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Health & NHS

The shape of things to come? Virgin Care named as preferred bidder for Bath's community health care

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.

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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.)

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As Jeremy Hunt stays as Health Secretary, the NHS gets a dose of reality

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 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."

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Changing of the guard for Wiltshire's NHS - just as Brexit poses new problems for health services

Deborah FieldingDeborah FieldingHaving steered Wiltshire's Clinical Commissioning Group (CCG) as its Chief Officer through its first - and pretty difficult - four years, Deborah Fielding has left to return to her home territory of Essex and a new NHS commissioning role.  Her place will be taken by Finance Director Simon Truelove - until he leaves in September.

Marlborough.News went to see her on her last day at Wiltshire CCG's Devizes headquarters - we wanted to find out what her legacy would be and what the future holds for the CCG itself.  And she had important news about NHS111.

The very next day we got evidence of a major part of her legacy: from July 1 the county's adult community health services are in the hands of a partnership or joint venture between the three major hospitals that serve Wiltshire (RUH in Bath, GWH in Swindon and Salisbury Hospital) under the title Wiltshire Health and Care.  

They were commissioned by the CCG after a long and careful tender process: "The joint venture gives us the opportunity to continue collaboration."  She sees this collaboration as key to the Sustainability and Transformation Plans (STP) she has been working on with Bath and Swindon CCGs and the three hospitals during her final months in Wiltshire.

"The STP could be the solution.  I think it could be a real opportunity for Wiltshire.  There's unparalleled collaboration. Not everything can be commissioned at local level."

However STP will alter the position of CCGs in the NHS organisational hierarchy: "The role of the CCG is changing.  I think the CCG has a really important role in developing primary care and community based services.  Eventually those services will become Accountable Care Organisations (ACOs) - commissioners and providers.  The CCG will be needed to manage and monitor ACOs. But it'll become smaller."

"We have", she says, "improved collaboration across the system".  She came to Wiltshire for the CCG's start-up period and her first task was to prevent Wiltshire having three separate CCGs - both the south and west of the county wanted to go their own way - on their own.

She and her team set-up one CCG for the county with a three locality structure: "We developed a common strategy that could be implemented locally - depending on local conditions - based around integrated teams of health professionals serving populations of around 20,000."

How have these changes to the NHS in Wiltshire come about: "Partly economic necessity, partly leadership - including the leadership of our GPs.  We're lucky in Wiltshire to have such good primary care."  One result will be a new building to house Devizes urgent care service - the application for planning permission will be made in September.

From time to time during her four years relations between the CCG and Wiltshire Council have been strained - sometimes very strained, for instance over the ownership of NHS funding: "Relationships have been repaired. We have to work through the challenges. The government haven't helped by funding social care particularly badly."

She says Council leader Baroness Scott has the needs of the people in mind: "Strategically working together is not difficult - because we both work through localities and both want Wiltshire patients treated within Wiltshire.  The population needs to become paramount - at the local level."

The controversial contract for the NHS111 telephone service for Wiltshire comes up in 2018: "We are working on a more integrated urgent care structure which will include 111.  It will be more locally sensitive and make better use of clinical skills and new technologies - so patients are directed to the right place at the right time."

"Safety is not the biggest problem with the current service - if anything they're over cautious - sending more people into A&E."

We spoke to Deborah Fielding during that strange gap in contemporary history between hearing that Gove wanted to be the new Prime Minister and that Johnson realised he could not be the next Prime Minister.  So Brexit was much on our minds and will be hovering over the NHS for years to come.   What would the impact of leaving the EU be for the NHS?

Deborah Fielding says there are two really big and important things that affect the care you will get - money and people - and both are put in jeopardy by Brexit: "If Britain goes into recession there will be less money for the NHS - there is no doubt about that."   The people part is all about the workforce: "The NHS is dependent on our European workforce and that's dependent on the free movement of people."

Then our talk turned to a photo [see below] that had been whizzing around social media that morning.  It shows the surgical team a hospital in England.  Just one member is a British citizen (of Pakistani origin), the rest are all European (that's European as in 'from the EU').

