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 nhsManagers.network 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."
Thursday morning (September 1) and GWH's Academy, down in the hospital's extensive basement, is full of staff from many departments and members of the board. They were all listening to an inspiring talk on patient safety - the start of a day-long Speak Out on Safety event.
Martin Bromiley (Photo Medical Protection Society via YouTube)The speaker was Martin Bromiley, an airline pilot who has become a much respected expert on patient safety - speaking to and advising nurses, government ministers and NHS managers.
Tragically, his wife died during a routine operation - due to human error. In response he founded the Clinical Human Factors Group - a charity which seeks to help healthcare workers understand how human factors relate to patient safety and quality of care.
Thirty minutes later the board members went upstairs a couple of floors for their monthly meeting - to face so many factors that impact on patient safety. Uppermost in their minds was the junior doctors' decision to start a series of five-day strikes, which if directors did not prepare for appropriately might also impact on patient safety.
They are today starting their planning for the strikes - but do have the experience of the junior doctors' previous two-day strikes to build on and learn from.
The strikes aside, the main risk for the GWH as the year proceeds is that it will not meet its financial target - or, in a worst case, run out of cash. At the moment the books look pretty good once the Department of Health's top up funding arrives.
£2.25million arrived suddenly last month - it had been expected in July. And if GWH ticks all the right boxes, another cheque will come through in October.
Apart from the financial squeeze, there are two major pressures on GWH at present: the Emergency Department (they call it ED, other people call it A&E), and staffing.
Basically the ED problem is that they are well away from meeting the national target of 95 per cent of people arriving at ED being treated and either sent home or admitted to a bed within four hours.
While it is fairly simple to admit someone (if there is a free bed), it is much more complex to discharge them - especially if they are old and infirm and need care at home or somewhere else. And 'delayed transfers of care' (DTOCs) - or blocked beds - means there may not be a bed free and so someone has to stay in the ED.
During July - "an extremely challenging month" - 7,545 attended GWH's ED - 500 more than in June and 400 more than in July 2015: "The relentless pressure in ED during the month contributed to 76 patients enduring stays of greater than 12 hours in the Emergency Department..."
Around one in three of those 7,545 will need admitting to hospital (besides those sent directly by the GP.) GWH should be operating with 85 per cent of its beds occupied by patients.
At present its bed occupancy stands at 111 per cent - meaning they have brought into use every possible extra bed space they have. Daily bed occupancy "...has not been below 100 per cent in the last two weeks of August."
As one director pointed out: "111 per cent - with 80 patients who don't need to be there." Which brings us to DTOCs...
There has been a summit meeting on DTOCs and Wiltshire Council has assured NHS Improvement and NHS England that its new social care provider (Mears) will sort the problem out. In July there was a rise of 83 per cent in DTOCs that was down to Wiltshire Council's inability to find appropriate after-hospital care. And the problem with Swindon's social care is yet to be resolved.
Sitting in the meeting you could feel some sympathy with the patient's story presented to the board. After eight hours in ED, he wrote: "I think this hospital is too small for the high demand of Swindon emergencies and desperately needs more space and extra staff."
The board was told that putting in 100 extra beds was the equivalent of adding lanes to a motorway - they would give "a few days leeway" and then they would simply fill up. However, it is clear that Swindon's population growth has out-stripped what the NHS now provides.
But even 70 extra beds would pose the immediate problem of finding those 'extra staff'. And shortage of staff is a severe current problem - affecting risks to patient safety as well as risks to the hospital's finances.
Currently GWH is showing a vacancy rate of 10.5 per cent. And a consequent rise in the spend on agency staff. Overseas recruitment is starting again and this month a new cadre of newly registered nurses from the local Oxford Brookes college starts work.
Then last week came the news that the Treasury, who apparently have not understood that the NHS is in financial difficulties, is cutting two per cent (equivalent to about £48 million) of the education and training cash paid to hospitals. Health Education England will make the money up this year, but it will vanish from next year's budget.
