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Health & NHS

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

Healthwatch Wiltshire's Young Listeners in actionHealthwatch Wiltshire's Young Listeners in actionA three part series on the treatment of children and young people's mental health problems - in Wiltshire and in the Marlborough area.

There is a growing awareness that child and adolescents' mental health is posing a problem of crisis proportions for health services and schools.  Most importantly, as answers are being found, the children and young people themselves are being asked their views on the services and suggesting improvements.

Healthwatch Wiltshire, the independent organisation speaking for local people on health and care, has published a report on young people's views and worries.

They trained a number of young people to be Young Listeners - and hear first hand and without adult interventions (interference?) about children and young people's experience of Wiltshire's health and social care services.

When it came to mental health there were three clear areas of concern: lengthy waiting times for treatment, the problems when young people had to 'transition' to adult mental health care, and the need for continuity of care.

A student survey at St John's Academy highlighted ways to improve how early signs of mental health worries can better be treated - see Part Three of this series.  

Other views have come from the recent Wiltshire Youth Summit on health and police issues (with representatives from all the county's secondary schools), from Wiltshire's Children in Care Council, from local user participation groups, from the Wiltshire Assembly of Youth, Wiltshire Council's Health and Wellbeing Pupil Survey and Council-led participation in workshops and surveys.

NHS figures show that nationally the number of children and young people with mental health problems attending A&E has increased over the past four years by 89 per cent.  Even if that rise was from a relatively low base, it is an alarming statistic. Childline has seen calls about mental health issues rise by 36 per cent over the last four years.

Half of all mental health problems in adults start before the age of fifteen and three quarters before the age of eighteen.  As one health professional told me, intervention when mental health problems first arise makes not only ethical, but economic sense.

After years and years as a fairly neglected or somewhat hidden part of the NHS, mental health services for young people are coming steadily closer to the top of the agenda.  The Prime Minister has made it clear that young people's mental health is now a priority.   

Young people's mental health services go by the NHS acronym of CAMHS - pronounced 'cams' and standing for Child and Adolescent Mental Health Services.  And the latest figures show that nearly 3,000 children and young people were treated by CAMHS in Wiltshire in 2015-2016.

The lead commissioner for child and teenage mental health who works for Wiltshire Council and NHS Wiltshire told me: "Investment in CAMHS hasn't really kept up with demand - this is now being addressed."

NHS England has provided more funding.   Funds available for Wiltshire's services increased from £5.7million in 2014-15 to £7million in 2016-17 - with increases continuing until 2020-21.  The more CAMHS are improved - or 'transformed' - the more funding comes from NHS England in the form of transformation bonuses.

At present CAMH services for Wiltshire are provided by Oxford Health NHS Foundation Trust - available for 0-18 year olds who are referred by their GP, health visitor, school or hospital doctor.  Several charities also work in this area - for instance Relate provides community and school based counselling.

However the two main tiers of the CAMHS are paid for and overseen by different organisations.  The primary tier - catering for mild to moderate conditions - comes under Wiltshire Council and has about ten staff.  There are also seven consultants providing emotional wellbeing support.

The specialist tier - catering for more severe cases - comes under Wiltshire Clinical Commissioning Group (so is from the NHS budget) and has about 66 staff.

Oxford Health have a CAMHS unit at Savernake Hospital as well as the eating disorders unit there.  Another tier up, Oxford Health also run the 12-bed facility in Swindon - confusingly called Marlborough House - for in-patients from much of Wiltshire and Swindon.

This current organisational structure is described in a Wiltshire Council/CCG document as providing a 'patchy and incoherent service' and it is stretched: "Parts of the local CAMHS system are almost at gridlock with increasing pressure on GPs, primary and specialist CAMHS and A&E departments."  

There are still problems with spotting young people's mental health problems and in dealing with them.  

Emily Palmer - who has had first hand experience of CAMHS and wrote Scrambled Heads - A Children's Guide to Mental Health - did a straw poll of teachers via the internet.  Ninety per cent said they had had no training in mental health and did not feel able or competent to help a student.  

She says teachers often do not want to interfere - feeling they may be 'crying wolf'. When some teachers spot signs of anxiety or worse "There's a dilemma between breaking trust with students versus the duty of care - so they tend to avoid conversations about issues."

