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Health & NHS

STP WATCH: Did anyone notice? NHS Sustainability and Transformation Plans have become Partnerships - and permanent

 

There was a bit of noise during the election campaign around the government's latest move in the continual and discreet reorganisation of the NHS - the STPs aka Sustainability and Transformation Plans.  This noise of protest centred on rumours of cuts some STPs are going to make.

This kind of noise will get very loud indeed as the plans of some of England's 44 STPs focus on money saving closures of services and buildings - all in the name of sustainability with reduced funding.  But in case we got frightened by 'plans', the STPs have had their 'P' changed to the cosier and much more user friendly 'Partnership'.

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“The Doctor will see you now’”…but in the future? Maybe not

The general election brings - as usual - a wealth of promises and opinions about the NHS.  There is not, however, much talk about the GP crisis.  

About ten per cent of NHS doctors (not all of them GPs) are EU nationals - so unless the post-Brexit status of EU nationals to remain is not fixed soon, the shortage of GPs could get a lot worse.  A poll in February found that nearly two out of three EU doctors in the NHS were considering leaving the UK.

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Young people want better access to mental health services in Wiltshire 

Zoe Tonks & Elley-May Timmins with the Young Listeners report - ready to present it to the Wiltshire Health & Wellbeing Board (Photos: Tim Gander)Zoe Tonks & Elley-May Timmins with the Young Listeners report - ready to present it to the Wiltshire Health & Wellbeing Board (Photos: Tim Gander)A group of Wiltshire young people are on a mission to change the way mental health services are run for their peers and will be presenting a report to Wiltshire’s Health and Wellbeing Board next Thursday (May 18).

Young Listeners from Healthwatch Wiltshire spoke to 174 children and young people in the county to find out how they felt about using health and care services.

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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?

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A crisis in children's mental health? How is Wiltshire coping? Part Three: How Marlborough's schools respond to mental health issues

St John's Academy: healthy mind, healthy lifeSt John's Academy: healthy mind, healthy lifeThe last in a three part series of reports on the treatment of children and young people's mental health problems - in Wiltshire and in the Marlborough area.


One former pupil of St John's Academy we spoke to said they had found CAMHS "Brilliant - with its friendly waiting room and willingness to suit your timetable - very different to what was available at school.  But when I needed more serious help there was a huge gap - going to a hospital felt like a big step up.  It's scary - lots of long names and corridors."

Attitudes in secondary schools are changing - and schools will, as we have seen, be at the centre of the new CAMHS regime for Wiltshire.  I met with St John's Academy's Assistant Vice Principal in charge of safeguarding, Miss Maeve McNeill, and with the school's part-time counsellor, Rona Muller, to discuss mental health issues - especially anxiety and panic attacks.

At St John's they were very open and keen to discuss the issues.  Why did they think there was such an increase in pupils wanting help? "Twenty years ago there just weren't so many issues. Now there's a greater awareness of the issues and discussion in the media and on social media."

"Much of it is anxiety - quite often at a low level.  There's a lot of tension in the world and they pick up on it. They're connected all the time to 24-hour news - they will know instantly that something has happened - and they worry more about what they hear or read. There may be family tensions too. It's an intense time of life. But teenage years are hard enough without these kind of issues."

There are worries too about achievement and exams - these may be internal school or parental pressures to excel or they may be pressures they put on themselves when they realise they need good results to get a good job or move into further education.

Wiltshire's lead commissioner for CAMHS had identified for me a further and interesting cause of the rise in teenage mental health issues: lack of sleep.  Whether it is chatting via social media, watching television in their bedrooms or playing computer games, sleep time is being lost.

The Marlborough area is not yet on Wiltshire's programme for secondary school Thrive Hubs.  But St John's Academy has Rona Muller, and can also call on two part-time mentors.  She has her own room, which was included in the design for the new school buildings: "We're very lucky that it is a very nice room - conducive to counselling!"

Rona Muller sees students during the school day - the average is about five one hour sessions and she swops appointments around so students do not miss the same lessons again and again.  Appointment times are delivered in envelopes - for privacy: "We do respect students - we're very discreet."


