for health and social care providers to collect data. This UK-wide data has revealed that Indian, Pakistani and Bangladeshi groups report a poorer experience than White British people. But it is not clear where in the system they are experiencing unfair or inequitable treatment.
Where research has taken place, the key issues were language barriers and knowledge of services and cultural challenges. For example, in Bengali, Gujarati, Urdu and Punjabi there is no word that translates to ‘carer’, so the role may not be recognised or perceived as a role that needs support. There are also concerns that NHS services could not meet cultural and religious needs, so services were not taken up.
While Healthwatch Croydon is here to represent the views and experiences of all Croydon residents, we do also have a duty, in law, to gain the views of those least represented. BME carers clearly fall into this category, particularly where we have a population that is 54% BME.
This area of work is clearly under-researched and has many contradictions. Therefore, the focus of the first of our in-depth research reports in 2017-18 will focus on asking BME carers about their experience of using Croydon’s GP services, to see if their needs are being met.
It is important that anyone irrespective of background gets the neccessary support they need. In a borough with such a rich diversity of people, services need to be able to respond to all service users wherever they come from. The aim of this report, will show any barriers to access and therefore guide NHS buyers in delivering services that give BME carers the support they need, but we cannot do it without the views of BME carers.
If you are a BME carer, come and share your experience at by filling in our survey by 21 July or contact our Community Engagement Manager, Geraldine Bolam on 020 8663 5632 or email@example.com for a one-to-one chat. We can only influence change with your experiences.
By Gordon Kay, Healthwatch Croydon Marketing Officer, 5 April 2017
Recent decisions by Croydon CCG, to close Foxley Lane women’s mental health unit and to cease assisted conception (IVF) services despite public engagement resulting in substantial opposition to these cuts, raise two important questions for me. Firstly, what power should patient have to influence decisions on healthcare and secondly what is effective engagement and how does it differ from consultation?
The NHS Constitution states that a citizen we have the right to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services.
Section 242 of the consolidated NHS Act 2006 and 2012 Health & Social Care Act places a duty on NHS trusts, CCGs & strategic health authorities to make arrangements to involve patients and the public in service planning and operation, and in the development of proposals for changes.
While the legislation defines that patients and public need to be engaged it does not define effective models of how this should be delivered. So, what is a good example of engagement?
David Gilbert of InHealth Associates, a specialist consultancy that helps NHS organisations deliver better patient and public engagement suggests proposes an engagement cycle. At each stage, patients and the public have a role to play in services.
What is interesting about this cycle is that is looks at getting public, patients and communities involved right at the beginning.
It focuses on five stages:
- Working with communities (of geography and of interest) to identify needs and aspirations
- Working with the public (as citizens and taxpayers) to plan and transform services
- Working with patients and carers to design services and improve quality and safety
- Working with patients and the public to procure and contract services
- Working with patients and carers to monitor services and share learning.
This engagement cycle isn’t very new, it has been adapted and tested by dozens of CCGs and NHS organisations across the country. Utilising this model is more likely to result in the public feeling valued, trusted and in a position of influence, the commissioner understanding that they have reliable data, and the backing of the public in their decision-making. And with the right commitment, it could happen here in Croydon.
Which takes us back to the Foxley Lane and assisted conception decisions. Had the CCG sought public engagement right at the beginning of the process, instead of consultation towards the end, the public may have gained a greater understanding of the complexities and this might have helped the CCG in terms of trust. The same decision may have been made, but at least the public would have been engaged in the process and had some ownership of it.
That is not to say that this kind of public involvement does not happen in Croydon. A Healthwatch Croydon volunteer was recently part of the procurement panel for the new urgent care services contract. The insights he gained as well as the input he gave shows what can be possible. What’s more he feels, that he contributed to this shared decision. An example of the CGG doing with its service users not too its service users.
Another positive example of this, is the commitment given by Croydon Council’s public health team to work with HWC in involving teenagers in the service design of sexual health services in the borough. based on the recommendations of our research report. We need to see more of this kind of public engagement but earlier in the decision-making, and it is not just the CCG, but at the two NHS Trusts and with the Council. Public engagement is not rocket science.
This discussion is even more important when you consider that there are due to be major changes to health and social care in Croydon as a result of the South West London Sustainability and Transformation Plan. Now more than ever is the time to consider real engagement, particularly when the changes to services are substantial and predicated on hard financial decisions to be made. So, when are the commissioners are going to take up the challenge of the engagement cycle and engage with the public as true partners?
The benefits could be transformational for all concerned.