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The NHS crisis: controversial changes may be coming to Wiltshire's health services - sooner or later?

Later this month leaders of the new NHS grouping that includes Wiltshire, go to London to hear the official response to their draft Sustainability and Transformation Plan (STP) that will also cover Swindon and Bath & North-East Somerset.  This so-called 'footprint' for the STP reorganisation is known in NHS-speak as BSW.

This response matters as an approved STP brings with it extra funding from a £2.1 billion central fund for the NHS in England.  In the first month of the new financial year, Great Western Hospitals Foundation Trust was £100,000 adrift from its target.  And that included a month's share of the promised STP funding - without that money they would have been £788,000 in deficit.

The majority of Trusts across England finished the last financial year in deficit.  As the graphic [below left] from the Health Foundation shows, this situation has been deteriorating over the past four years

BSW's plan is at a formative stage and its workings are largely below the radar - though it is said to be "all consuming" as regards Wiltshire CCG's executive team.  There are some hints as to what will be coming Wiltshire's health services way in the near-ish future.

[Click on image to enlarge it][Click on image to enlarge it]The NHS Chief Executive, Simon Stevens, floated the idea of 'combined authorities' that could emerge from decisions made under the STP.  These would probably unite commissioners and providers - for instance a CCG and one or more hospital trusts.  

Another set of initials introduces the Integrated Care Organisation (ICO) - joining social care departments and hospitals.  An ICO in Salford is already being formed and 400 council staff have been moved to the Salford Royal Foundation Trust's payroll.  At least stabling them with the hospital trust rather than the local Council will avoid further politicising health services.

One thing is certain: STPs will involve 'controversial changes' - so much so that Stevens has promised 'safe harbour' for NHS leaders who make those decisions.  This means, it seems, that NHS national bodies will sign those leaders up for a period of 'three, four, five years' - so they can survive in the face of any fierce public or political firestorm in reaction to their decisions.

Perhaps that is what the CCG's outgoing Chief Accountable Officer, Deborah Fielding, meant when she told her board (May 24): "The next couple of years are going to be really difficult for CCGs."

In some recent minutes of Wiltshire CCG committees there are hints at how stringent (some would say ruthless) the STP regime is going to be.  Talking about human resources matters, one executive notes that " would be even more important to support staff with the advent of the STP and the Accountable Care Organisation."

Does this mean the CCG or the STP grouping have decided to go down the Accountable Care Organisation (ACO) route?  A CCG can contract a single ACO (made up of hospitals, charities and private companies) to arrange and provide all health care for the CCG's population.  And, with the CCG's responsibilities then reduced, its staff is slimmed down accordingly.

At a CCG meeting in February there was a warning too about other members of the STP grouping: "The Committee discussed the STP and it was reported that Swindon and BaNES have an estimated funding gap of £70million for 2016/17.  An action plan needs to be in place by June 2016 to address this gap."

And discussing 'affordability' of services and the CCG's budget, the Chief Finance Officer said: "...with the 2016/17 population growth, it was essential that more people were kept out of hospital.  It was necessary to reduce hospital capacity in order to keep admissions down."

Does this fit the 'by-pass' theory of supply and demand?  In terms of traffic management, if you build a new by-pass it will fill up with cars.  But the theory does not explain where the cars were before the by-pass was built.  

If this theory is applied in reverse to a reduction in hospital capacity - that is closing wards or even hospitals - it presumably means that with fewer hospital beds there will be fewer people needing to be in hospital.   

But the theory certainly does not explain where those people who are now ill enough to be admitted to hospital will go when there are no beds for them.  Not everything can be treated at home.

Seen from GWH - at the northern end of the BSW 'footprint' - there is a very different view of hospital capacity - see separate story.

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Charity amidst the alien corn

Some will - probably - say it was aliens wot dunnit. Others that very clever crop circle designers have returned to Hackpen Hill with charitable intent and a very large design that goes way beyond the term 'crop circle'.

This pattern-in-the-field is on Weir Farm, Uffcott. Last year James Hussey, who had recently lost his wife to cancer, opened up his crop-circled field at Hackpen to raise money for the Great Western Hospital's Brighter Futures fundraising campaign to build a radiotherapy unit to GWH - bringing cancer care closer to Swindon and the northern population of Wiltshire.

