Here we go again - the organisation of the NHS in Wiltshire is about to change dramatically
Local politics is coming back to Wiltshire's NHS. Creating the very NationalHS in 1948 was a brave political decision - ever since, tinkering national politicians have sought to leave their mark on the NHS and played with its budget.
So far, the NHS has never been re-invented. However, as we are all aware, it has been reorganised - often. We remember the political rows surrounding the Coalition/Lansley reorganisation that cost the NHS £3 billion - and has been widely judged as at best inadequate and at worst, by some, to have been a political flop.
Now, coming into view, is the integration of health and social care in Wiltshire - with Wiltshire Council (social care & public health) working in tandem with Wiltshire Clinical Commissioning Group (holding the county's NHS budget & commissioning services.) This will bring politics right to the heart of local decision making about our health services.
To date the only practical sign of this radical change is the imminent appointment of a new Chief Accountable Officer for the CCG who will double as Wiltshire Council's Director of Adult Services.
Why is this happening? NHS England has decreed that the 'traditional divide between primary care, community services, and hospitals...is increasingly a barrier to the... health services patients need.' Integration seems a sensible - even a 'no brainer' - in practice - yet with politics so centrally involved, how will it affect both Wiltshire and the Marlborough area?
Another and - unsurprisingly - unspoken reason for this development is that recent attempts to prop up local authorities' social services with many millions pounds of NHS funding under the so-called Better Care Fund, have not been effective across England. Though in Wiltshire the BCF is deemed by the Council to have been a tremendous success.
This move towards integration in Wiltshire is not unique. To the west, Somerset CCG (rated in July as an 'inadequate' CCG) is linking up with Somerset Council to plan a single commissioning body for all health and social care. It has already identified problems ahead.
Some health services - including surgery, radiotherapy, abortions and some other invasive treatments - cannot legally be commissioned through pooled budgets. And under the Lansley Act of Parliament, CCGs are established under law with defined responsibilities.
Late last month the leader of Wiltshire Council (Baroness Scott) and the outgoing Chair of the CCG (Dr Peter Jenkins) issued a 'statement of intent' setting out 'the ambitions of partners' for developing this process of integration.
The document is long on fine words - many of them reminiscent of early statements of the CCG. It talks, as the CCG has been doing since it took over commissioning for Wiltshire, of moving the emphasis of budgets from hospitals to primary care: "...shifting the focus [from] acute to primary and community care and, in turn, to prevention and population [sic] health; whilst disinvesting in wasteful and ineffective interventions."
It will be interesting to see the reactions when these 'wasteful and ineffective interventions' are named and then abandoned. Will 'patients first' and 'patient choice' survive the local politicians' policies?
The 'statement of intent' states that the Council and CCG's 'partners in the acute [i.e. hospital] and mental health sectors have agreed to a combined leadership and to 'further enhance collaboration.' It nowhere states who all these partners are or to what precisely they have committed.
One of the problems facing Somerset CCG is appropriate governance. They say their new board will meet in public, but they will have to comply with differing and legally imposed governance of CGG and local authority. That will be complicated.
How can Wiltshire Council's cabinet system - rather than the previous committee system - fit in with this new arrangement? We know that not so long ago there was a dispute between the Council and the CCG over how pooled budgets were being spent.
Looking ahead, the statement from Baroness Scott and Dr Jenkins, says: "Partners within the accountable care system will develop the ability to move finances around the system with the agreement of those involved."
The Council's need for more funding for its not very efficient or robust home care services will face the CCG members of this integrated operation with the possibility of money being taken away from primary care. The CCG is, after all, in the end run by its members - who are GPs and, of course, keen to promote primary care for all they are worth.
In the longer term, the 'statement of intent' looks to the establishment of an Accountable Care System or ACS. In brief, the ACS brings all parts of the health and social care provision together to take responsibility for a given population over a defined - and lengthy - period of time: "Most importantly, the partnership is held to account for achieving a set of pre-agreed quality outcomes within a given budget."
Mention of the budget brings us to paragraph thirteen of the 'statement of intent': "These objectives for transforming the way in which business is done will help to deliver the triple aim of improved population health, improved quality and experience and reduced cost per capita."
Is this a reorganisation born of austerity? Will it bring cuts to services? Do not get too gloomy: remember that the NHS was born during the great and lengthy post-war period of austerity.
It remains to be seen, however, how far new decisions on the provision of health care will be made on the same political lines as Wiltshire Council's recent and current spending decisions.
There will be a chance to question Wiltshire Council leaders on this development when they hold "...a series of interactive meetings about the challenges the council is facing and the impact that these could have." The one closest to Marlborough will be at the Devizes Corn Exchange on Tuesday, 26 September 2017 at 5.30pm.
NOTE: The STP - now the Sustainability and Transformation Partnership (no longer P for Plan) - of which Wiltshire is part with Bath & North East Somerset and Swindon - seems to have sailed silently into the doldrums. Its leader - James Scott of the Royal United Hospital Bath - has resigned and has not yet been replaced.
Far from acting across the three populations,the STP has, the 'statement of intent' says, agreed that the "...STP plan is likely to be implemented most effectively at a local level through three accountable care structures: one for B&NES, one for Swindon and one for Wiltshire."
NOTE: The Wiltshire CCG has been rated as Good overall and Good in every rated category except for 'Performance' which 'Requires Improvement'.