NHS funding crisis: Wiltshire's part in plan to balance Department of Health's end of year accounts
Squaring the circle of the NHS' financial position at the end of the financial year 2016-2017 is proving a complex process - one that changes almost daily and which calls for the proverbial wet towel around the head and a strong cup of coffee.
We will not be encouraged to show any surprise at all when Wiltshire Clinical Commissioning Group (CCG) - which buys primary (GPs etc) and secondary (hospitals etc) health care for all the county's residents - ends the year with a 'surplus' that runs into eight figures. It will be in excess of ten million unspent pounds.
The previous financial year (2015-2016) ended badly with the Department of Health overshooting its total resources. Balancing the Department's books is done by setting those parts of the NHS that are underspent (NHS England's budget and most of the CCGs) against those parts that are overspent (mainly hospitals.)
If the whole system has overspent its agreed financial resources then Jeremy Hunt has to explain himself to the Treasury - and the NHS may simply get less the following year.
This financial year the NHS' finances have been stretched every which way. Basically the hospitals are, as the providers of acute health care, deeply in deficit for 2016-2017 and the commissioners (the CCGs) who buy services from them (and from others) are largely in surplus. That, anyway, was how it looked at the end of the third quarter of the financial year.
So what is this £10m to be left as a surplus on Wiltshire CCG's annual accounts?
Over £5m of it is the one per cent all CCGs have to put by as a 'surplus' - which is returned to them for use the following year. The second £5m-plus is being used as a new way to try and balance the Department of health's books for 2016-2017.
Without getting into all the figures, each year the CCGs have to keep back another one per cent of their resources - known as 'headroom'. This money is held to spend during the year on redesign and transformation costs for local services.
Sensing the financial problems to come, for 2016-2017 the CCGs were required to hold back this one per cent as a 'risk reserve' for the NHS as a whole. It could only be spent with Treasury permission. Across England this 'reserve' adds up to about £800m - which would go part of the way to making up the hospitals' deficits.
Now CCGs have all been told to add this money to their bottom line - making many CCGs' surpluses look alarmingly healthy. How does this help the NHS as a whole?
Wiltshire CGG's Chief Financial Officer, Steve Perkins, explains: "Within all the available resources, there are differing pressures between the providers and the commissioners. This money on our bottom line is in the system - with providers in deficit and commissioners in surplus - this money will balance the books."
That was then. And then was the beginning of last week. Since then new figures have emerged for February which make the challenge of balancing those books look harder still. And there is now only one month left to get things back on track.
Many of the CCG cavalry that had been riding to the rescue of the NHS accountants clutching their underspends, have suddenly gone lame.
As the Health Service Journal reported: "The figures released today (March 30) show that the financial position of the CCGs has worsened by £180m - nearly 50 per cent - in just two months, with approximately a third of groups predicting an overspend at the end of February." (Wiltshire CCG is not among those predicting an end of year deficit.)
Now it looks as though all the CCGs' £800m-that's-not-allowed-to-be-spent may only just bridge the gap. It is going to be a very close run thing - or as NHS England's finance director put it: "tantalisingly close".
Unless the March figures show some serious depletion of funds following February's very high demands for treatment, the result across the whole NHS system could show it is in the black by £34m. Not at all bad out of a total 2016-2017 NHS budget of £120 billion.
The NHS has reached a financial 'precipice' point just as it is about to plunge over the Brexit precipice. As we have reported, the already perilous staffing crisis is threatened with a catastrophic departure of EU clinical and care workers.
And talking of Brexit, that £34m figure is, of course, less than 10 per cent of the post Brexit bonanza the NHS was to expect once we have left the EU - remember the 'Vote Leave' bus and its extra £350m a week for the NHS?