He raised a tidy sum.

You can visit this year's 'circle' - in return for a donation to this fund.

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The little machine that's helping doctors tell when antibiotics are NOT needed

Antibiotics, having revolutionised medicine in the twentieth century, now find it hard to keep out of the headlines.  One day it's their crippling cost to the NHS' finances (about £190 million a year), the next day they are being over-prescribed by doctors, and on very bad days it's reports that some ordinary bugs have developed resistance to antibiotics and they're not effective against new breeds of superbugs.

A little machine - pictured on the right - sitting on the bench in a local surgery could become an essential part of the struggle to keep antibiotics effective - and save the NHS some money.

It's the Alere Afinion blood testing system and it has been helping doctors at Great Bedwyn's Old School Surgery since October.  A grant from the Friends of Savernake Hospital and the Community enabled the medical practice to rent one of the machines and set itself up with the equipment needed to make each test.

The test is used for two main groups of patients.  First for those who come in with cold or flu-like symptoms and want - even demand - a course of antibiotics.  The machine will give a very fast read-out of the CRP (which stands for C-Reactive Protein) level in the blood.  

This tells whether the body is suffering from a bacterial infection or whether the condition is viral and will not be cured by antibiotics. Even before they know what is wrong with them, many patients expect antibiotics will cure them.

As Great Bedwyn's Surgery's Practice Manager, Keith Marshall, explains: "There's so much pressure on doctors to prescribe antibiotics, but the more you use them the less effective they become."

The Old School Surgery, Great BedwynThe Old School Surgery, Great BedwynThe second group of patients who will benefit from this new technology are those being tested for diabetes or who have diabetes and need to be tested regularly.  The system will measure the HbA1c levels which are the main indicator for diabetes - measuring how much sugar is attached to blood cells.  

Because our blood cells only last 12 weeks before they are replaced, doctors can use this test to gauge blood glucose levels over the 12 weeks leading up to the test.

The test involves blood from a finger prick being put via a capillary tube into the analysis machine.  Marlborough.News has seen the (anonymised) results of the 80 tests carried out by a nurse at the Old School Surgery between October and the end of January.  

These show that antibiotics were prescribed after only 15 tests.  Of patients tested at the surgery who had lasting coughs, colds and other conditions - which might normally have all attracted a course of antibiotics - 78.75 per cent were shown not to need antibiotics. Two patients were admitted to hospital following tests.

Will the Alere Alfioin system save the NHS money?  The machine costs about £700 a year to rent on a four year contract.  And the equipment for each test costs £4.  For diabetic patients the test is almost instant and saves the costs of blood samples being sent off to a lab.  

For tests to see whether antibiotics should be prescribed the calculation of costs saved is more complicated.  A week-long course of a basic antibiotic can cost as little as £1.20 (not counting dispensing costs.)  

Savings to the NHS will come as much from patients not needing appointments with a doctor as from avoided prescriptions.  But as Dr Hannah Graystone of the Old School Surgery puts it: "This machine is more about using antibiotics appropriately than about saving money."

She explained that it was originally installed as part of the surgery's preparation for the 'winter hit of coughs and colds': "We use it a lot - we've found it very useful."

So what is the likelihood of this machine and its instant testing system getting widespread use in primary care?  Such are the over-tight finances of the NHS that Wiltshire Clinical Commissioning Group were not able to fund its use in Great Bedwyn's surgery.   

If NHS England was really serious about limiting the use of antibiotics and so prolonging their usefulness in fighting patients' infections, they might think a bit harder about funding one of these systems in every one of England's medical practices.  

Bacteria developing resistance to antibiotics is not a new or even an unexpected phenomenon.  Alexander Fleming, who discovered penicillin (one of the first antibiotics), warned it might happen when he accepted his Nobel 1945.

When the system was first operational at the Great Bedwyn surgery it was featured in a report on ITV News.

The AGM of the Friends of Savernake Hospital and the Community is on 11 May - details here.

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