A poster for an the online services designed for teenagersA poster for an the online services designed for teenagersSt John's are also lucky to have the area's CAMHS unit so close by - at Savernake Hospital.  Sometimes CAMHS staff from Savernake Hospital work with pupils in the school and sometimes go to their home:  "It's a very bespoke service and they now work more closely with schools."

Since September, teachers have seen an improvement in the service provided at Savernake.  Before there had been too much 'bouncing back' of students who did not meet the CAMHS severity threshold: "There's especially been an improvement in turn-around time - it's down now to two or so weeks from referral to being seen."  

There are still, of course, varying degrees of 'awkwardness' about mental health problems: "The key to being successful with our young people is knowing them as individuals."  Only then can open discussions between teacher and student take place.

While year seven students at St John's - in their first year at secondary school - have a separate regime, students up to year eleven are in mixed age tutor groups and see their own tutor every morning.  Sixth formers are grouped together. These arrangements make mentoring schemes easy to arrange.

St John's Academy has found an innovative away to help students at the early intervention level.  Currently there is not the time or the resources in school to address all the needs of those suffering panic attacks or anxiety - conditions that do not automatically qualify for CAMHS treatment.

It was the students themselves - in a recent survey - who asked for help with these mental health issues.  And it was Wiltshire Council's area Youth Facilitator, Helen Bradbury, who canvassed students and suggested the school apply through the Area Board for a grant from Local Youth Network funding to run a pilot programme of weekly 'mindfulness' sessions.

The sessions with a specialist practitioner will teach techniques and exercises to calm the mind and through self-awareness help students manage their stress and anxiety.  The school will support this with an hour a week of one-to-one work with the practitioner.

During the pilot, the school will evaluate the effectiveness of the programme subjectively, with a questionnaire at the beginning and end of the programme.

St John's asked for a grant of £5,000.  In January, the Marlborough Area Board approved a grant of £3,500 to fund the pilot for the rest of the academic year - with £500 of the grant put for a proper evaluation of the pilot.  And they wanted this work to become part of the school's budget and spread to other schools in the Academy Trust.

St John's reckons that about five per cent of their students need some attention for mental health issues.  That equates to about one student in every class.  

Wiltshire's lead commissioner for CAMHS explains: "Locally, the bulk of the CAMHS caseload is made up of teenagers - mainly anxiety, low mood and depression." The problems are not so serious or numerous at primary school level - but early intervention is the watchword.

Marlborough St Mary's Primary school is still operating on its two sites - and due to move together into the new school in September.  At the moment they do not employ a counsellor.  

Headteacher Anne Schwodler told Marlborough.News:  "CAMHS offer a very useful service but along with everyone else have very limited funds to cope with the increasing demand for mental health services and it is therefore sometimes quite difficult to get support when it is needed."

The number of pupils who need support for emotional problems has been rising, but it is difficult to give a percentage as the level of need varies widely:  "We have children in Key Stage 1 and Key Stage 2 - pupils between five and seven years old - who need some support with emotional needs for a variety of reasons."

"We have trained Emotional Literacy Support Assistants on both sites who work with children one-to-one or in small groups to support children with emotional issues."

One of the Prime Minister's plans is to offer every secondary school in the country mental health first aid training over three years.  With 'early intervention' the watchword on the lips of politicians and commissioners, it might be advantageous if this was extended to primary schools as well.

In development: part of the home page of the new On Your Mind websiteIn development: part of the home page of the new On Your Mind website

CASEBOOK THREE:  Names have been changed throughout these accounts of CAMHS at work

A third parent who lives in Wiltshire but outside the Marlborough area and has shared her experiences with Marlborough.News, confirms that CAMHS do not always cope well with pre-existing conditions that turn into or come to include a definable mental health problem.  
We will call her Jenny: she sees her teenage son's depression, anxiety and suicidal thoughts as quite separate from his ongoing autism and aspergers: "I just couldn't get through to them how he needed handling differently due to the autism, but that it wasn't necessarily the main cause."
"The CAMHS were lovely people. I did find the young girl we spoke to a bit unsure of how to approach a child with autism.  She did keep saying that some of the negative feelings were caused by the autism, but did not say how to help him."
"Six sessions were nowhere near enough to get a testosterone filled austistic teenager with anger and suicidal issues back to 'normal'. It wasn't even long enough really for them even to get to know each other, to form a trust."
"He also," Jenny says, "lies."  He will lie to create the easiest path: "His keyworker knows this and we have spoken quite often about it.  But in six sessions the CAMHS worker just did not know him well enough to help him."
"He is still bad now, last week we went back to the doctor and he has pretty much demanded more sessions, but it's the school that has to implement this and I don't think they have the clout to get it done.  The doctor did say she would write to the school if it helped - but that my son needed help and needed it now."