And a leading eating disorder charity (Beat) claims that nationally GPs are routinely failing to provide adequate care for patients - with just one in three referred for specialist assistance.  Of 1,267 people questioned who had sought help for an eating disorder from their GP, 34 per cent said they did not think their doctor knew how to treat them.

Moves to provide a fit for purpose CAMH service in Wiltshire have already brought significant improvements.  And next year there will be a step change in the service with a new contract for a single provider across all CAMHS services - to answer the challenge of turning CAMHS into a whole system rather than a series of providers.

Like commissioners across England, Wiltshire Council and the CCG will be under 'significant' scrutiny to make sure all the new money designated for improving CAMHS is really getting to the font line. It is there it is so badly needed to help children and young people ward off the mental health problems to which they are  prone.

A recent letter from NHS leaders warning that local NHS bodies must meet the 'acid test' and prove where the money is going, shows they are worried new cash for mental health may not be properly used.   They are demanding accountability and transparency for mental health spending.

Part Two will be online soon:  Transforming CAMHS services for Wiltshire

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

We will call her Anne.  One of her two children - who we'll call Jill - is now sixteen. At primary school Jill was very disruptive, but at secondary she appeared to have calmed down.  Then one day at school, when she was twelve, she tried to hang herself - and was automatically referred by the school to CAMHS.

"CAMHS", Anne says firmly, "were good."  Her daughter was seen quite quickly.  She was prescribed talking therapies.  Then there was a gap while a new therapist was employed - and during that time she tried to kill herself again.

Although she got a bit better, Anne says: "Talking therapies were not really successful for her."  She was discharged after five months.  

Anxiety about school work and the pressures of school exams got the better of her again.  They tried more talking therapy.  It did not work.  So she saw a psychiatrist who put her on medication and she is still on it.  She has recently had another 'lot' added to her dosage: "And that seems to work".

Anne told me:  "CAMHS were wonderful."  They worked with the school to find ways to make things easier for Jill.  And Anne has meetings at the school every six weeks.  

Jill sat her GCSEs: "She didn't get the grades they'd predicted - ABs. But she got good grades - BCs.  Better than we hoped. We were quite impressed because we didn't think she'd make it to the exams."

Now in the sixth form, she is finding the going very tough.  She is getting a lot of support - a teaching assistant, who has a long experience in this area, sees her three times a week. "There's been no talk of suicide for the last two months - and her panic attacks have calmed down."

Anne stresses the help given by her other child, who is two years younger than Jill, has been "Fantastic - he's been brilliant with her.  The times she won't talk to me, she'll talk to him."  He has had help from his school and been supported by Young Carers Wiltshire.

Anne is very positive about the changes coming to CAMHS.  She is especially hopeful that parents will be able to refer children to CAMHS - up to now referrals are mainly  by a GP or teachers.  And she favours self-referral too.  She wants more schools to sign-up to having CAMHS staff on the premises.

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Home to Assess: GWH pilots new scheme for earlier discharge to free up beds & relieve pressure on A&E

GWH's Home to Assess leaders: (l to r) Emily Hussey, Alison Koster & Jill KickGWH's Home to Assess leaders: (l to r) Emily Hussey, Alison Koster & Jill KickNo one can keep admitting sick people to a hospital if those whose treatment is complete and are ready to go home are not leaving the wards.  

Blocked beds - also known as 'delayed transfers of care' (DTOCS for short) - cost the NHS dearly and cause longer queues in the hospital's emergency (or A&E) department.

At Great Western Hospital they have started a pilot of a system called Home to Assess and it is already having an impact on the number of empty beds GWH has available on any one day.  

At present it - as Chief Executive Nerissa Vaughan told the GWH Board - '"Small stuff'. But the results in terms of freed-up beds were, she said, good: "It's the first time ever we've had positive information about DTOCs"

When I went to meet the leaders of the Home to Assess team, GWH was on a high state of alert - that means the hospital was FULL.   During October GWH was running with bed occupancy at 104 per cent - with extra beds brought into use. The level of bed occupancy for safe and efficient treatment of patients is considered to be 85 per cent.

For those fit enough after medical treatment, Home to Assess moves the assessment process for the care they will need, from hospital to home.  

To explain how it works I met the three people leading the scheme: Senior Occupational Therapist Emily Hussey, Jill Kick working in Discharge Services and Alison Koster, with a nursing background and now GWH's Associate Director of Patient Flow.

