The NHS crisis: short of nurses and short of money - how will costs be reduced?
The NHS does not, of course, close for the summer holidays - unlike schools. But August has traditionally been a quiet month in the health service as executives prepare in earnest for the winter ahead and prepare to open their finance directors' half yearly budget forecast.
This year as nurses take their annual summer breaks, executives have to find cover for them that does not breach the new spending rules on agency nurses. Money and nurses - and the shortage of both - are inextricably linked in the twists and turns of this NHS crisis.
So let's take a look at these two elements of the crisis. First nurses. And the initial point to make about nurses is that the NHS is short of tens of thousands of them. The second point is that the supply gap in nurse training was supposed to be closed by 2019-20. But this month it was announced that the shortage will continue beyond 2020.
The reason given for this is the bizarre assertion that the 2020 end date was only achievable if hospital trusts obeyed NHS England's Five Year Forward View plan to reduce 'hospital activity'. This seems to be 'chopped logic' on a wilful scale: one way hospital activity is reduced is by treating more people in the community - where they need nursing care. In addition, as the NHS knows all too well, the population is ageing and the elderly's conditions are getting more complex and costly to treat.
A money-saving shortage of nurses was identified in the Francis Report as the main cause of the Mid-Staffs scandal - several hundred patients died due to poor care between January 2005 and March 2009 at Stafford Hospital.
Robert Francis' call for safe nursing numbers has fallen foul of the Treasury's tight funding of the NHS - and contrary guidance on safe nursing numbers seems to come round in time with the warnings about NHS overspending. Earlier this month, as part of a 'financial reset', the trust regulator tried to show that some hospitals' clinical care bills were too high - too many nurses etc etc.
Last week the former chief of the Royal College of Nursing, Peter Carter, laid the cut 18,000 nurse training places over three years, at the door of the coalition government. He believes Brexit will be a disaster for healthcare and that "...the Brexit people seriously misunderstood just how dependent we are on people from overseas to staff the health service."
Indeed, the nursing gap has been filled in part by the recruitment of very many EU nationals (especially from Spain, Portugal and Italy) - and with nurses from further afield.
The attitudes exposed - and encouraged - by Brexit campaigners will undoubtedly make recruitment of nurses much, much harder. Immigrant nurses may be loved and valued when they are in uniform, but off-duty they will be as likely as any other immigrant to be shouted at and abused in the street.
News of this new brazenness in anti-immigrant behaviour will precede the recruiters as they travel abroad seeking more nurses to look after all sorts and conditions of British men and women - whatever their attitudes.
One thing is almost certain: nurses' pay will not rise enough (after years of one per cent increases) to make the job of recruiters and those offering training places any easier.
So we get to the money. At the end of the last financial year the Department of Health escaped Parliamentary humiliation for overspending its budget by some clever accounting wheezes and a major raid on its capital budget.
This year it looks as though there will be a gap - otherwise known as a 'deficit' - of £1.2 billion. That figure relies on major savings being achieved by Clinical Commissioning Groups and the acute hospitals - and savings means trimming services.
It may also mean a 'reset' for the controversial Sustainability and Transformation Plans (STPs) reorganisation programme. If savings targets look liable to sudden deficit warnings, then STP plans - due for completion during September - may turn into much more of a programme of reductions in services. (You will notice the word 'cuts' was not used in that last sentence. It may have to be dusted off as the autumn proceeds.)