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A Wiltshire GP practice disappears as staff shortages hit NHS and social services

On Wednesday (March 29) the Prime Minister will trigger Britain's departure from the European Union.  This will undoubtedly leave the estimated 57,000 EU nationals who work in the NHS feeling even more unsettled and anxious than they have been since June.

We know that Brexit is already having an impact on the NHS.  During 2016 2,700 EU nurses left the NHS - compared to the 1,600 EU nurses who left in 2014.  And only 96 nurses joined the NHS from other EU countries in December 2016 - compared to 1,304 who joined last July.

A morning spent at the Wiltshire Clinical Commissioning Group (CCG) board meeting offers ample evidence of the way the NHS is already, in pre-Brexit times, struggling with recruitment - and the shortage of staff is also hitting social care which in turn affects the NHS.

1)   It was the impossibility of recruiting two GPs to the Marlborough and Pewsey GP surgeries that has caused their merger.  Now, "due to unforeseen GP shortages",  the Smallbrook surgery based in the Warminster Community Hospital has collapsed - leaving its 4,300 patients unsettled and anxious.

This surgery - which in December had been rated 'Good' by the regulator - lost one GP to maternity leave and then two partners suddenly left.  Recruiting one doctor  - let alone three doctors - in a hurry proved, understandably, impossible.  The surgery has now been 'integrated' - temporarily? - with the Westbury Group Practice.   

Smallbrook is still open for three hours a day with priority for appointments given to those who cannot travel to Westbury. The CCG are working on more permanent plans to make sure those 4,300 people have a full and local GP service.

2)  The Avon and Wiltshire Partnership (AWP), which provides the county's adult mental health services, shows a scary example of the endemic recruitment shortfall.  Their teams in Wiltshire have 117 vacancies - a vacancy rate of about 22 per cent.

3)  There was some wry laughter during discussions on the ongoing 'crisis' in A&E and the missed four-hour-wait target. The CCG Board heard that capital money was available to meet NHS's insistence that GPs should be placed at A&E 'front doors' to act as a first line of triage.  The elephant stalking that room was simply: "Where are they going to find all those doctors?"

4)  The CCG and Wiltshire Council's Better Care Plan work to keep the elderly out of hospital and, if they do have to go into hospital, to get them back home faster, will be supported from April 1 by an experimental scheme involving 30 Rehab Support Workers - a new role.  

The plan is for them to help people during their first ten days at home and, over a year, should effect 1,091 timely discharges from hospital.  In the first year they will be costing £1.2million.

Seven of those thirty recruits have come from Wiltshire's Help to Live at Home  providers - leaving them, in turn, short of seven staff who should also be helping patients get home from hospital - and at a time when their work is getting harder.  

A report to the CCG Board stated: "Help to live at Home providers are experiencing increased acuity and are delivering more hours of care, supporting the same number of clients".  

As one CCG director put it, when it comes to recruitment "We are all fishing in the same pond."

5)  Virgin Care which last April took over community health services for Wiltshire's 110,000 nought-to-eighteen year-olds, is also having recruitment problems.  In January their nursing vacancy rate rose by eleven per cent.  

In the last quarter of 2016 they were short of six whole-time-equivalent school and community nurses and currently have clinical vacancies equivalent to 22 whole-time-equivalent posts.

That is probably enough examples to show how great a problem Wiltshire faces.  Why is Wiltshire affected so much by these shortages?  Recruitment plans and staff retention plans abound.  To some extent it is true that "We are at the mercy of the market." But it may be much more of a cultural issue.

AWP appears to have no problems of recruitment for its services in the Bath and North East Somerset area.  Presumably the cultural and night-life of Bath solves their problem.