And sustained flow through the hospital is what this is all about: it is crucial not just to free up beds for those who need to be admitted from the emergency department, but also for the safety of frail and vulnerable patients.  

These three health professionals know well that staying in hospital too long can be bad news.  The old can very quickly become institutionalised so losing independence, they can pick up infections and they can have falls: "Family members," says Emily, "really came on board - once they had it explained that hospital is not the best place for their relative."

The Home to Assess (H2A) scheme turns the usual process upside down: instead of waiting in hospital while they are assessed for the type of care they need and an appropriate care package is assembled, some patients who are deemed fit enough will go home and be assessed in their homes. But no one is sent home who will not be able to manage between care calls.

"Hospital", Alison Koster told Marlborough.News, "is quite a false environment for assessment for what care and help they need at home."  It is one thing to ask a patient while they are lying in a hospital bed and hoping to leave if they can make themselves a cup of tea at home - and tick the box.  It is so much better to see them making a cup of tea in their own home.

If, after medical treatment, a patient needs a wheeled Zimmer frame, they may find it easy and safe to use on the hospital's flat and uncarpeted floors.  Get them home and they may well fall as they try to negotiate carpets, rugs, narrow doors and hearths.

Patients are chosen for H2A with reference to the NHS' exacting codes of fitness and they are discussed with the clinical specialists treating the patients and at daily multi-disciplinary meetings. Individual needs and the wishes of relatives are taken into account.

When each H2A patient arrives home they will have someone there to make sure they are all right for the night.  Next morning the assessment starts - with a "burst of support" to complete their assessment within their first 72 hours at home.  It is a staff intensive scheme.

They will be seen first by an occupational therapist, followed by nurses and sometimes a physiotherapist.  The occupational therapists do the functional assessment - making sure a patient can cope with personal care, is safely mobile and can carry out domestic tasks.  This is the key element in determining a patient's care needs.

The H2A team at GWH is small at present - two occupational therapists, a physiotherapist and intermediary care nurses from the community team.  The current pilot scheme only concerns patients from Swindon.

Emily Hussey and Jill Kick are new members of GWH's staff.  In October they transferred to GWH from the social enterprise organisation SEQOL when GWH became caretaker for Swindon's community healthcare services.  GWH takes over the full SEQOL contract in February.

Emily and Jill's close involvement with this scheme shows the advantages that more integrated community healthcare services will bring to GWH and its patients.

This team have many plans for the future - more use of tele-care and tele-health (remote monitoring of vital signs) and the introduction of single-handed equipment - aids for the old and disabled which only need one person to handle patients safely.

This H2A scheme is not unique - it has been used by a hospital in Aintree and a similar scheme is used by Salisbury Hospital.  At GWH the scheme was set-up as part of the hospital's plans to combat 'winter pressures' and was funded by the Swindon Clinical Commissioning Group.   

It started on November 14 and has so far involved 32 patients - all but one of them continue to function well at home (one needed 'reablement support'.) In the new year, the team's aim is to use the scheme for five patients a day five days a week.

Delayed discharges are at crisis point.  In October GWH lost the equivalent of 805 bed days due to delayed discharges.  This was less than the September figure but was a 42 per cent increase on October 2015.  The November figures are expected to be more sertious still.

Beds are in demand:  GWH had to cope with 165 more emergency admissions in October than in September - and that was an 8.7 per cent increase on October 2015.

The hospital's plan to reach required government target for number of people coming to their emergency department and being seen, treated, admitted or discharged in under four hours, relies on the number of DTOCs being halved.  So the success of H2A is very important.

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STP WATCH: "Time for change" - full plan for future of Wiltshire's NHS to go public in three weeks

It is forecast to be 'fairly uncontroversial', but the Sustainability and Transformation Plan (STP) for the area that includes Wiltshire dominated the AGM of the Wiltshire Clinical Commissioning Group in Salisbury on Tuesday (November 22.)  

We have already had a published summary of the plan, which mainly spelled out the intentions for the NHS across Bath and North-East Somerset (BANES), Swindon and Wiltshire - an area known as BSW.  It remains to be seen how detailed the version to be published on December 14 will be.

