The Bath and North East Somerset (BANES) Clinical Commissioning Group (CCG) has selected Virgin Care as the preferred bidder for its £700 million community health services contract. The contract is worth £69.2 million annually over seven years - with an option to extend by a further three years.
The contract covers 200 different services - from district nurses to the falls prevention team - currently provided by 60 different organisations.
The Virgin Care bid looks set to be approved by both BANES CCG and BANES Council during November - with a handover in April 2017. The CCG is selling this as bringing "more community care, closer to home."
Does this matter to Wiltshire's NHS provision? It probably matters quite a lot - BANES is part of the new area organisation for Sustainability and Transformation Plans that includes Wiltshire and is currently drawing up new plans for the delivery of NHS-funded sertvices across the STP area.
In addition, the Virgin Care offer looks very much like a version of an Accountable Care Organisation (sorry - that's an ACO) - one of the new ways of delivering services on the NHS' current reorganisation agenda. An ACO passes the responsibility for the detailed commissioning of health services from the CCG itself to a single commercial or NHS provider.
In this case the CCG will be contracting with a single organisation to commission and monitor those 200 community health services - that will in effect see Virgin Care acting as an ACO. A slimming down of CCG staff can be expected to follow the April handover to Virgin Care.
It is understood that Virgin Care will be able to sub-contract as many of the 200 services covered by the contract to other providers - commercial, NHS or charities - as it sees fit. This change could well result in months of uncertainty for the employees currently delivering the services.
In the CCG's announcement, the BANES Council cabinet member for Adult Social Care, Councillor Vic Pritchard, says people who were consulted on the contract "...asked us to join up services and information so that it’s easier for different professionals to work together to coordinate care. Virgin Care will enable this to happen by bringing people’s health and care records into one secure place.”
He adds: “We will also include a clause in the contract which requires any financial surplus made by the new prime provider to be reinvested into services in BANES.” This will parallel the Wiltshire deal for children's community care with Virgin Care which Baroness Scott has said has a clause stating that no profit will be made from the contract.
According to the Health Service Journal, Virgin Care was preferred over a consortium led by the Sirona Care and Health (a social enterprise group), in partnership with the Avon and Wiltshire Partnership Mental Health Trust, Bath's Royal United Hospital and a local group of GPs.
It was only six years ago that BANES council put Sirona in charge of its social and health care services - moving 1,700 members of staff into the social enterprise organisation. Sirona's website still says it is "In Partnership with Bath & North East Somerset Council". Sirona also have an active role in Swindon's health services.
Recently BANES CCG was given the headline rating of 'Requires Improvement' - as were several others of England's CCGs. This related mainly to the CCG's failure to meet NHS targets - notably for urgent and emergency care and access to elective care.
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.)
After they had reported rumours he was being sacked, the television headlines said simply ‘Jeremy Hunt remains as Health Secretary'. They did not mention that the NHS remains in dire circumstances. Nor did they warn that the sacks of gold promised by Brexit campaigners for the NHS are most unlikely - repeat most unlikely - ever to be delivered.
In fact the situation in the NHS is getting steadily more alarming. Should anyone think that is 'doom-mongering', listen to Jim Mackey, head of NHS Improvement and probably the second most important person in the NHS. On the day (July 14) Mr Hunt kept his job, he told a conference that the NHS is "in a mess."
Finances are tightening still further, hospitals have posted record deficits, recruitment of staff from overseas is under Brexit threats, the latest way forward - through Sustainability and Transformation Plans (STP) - are taking longer than expected to draft and now the safety of patients is being set against cost.
Members of this government have poured scorn on the Labour government on whose watch the Mid-Staffordshire scandal occurred. Now this government is telling hospitals which are running deficits that they should not automatically employ staff or improve facilities to meet levels advised by the regulator or standards set by royal colleges.
This latter move has shocked those colleges. The Health Service Journal quoted Royal College of Nursing chief executive Janet Davies: “This gives completely the wrong message to trusts, whose boards are responsible for the care, treatment and safety of their patients, by suggesting that finances are more important than patient care."
The move will create a new splash of red on hospital risk registers which are already facing a blizzard of new rules - such as caps on agency pay and on management pay - and are still struggling to reduce their deficits.
There are warnings in there air of cuts to services and loosening of targets - the four hour target for A&E waiting times is thought likely to be changed to ease hospitals’ woes.
A reality check is being published by Wiltshire's Clinical Commissioning Group (CCG) in a series of paid, full-page newspaper announcements. The first one came under the headline "Our challenges".
The CCG warns of "Future cuts - Annual funding is less than needed to meet demand" and talks about the 'impact of the cuts to social care services' and points to the "£500million funding gap across Wiltshire, BANES and Swindon for 2017."
The first advertisement quotes Dr Richard Sandford-Hill a GP at Market Lavington Surgery and member of the CCG's board: “Providing health care for an increasingly ageing population is difficult. In my own practice a majority of my routine appointments are attended by people aged over 65, and those people often have complex long term needs."
The CCG's text continues: "The NHS is used to doing as much as it can with ever-stretched budgets. The shortage of people working in social care means that together with Wiltshire Council, we're doing our very best to make sure we can support people. And it's not all doom and gloom - we're making some great strides forward to make sure we can properly deal with some of the issues we are facing."
The second advertisement in the series concentrates on explaining 'How we support you to live well' and has a careful guide to choosing the right healthcare when someone is feeling unwell.
On the day Mr Hunt was confirmed in his cabinet post, the much revered King's Fund produced a report on Deficits in the NHS 2016: "There needs to be realism about what the NHS can achieve with the funding allocated for the rest of this parliament."
The King's Fund calls on the government to review the promise of a full seven-day service and believes the government "...has a responsibility to be honest with the public about the consequences of the NHS 'offer', particularly in view of its manifesto commitment to 'protect and improve' the NHS."
The Wiltshire CCG is certainly being honest with the public in its series of advertisements.
Wider planning for Wiltshire's health services:
Amidst all this turmoil, senior NHS leaders in the county are working hard and to very tight deadlines on the STP across Wiltshire, Bath and North-east Somerset and Swindon.
Not everyone is happy with how the STP is being drawn up. One the most vocal critics is Wiltshire Council's leader, Baroness Scott. Her unhappiness about the process and the role given to the Council and its staff (first reported by Marlborough.News in April) has now been repeated - even more forcefully.
At the full council meeting on Tuesday (July 12) Independent Councillor Chris Caswill, asked when the plan would be made public so it can be scrutinised by the public. Baroness Scott: "I would love to know. This is not being led by this Council."
"I was very disappointed when NHS England changed the rules...to the Health and Wellbeing Board (HWB) and the Council being just consultees on it."
"That is not what I think should be happening if we are going to integrate health and social care." She did say the HWB was getting updates on the planning talks. But ended her reply: "I haven't seen it yet."