Facing the closure of Smallbrook Surgery, one Warminster town councillor was quoted as saying: “The town council doesn’t have much on a say on healthcare, but what we can do is do our best to make the town a more attractive place to live - to encourage more GPs to want to come and work here.”

Locally these staff shortages may be partly due to cultural and partly to housing costs.  The problem may be partly a matter of rates of pay and, more generally, of government imposed pay restraint. 

But as Brexit proceeds and EU nurses, doctors and surgeons (and for that matter those from beyond the EU) feel even less welcome in Britain than they have been made to feel since the EU referendum, then recruitment and staff retention could well become the next great problem that threatens to break the NHS.


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A crisis in children's mental health? How is Wiltshire coping? Part Two: how Wiltshire is changing the system

The cover of the Wiltshire transformation plan for children & young people's mental health services The cover of the Wiltshire transformation plan for children & young people's mental health services A three part series on the treatment of children and young people's mental health problems - in Wiltshire and in the Marlborough area.


Does Wiltshire have a special problem with mental health issues among its children and young people?  The county's rate for hospital admissions for mental health conditions (2014-15) was 57.7 per 100,000 0-17 year-olds - against the national average of 87.4.  But the rate for self-harm admissions was above the national average: Wiltshire 478.3 - national average 398.8.

Of course much of the impact from anxiety, depression, suicidal thoughts, fear of exams, bullying, social media problems, shows itself and does harm long before children and young people reach the stage of a hospital admission.  Early intervention is one of the keys to the new strategy for Child and Adolescent Mental Health Services (CAMHS) in Wiltshire.

Last month the Health Secretary told Parliament that a green paper aiming to 'transform' children and young people's mental health will be published before the end of this year.  As is often the case, local health and social care providers are way ahead of the politicians.

New money from NHS England specifically targeted at CAMHS has already brought changes to Wiltshire. Among the improvements bearing fruit is the Improving Access to Psychological Therapies Programme (IAPTP) for children and young people, which began in 2011. 

And Oxford Health are now offering a wider range of treatments and interventions. IAPTP also concentrates on training staff - something that will soon come under NHS Wiltshire's budget.


Another innovation has been the online counselling service for teenagers run by Kooth - with face to face access via web messaging available seven days a week - a format that is appealing to more and more teenagers.

The onyourmind.org.uk website, which is in the process of development, will give information about mental health services and will eventually include an online route to self-referral.  And self-referral is one of the main pleas from older children.

A prime aim has been to build stronger links between CAMHS and schools. The main way this is being implemented is in Thrive Hubs at secondary schools.  It began with six schools in the areas of most need and this is being increased to twelve - see map below.

Each hub has a named mental health practitioner at the school one-and-a-half days a week.  The hub has a drop-in 'surgery', does group work, supports onward referrals, conducts one-to-one sessions, sets up peer mentoring and organises youth activities to build resilience.

  The first six schools to get Thrive Hubs are named in black - the second six in blue (click on image to enlarge it)The first six schools to get Thrive Hubs are named in black - the second six in blue (click on image to enlarge it)

Ian Tucker, headteacher at Chippenham's Abbeyfield School - one of the first tranche of hub schools - is very enthusiastic about its results: "Can I just reiterate the positivity and impact that the Thrive Hub project is having here at Abbeyfield for our students, their families and staff?"

No Thrive Hub yet in the Marlborough Area.  But by April 2018 every secondary school will have a Thrive Hub with a named CAMHS practitioner.  

Changes in Wiltshire's CAMHS over the next three years will be largely based on the joint Wiltshire CCG and Wiltshire Council 'Transformation Plan'.  This is a very comprehensive document that is still at the consultation stage.  It includes many worthy and many welcome ambitions, and it explains the ways in which much of the extra money will be spent to improve services.

Reducing waiting times, bringing services into the community, building up the capacity of services, easing transition to adult services, training mental health workers and teachers and helping parents understand the problems their children face - all take money and time.  

There is one specific area Wiltshire lead commissioner is keen to improve: "We do need to improve support for children and young people with autism."

A step change in these services comes with the end on 31 March 2018 of Oxford Health's contract for Wiltshire's CAMHS. This contract will be replaced with a single new contractor to take over all CAMH services not just for Wiltshire - where it is being commissioned jointly by the Council and Wiltshire CCG - but also for Swindon and Bath & North East Somerset.  Thus contracting one provider for the whole 'footprint' of the Sustainability and Transformation Plan (STP) for our area.  