The leader of the BSW planning, James Scott (Chief Exec of the RUH in Bath), told a recent meeting of Wiltshire councillors that details will not become clear for six months.  Tuesday's meeting of the CCG was told that BSW is " the early stages as regards the maturity of our plan."

The basis of the plan was spelled out to the meeting under the heading: "Time for Change".

Tracey Cox (Accountable Officer for BANES CCG and at present for Wiltshire CCG too) was quite open about the problems the STP team faced: "In an extended period of financial austerity, the resources are not enough for the needs and demands we are facing."  But she described the BSW plan as 'fairly uncontroversial': "If anything our plan isn't radical enough - to be honest."

Tracey Cox gave an outline of work being done on the four main areas of health care the plan addresses: primary care, urgent care, planned care and preventative care.   She leads the work on this last area and explained work planned to combat diabetes.

A member of the public asked why there was no mention in the STP summary of mental health.  The answer was that each area has mental health components within it - and further plans for mental health care in Wiltshire will be announced by the end of next month.

And Dr Chet Sheth, of the CCG's Sarum locality, said that mental health 'is all our concern': "It's not just about the STP working downwards, but about all of us working upwards."

One of the difficulties with the STP policy is finding a balance between what is good for the wider STP area (or 'footprint') and the more locally identified needs and decision making which have been the mainstay to date of Wiltshire CCG's policy making and programmes for community based health care.

This difficulty was acknowledged at the meeting.  It may become more of an issue as procurement of services is going to be done on a 'footprint' wide basis.

Another main topic for the AGM was the unreliability of the Arriva non-emergency ambulance service.  A member of the public said there had been no sign of improvement.  

He had canvassed nurses who were 'unanimous' that it had not improved and that ordering an ambulance by phone sometimes took half-an-hour.  He stressed that the drivers were being put under unreasonable pressure: "Drivers come out of it well - it's the management."

There were reports of patients being kept in hospital for an extra night because an ambulance was not available to take them home.  

For the CCG it was said that the contractual process that was underway to ensure improvements could end in the cancellation of the contract. However: "We can't terminate the contract immediately."  

If a new contractor has to be found for this Wiltshire service will it be drafted purely to suit the county’s rural geography or, if it is an STP-wide procurement, will one contract cap have to fit Wiltshire, BNES and Swindon?

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The NHS in crisis: Wiltshire's health services hit by staff shortages - and we have not got to Brexit yet

GWHGWHThe NHS is all things to most people. It has been called a super tanker (slow to turn around), Britain's answer to Americans' 'motherhood and apple pie', an organisation so big it can be seen from space (like the Great Wall of China, but much more useful), the Daily Mail's favourite target as a gross interference with capitalism...and, much, much more often than not, it is called a lifesaver.

If the NHS was a stick of rock the word written from one end to the other would undoubtedly be 'workforce'.  At a recent meeting of the Wiltshire Clinical Commissioning Group's board, 'workforce' problems were mentioned during discussions on just about every agenda item.

The NHS is facing this crisis of underfunding and a huge growth in demand with one hand tied behind its managers' and clinicians' backs: the appropriately trained and willing workforce is not available.

Jeremy Hunt's promise - made, we should not forget, to raise applause at  the Conservatives' conference - of 6,000 more British doctors may be a long-term fix.  In the short term it simply tells overseas doctors working in the NHS that they are not valued and may not be allowed to stay.  Not totally helpful.

The 6,000 may not fix the problem at all once Brexit has meant Brexit and an unknown number of overseas doctors decide they do not like working here labelled as 'foreigners' and likely to be asked in the street when they are going home.

It is not only a problem for hospitals.  The Marlborough Medical Practice have been trying for nine months to recruit a doctor.  And now one of their doctors has left, they are one doctor down.

Lets have a look at the impact of this workforce crisis on one of the three acute hospitals that serve Wiltshire: the Great Western Hospital NHS Foundation Trust south of Swindon.  

Their board meeting was told (October 6) the hospital has vacancies equivalent to 9.6 per cent of its planned staffing level - that is equal to 366 fulltime staff members.
283 of those vacancies are being filled with locum and agency staff and with staff from their own 'bank' of part-time staff.

The current (July) vacancy figures include a nurse vacancy rate of 11.3 per cent and for Band 5 nurses ('staff nurses') of 18.29 per cent.

