In July 2015, Cornwall was the first rural authority to sign a devolution deal. So what has happened in the subsequent 18 months? Have our ambitions been realised? And does devolution remain a key enabler for the future of health and social care in Cornwall? Every place has a claim to being unique, and this is often the driver for devolution. Such a sentiment is felt no less strongly in Cornwall where we gain from Cornish national minority status and from significant European Regional Development Fund investment, based on European classifications of identity and economic need respectively. Our geography provides advantages as well as challenges. Rurally isolated, we have little opportunity for resilience: our 1,000 km coastline is the longest of any region outside of Wales and Scotland and we have just one county boundary, with Devon.
An outsider might think that because we ostensibly have ‘one of everything’ when it comes to organisational bodies that deliver health and social care, their integration must be straightforward. One clinical commissioning group (CCG). One unitary authority (although the Isles of Scilly have their own local authority and we must not forget the additional unique challenge of providing services to an isolated island community). One acute health trust (but 20 per cent of our 550,000 population look over the border for hospital services in Plymouth and North Devon). While this organisational coterminosity may provide opportunities for alignment, our communities are characterised by dispersed settlement patterns. There is no defined central conurbation and it will surprise many that our largest settlement is Falmouth, with a population of 22,000. Our communities reflect Cornwall’s fierce independence and those living in the remote Lizard peninsula do not necessarily have much in common with those in Bude in the north, or the ‘gateway to Cornwall’ in the south east of the county. While we may have organisational alignment, communities even within a defined region are complex, and diffuse. One size certainly doesn’t fit all.
The financial challenges too are significant for Cornwall. The CCG has a deficit approaching £50m and the fiveyear sustainability and transformation plan sets out a position in five years of a system-wide deficit of more than £260m (the total annual health and social care budget is £1.1bn).
Funding and allocation arguments aside, our analysis describes a system – over-reliant on a bed-based model of care and an overstretched care market – ready for change. Underpinning our lack of resilience is our ageing population, with almost full employment, in a low-wage economy. We also face challenges due to the seasonal variation of the labour market in Cornwall; which means it is easier to recruit carers in the winter, as we have a workforce that quickly moves to tourist employment in the summer months.
How, then, does devolution aim to tackle these challenges? The original devolution document for Cornwall refers to health and social care in just a few paragraphs, providing a business case for the devolution of health and social care. The advantages, opportunities and benefits are laid out in the wider document and its aspirations. Alignment of a single public estate, an integrated transport network, economic growth and the integration of national and local business support have more to offer to the health and wellbeing of our population than simply integrating a health and social care system. The wider determinants of health are of more significance than direct medical interventions. Put simply, a secure home, job, stable finances and being part of a supportive community are the true aspirations of our devolution deal and they are what will ultimately result in our sustainable future. Devolution in Cornwall offers an opportunity to bring all of these wider determinants together to deliver better public health outcomes in an integrated way that will ultimately support the prevention agenda that is so important in reduce the pressures on our health system.
We have had very little trouble in seeking local opinion on any changes to services. Most of our towns have their own small community hospital, held dear to local hearts. Any perceived threat to their continued existence raises the emotional temperature. In 2009, when the West Cornwall Hospital was under threat more than 27,000 people marched in protest – a higher number than live in our most populated town. Our opportunity now is to use that energy and opinion. Community responsibility for health and wellbeing can be achieved through local devolution, and our statutory organisations are supporting that through integrated projects reviewing our public estate, developing our workforce and bringing our commissioning functions together.
So, has devolution made a difference? It has brought all our partners in health, care, other public services and economic development together; it has strengthened relationships around a set of common aims for our population, and has promoted discussion about where devolution for the local system could go next. Devolution has produced what is perhaps an unintended consequence – a binding force that has created a framework within which local partners can work together to deliver on common goals. Time will tell whether our ambition is realised. But there is no other binding or transformational vehicle that understands, or has the motivation to develop and build, Cornwall. It is in the uniqueness of our place, like the uniqueness of every place, that the potential to make relevant decisions locally, retaining what is most important and defining our own future, rests.
Image: Thomas Tolkien