This contract went out to tender in November and the preferred bidder will be named soon.  And the new provider will take over on 1 April 2018.  

Wiltshire's share of the new contract will be £4,443,400 a year - which will just over half the total value of the seven year contract for the whole STP area. The contract will still rely on the involvement of the voluntary and community sector.  This will include the Area Board Local Youth Networks as well as leisure centres and campus facilities.

There is one underlying feature of the new service - integration.  The division between Council and NHS responsibilities will go.  There will be "No more tiers", a single point of access for all referrals and not such a cliff-edge threshold to overcome  before treatment can begin.  

Another feature the new contractor must address is the empowerment of children and young people in designing and reviewing the service as it develops - something that is already happening in the county (as we reported in Part One of these reports.)

As ever with social care and health plans there is the matter of staffing.  Is there a sufficient number of suitably trained staff available to meet the ambitions of the new service?  The lead commissioner for Wiltshire who is working on the new contract told Marlborough.News: "What we are finding in Wiltshire is that Oxford Health have a good track record in attracting staff - they do not have many vacancies."


But he admits: "Nationally there is an issue around workforce that we need to address." For example, nationally the number of specialist mental health nurses has fallen by ten per cent in the last five year.  

Locally they will need a workforce plan - seeing how to attract the necessary numbers of therapists and supervisors, how to retain staff and how to develop new roles.  

They are working with Health Education England to refine the role of Psychological Wellbeing Practitioners who have experience of child health but do not necessarily have a degree in psychology. They can, for instance, provide high volume, low intensity interventions for children and young people with mild to moderate depression.

Another of the government's plans outlined by the Prime Minister is that the current CAMHS system across England should be 'reviewed' by the Care Quality Commission - ahead of that promised 'green paper'.   When the review is complete, it will be interesting to see whether the plans for our area are ahead of the pack.

Part Three will be online soon:  How Marlborough schools are responding to increased pressures of pupils' mental health issues


CASEBOOK TWO:  Names have been changed throughout these accounts of CAMHS at work

Casebook One gave CAMHS a very positive report - not all experiences of CAMHS are the same:

Linda is a single mother living in Wiltshire with an eighteen year-old daughter (who we will call Frances) and another and older child.  Frances has severe learning disability.

"Generally", says Linda, "she functions pretty much like your average 3-6 year-old."  Two years ago Frances was hit by a series of losses - deaths and absences - over a very short period of time: "She couldn't understand her feelings, let alone articulate them."

Linda was called into school because teachers could not get Frances to do anything.  One time she sat 'wailing in the corner'.  Another time while she was supposed to be eating lunch, she was repeating over and over again a single plea: 'Sing to me and make me happy.'

Linda took her to their GP who referred Frances to CAMHS.  How was CAMHS? "Useless".  The initial appointment with a consultant was, by Linda's account, a disaster.

"I got the distinct impression she had no experience of dealing with learning disability.  She directed every single question to me. Frances picked up on that straightaway. She has a heightened sense of that sort of thing and within a few seconds she wanted to get out. I said 'No'.  The consultant carried on asking me awkward questions in front of my daughter."

"At the end the consultant said 'We can't deal with learning disability'.  I thought that's not much help - and that was that.  Some months later CAMHS rang me back for an update."

Linda has heard of other similar cases - and always there is no explanation as to why CAMHS cannot help.

After discussions with Frances' teacher and senior staff, she was saved by her school:  "At the time they provided a private counselling service to come into school to help a couple of students.  They probably couldn't do that now because of the cuts."

"My daughter is a million times better than she was.  She's almost a different child."

Frances can stay at her special school till she is nineteen.  Special needs funding lasts for three years beyond sixteen - so she will have used that funding up by the time she leaves the school.  Linda hopes she can go to a farm college - she gets on well with animals and could get a certificate in horse studies and some work experience.

Linda is not at all happy that CAMHS will not help young people with a learning disability: "This is a huge chunk of society - and a vulnerable chunk.  You could even say it's a human rights thing."

This case is now being reviewed.

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