GWH lists many risks arising directly from "Staffing levels" and "Staff capacity" and some of these pose threats to 'patient safety' and to the 'patient experience'.  Some are at crisis level: "We have a crisis in paediatrics with only five out of eight Registrar vacancies filled in September 2016 and four out of eight filled in October 2016."

Or take another line in their very transparent register: "Risk to patient experience and quality of patient care (including patient safety) by a lack of timely access to in-patient bed capacity. As a result, the four hour access target is at risk of not being delivered resulting in patients having extended waits in the Emergency Department."

This risk is being met with a "review of nursing establishment and the patient flow team..." and writing a business case "to increase the nursing establishment in Patient Flow to cover seven day working."  And seven-day working was an unfunded  manifesto commitment - so where is the finance for an increase in the nursing establishment?

GWH has made strenuous efforts to recruit nurses - both locally (through their close relations with Oxford Brookes University's training courses in Swindon) and through recruitment visits overseas.  Last spring they went to India, but because of the very high level language tests, the nurses they signed up will probably not arrive for another twelve months.  

They have had successful recruitment visits within Europe and are about to recruit again in Spain, Croatia and Romania.

Part of GWH's problems with its workforce shortage is due to low retention rates - too many staff leave.  Over the last twelve months they had 828 new starters (excluding junior doctors), but 748 staff left the Trust - a turnover rate of 15.15 per cent, which is higher than at neighbouring Trusts.  Their target turnover rate is 13 per cent.

There has been some poaching of staff by other trusts waving 'inducements' at candidates - Gloucester offered an eight per cent premium to nurses.  And there is talk that the Sustainability and Transformation Plan (STP) for our area will include a 'one workforce' policy to avoid poaching within this STP's 'footprint'.

The GWH board heard the outline of a new Recruitment and Retention Plan with firm policies to create career paths for staff as GWH's service commitments grow.  From October 1 they are taking over staff for Swindon's community healthcare for adults.   The current provider, the social enterprise organisation SEQOL, are in some trouble and GWH are now 'caretaking' the service until they take over the contract in February.

Why does GWH have such a problem with retention?  It is largely to do with post- codes.  When newspapers rail against a post-code lottery in health services, do they really believe that there can be some sort of cloned and perfect service in every location - not even a command economy could provide that.

It is a matter of 'urban cultures'.  Swindon is not like tourist towns of Bath and Salisbury or like student-filled and vibrant Bristol.  There may be a recruitment and retention problem that is simply beyond the remit of the NHS to repair or improve.  Without wishing to denigrate Swindon, it is probably not the first place where a young graduate nurse might want to live.

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STP WATCH: neighbouring NHS 'footprint' to save millions by cutting number of registered nurses

Keeping an eye on forthcoming NHS changes that may also affect or influence plans for our area:

A neighbouring Sustainability and Transformation Plan (STP) area - or 'footprint' - has declared its intention to cut its workforce costs by £34,200,000.

The Buckingham, Oxfordshire and Berkshire STP area's newly published document states that the three counties are going to introduce more 'generic support workers' across health and social care and employ fewer registered nurses.  The document calls for "...skill mix changes to support a more flexible workforce".

A report in the Health Service Journal says that a projected workforce growth for the footprint of 4,526 full-time equivalent staff will be reduced to an increase of just 978 - despite admitting staff will face "...approximately fifteen per cent more patients".

Among those 'generic support workers' will be healthcare assistants and physicians associates.   They also hope to save a further £17,800,000 in their spend on agency staff by setting up an STP-wide staff bank - these are generally nurses who do not want full-time jobs but need to work fill-in shifts at hospitals.

We are constantly being told that the STP project teams will not be a permanent part of the NHS' organisation.  But this neighbouring STP footprint - known, apparently, as BOB - is planning to set up a board that will meet monthly to 'hold the three health economies to account' as they try and implement the new plans.  

Statutory responsibilities will remain with the clinical commissioning groups and with the hospital trusts and, presumably, with the local authorities - but there will be an executive for the all three counties that will be commissioning health provision.  One of their targets will be a saving of £60,200,000 by preventing an expected three per cent growth in commissioning specialised treatment services - see below.

This is beginning to look more and more like a major restructuring of the NHS organisational model set-up by the Lansley reforms during the coalition government.  Inserting an extra layer into the organisational hierarchy will get very close to reintroducing the Strategic health Authorities that the Lansley restructuring abolished.

