Changing of the guard for Wiltshire's NHS - just as Brexit poses new problems for health services
Having steered Wiltshire's Clinical Commissioning Group (CCG) as its Chief Officer through its first - and pretty difficult - four years, Deborah Fielding has left to return to her home territory of Essex and a new NHS commissioning role. Her place will be taken by Finance Director Simon Truelove - until he leaves in September.
Marlborough.News went to see her on her last day at Wiltshire CCG's Devizes headquarters - we wanted to find out what her legacy would be and what the future holds for the CCG itself. And she had important news about NHS111.
The very next day we got evidence of a major part of her legacy: from July 1 the county's adult community health services are in the hands of a partnership or joint venture between the three major hospitals that serve Wiltshire (RUH in Bath, GWH in Swindon and Salisbury Hospital) under the title Wiltshire Health and Care.
They were commissioned by the CCG after a long and careful tender process: "The joint venture gives us the opportunity to continue collaboration." She sees this collaboration as key to the Sustainability and Transformation Plans (STP) she has been working on with Bath and Swindon CCGs and the three hospitals during her final months in Wiltshire.
"The STP could be the solution. I think it could be a real opportunity for Wiltshire. There's unparalleled collaboration. Not everything can be commissioned at local level."
However STP will alter the position of CCGs in the NHS organisational hierarchy: "The role of the CCG is changing. I think the CCG has a really important role in developing primary care and community based services. Eventually those services will become Accountable Care Organisations (ACOs) - commissioners and providers. The CCG will be needed to manage and monitor ACOs. But it'll become smaller."
"We have", she says, "improved collaboration across the system". She came to Wiltshire for the CCG's start-up period and her first task was to prevent Wiltshire having three separate CCGs - both the south and west of the county wanted to go their own way - on their own.
She and her team set-up one CCG for the county with a three locality structure: "We developed a common strategy that could be implemented locally - depending on local conditions - based around integrated teams of health professionals serving populations of around 20,000."
How have these changes to the NHS in Wiltshire come about: "Partly economic necessity, partly leadership - including the leadership of our GPs. We're lucky in Wiltshire to have such good primary care." One result will be a new building to house Devizes urgent care service - the application for planning permission will be made in September.
From time to time during her four years relations between the CCG and Wiltshire Council have been strained - sometimes very strained, for instance over the ownership of NHS funding: "Relationships have been repaired. We have to work through the challenges. The government haven't helped by funding social care particularly badly."
She says Council leader Baroness Scott has the needs of the people in mind: "Strategically working together is not difficult - because we both work through localities and both want Wiltshire patients treated within Wiltshire. The population needs to become paramount - at the local level."
The controversial contract for the NHS111 telephone service for Wiltshire comes up in 2018: "We are working on a more integrated urgent care structure which will include 111. It will be more locally sensitive and make better use of clinical skills and new technologies - so patients are directed to the right place at the right time."
"Safety is not the biggest problem with the current service - if anything they're over cautious - sending more people into A&E."
We spoke to Deborah Fielding during that strange gap in contemporary history between hearing that Gove wanted to be the new Prime Minister and that Johnson realised he could not be the next Prime Minister. So Brexit was much on our minds and will be hovering over the NHS for years to come. What would the impact of leaving the EU be for the NHS?
Deborah Fielding says there are two really big and important things that affect the care you will get - money and people - and both are put in jeopardy by Brexit: "If Britain goes into recession there will be less money for the NHS - there is no doubt about that." The people part is all about the workforce: "The NHS is dependent on our European workforce and that's dependent on the free movement of people."
Then our talk turned to a photo [see below] that had been whizzing around social media that morning. It shows the surgical team a hospital in England. Just one member is a British citizen (of Pakistani origin), the rest are all European (that's European as in 'from the EU').