These plans came in the same week as research published in the British Medical Journal Quality and Safety Journal found that diluting the nursing skill mix increases the risk of patient death. The study revealed that for every 25 patients, substituting one registered nurse with a non-nurse increased the possibility of the patient dying by 21 per cent on an average ward.

One anonymous comment published on the Health Service Journal website says: "Mid Staffs anyone? It beggars belief that despite all of the evidence demonstrating the value of [registered nurse] time and the improved safety and quality of care - when faced with austerity they all cave in."

FAQ:  What are specialist services?  They are treatments centralised in relatively few hospitals serving a large enough area with enough patients enough patients with rare disorders so that expert teams can be recruited and can develop their skills.  They include services from renal dialysis to treatments for rare cancers and life threatening genetic disorders.  NHS England spends £15.6 billion on funding specialised services.

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The NHS crisis: "Slow down! Diversion ahead - consultations underway"

Changes to the NHS are hurtling towards us as the service lurches from crisis to crisis - and even, in some cases, is running out of cash.  

As Marlborough.News has been reporting - at some length, we're afraid - the Sustainability and Transformation Plans (STPs) will almost certainly have to find savings not just in the 'back rooms' of hospitals and GPs' surgeries, but in front line service reductions that will affect patients - affect us all.

But of course the changes will not be hurtling anywhere.  They will be held up by complex consultation processes and rows between councillors, local politicians and NHS managers and clinicians.

Councillors in Salisbury have already cried foul at changes made by Wiltshire Clinical Commissioning Group (CCG) to the opening times of the Salisbury Walk-In Centre.  From August 1 the Centre's opening hours were changed from 8am-8pm x 365 days a year, to providing an out of hours service in the evenings and at weekends.

Councillors took the opportunity of an extraordinary meeting of the full City Council on August 8, to pass a resolution noting the lack of consultation on the changes:

"The council calls on NHS Wiltshire CCG to consult fully on the proposals to reduce opening hours of the Salisbury Walk-In Centre from 84 to 41.5 hours per week and reconsider these reductions in service."

During debate at the meeting - which the Chairman opened to 'members of the public gallery' - another sentence was added to the resolution: "If the evidence suggests there is a need for 84 hours for the CCG to make arrangements to increase them accordingly."  The resolution was passed by 15 votes to one.

No change in the NHS can be taken on its own and councillors were worried this change would simply end up "...transferring costs to the Accident and Emergency Department at Salisbury District Hospital."

But perhaps the key statements came from local residents who "...voiced their concerns that money was being saved at the cost of local people..." and one of the residents commented "...on the short consultation period of 14 days."

There will obviously be a flourishing growth in NHS Nimbyism when all these changes are announced: how can they plan to save money "at the cost of local people"?  On the other hand, how can NHS money ever be saved without being at the cost of local people?   

And if money is not saved, and if the government fails to find the Gove-Boris Euro billions for the NHS, the cost to local people could soon be in collapsed services.

Like the proverbial super tanker, the NHS takes a good while to turn about.  But there is no 'good while' available here for some services will almost certainly run short of cash to pay staff before the end of the year.

Into this argument - which is central to the STPs that are very soon (we hope) going to be published for all to see - steps Roy Lilley.  He is a well known health service policy analyst, who runs the and writes entertaining and wise columns for them.

In a column this week he looked at the delays to change and savings that lengthy consultation periods bring - defying the urgency of the changes, in some cases obscuring their necessity and merely postponing savings that had to be made.  He wrote:

"The solution must be a new, fast-track consultation process.  Something like:
    •    Seventy days max, starting with the presumption... change will happen.
    •    No consultation documents longer than two sides of A4.
    •    No one may object unless they have actually been to a public board meeting and listened to the arguments.
    •    Social media [to be] the backbone communications route.
    •    Paramedics have to give an opinion, in public.
    •    All changes must be clinically led.
    •    ... and, NHS managers have to talk plain English and stripped-pine truth about money and why they are doing, what they're doing.
The changes the NHS needs are urgent.  They should not defy the democratic process, they should dignify it with the speed and clarity it deserves."

What do Marlborough.News readers think about his suggestions?  Are they worried about the future of the NHS?  Send us your thoughts: This email address is being protected from spambots. You need JavaScript enabled to view it. 

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