Just another pressure point for a hospital confronted with a register showing 25 risks scoring 15 and over and 14 risks concerning patient safety. Currently the top risks relate to staffing levels for unscheduled care, the design of the emergency department and patient safety on an understaffed ward.
Which gets us back to Martin Bromiley. He has learnt from the best safety systems and rules used by his own industry - aviation - by Formula One motor racing and the nuclear industry. But it all comes down, he says, to having "rules that make it easy to do the right thing". And of course to having the staff to work to those rules.
The secrecy surrounding attempts to re-fashion NHS services - and keep them within the government's tight funding limits - has suddenly become a major issue of media interest - and of public interest as well.
We first reported on the Sustainability and Transformation Plans (STPs) last March. Since then deadlines for the plans completion have come and gone - the next one is in October and may well be missed by some of the 44 'footprints' running the STP process.
Led by BBC News, the media have leapt on the STPs and the cuts to services they are likely to bring, as a strong August story. And while politicians are away - or simply keeping a low profile - the story has got, as they say in newsrooms, legs. And the 'story' may well run and run.
The online lobbying group 38 Degrees is actively involved in this news frenzy. They are drumming up support by telling members what cuts they think STPs will bring to their area and asking them to get their MPs to' lift the lid' on the secretive STP process: "...will you sign the petition asking Claire Perry to lift the lid on the plans for the NHS in your area?"
For the STP 'footprint' that includes the Devizes constituency - this 'footprint' covers Wiltshire, Swindon and Bath and North-East Somerset and is known as BSW - 38 Degrees have been told some changes to frontline services are coming: "...but the exact services haven't been nailed down yet."
They have also published a figure of £490 million as the deficit in NHS and social care to be faced by 2021 across 'BSW'. That must be a large under-estimate as the shortfall for BSW's health organisations alone will rise to £337million a year by the end of 2021. And we know that local authorities' social services and public health programmes are hurting badly from the government austerity cuts and should be counted into that deficit.
38 Degrees claim they have "uncovered Jeremy Hunt's secret plans for our NHS" - the truth is that many STPs are nowhere near complete, which may be just as worrying while the financial crisis threatens to engulf the service.
However many people sign their petitions, 38 Degrees are unlikely to get much joy from the majority of MPs who have, we should not forget, backed their governments' low level funding of the NHS - which has caused this crisis. Over the last six years this funding has edged up point-one-of-a-percentage-point (that's 0.1 per cent) over inflation - just getting over the promised 'real terms increase' threshold.
In the process MPs have wilfully ignored the NHS' own levels of inflation - rising drug and treatment costs and the big rise in demand from a population increasing in numbers and also ageing.
Coming un-invited onto budget spread-sheets are extra costs the NHS has to bear following cuts to social service budgets (causing, for instance, rising numbers of delayed transfers from hospitals - those 'blocked' beds), the government cuts to public health budgets (now also squeezed by local authorities to whom public health was passed) and government inaction on obesity and air quality.
All the while not forgetting the estimated £3billion costs of the Lansley reorganisation. These costs are still coming through - recently two Commissioning Support Units set up under the Lansley Act were closed costing £6million in redundancies. STP may well bring many more redundancy and closure costs.
As the media storm moved onto the Sunday newspapers, one former Health Minister woke up to the size of the problem and began talking about extra tax raising powers for social care. Why? Because cuts to social care were undermining the NHS.
The problem with secrecy is that it leads to a welter of half-truths and rumoured truths. The latest guidance from NHS England says that STP 'footprints' should be careful about asking for capital spending to re-jig their infrastructure or connect with new IT schemes.
The capital funds available will be "extremely constrained". There is even talk of STPs being advised to explore land sales to raise money. This is really weird as the NHS Property Services (known widely as PropCo - a company owned by the Secretary of State and probably on a fairly fast track towards privatisation) have been hoovering up NHS estate and ordered to charge commercial rates for its use.
We are told that that this is about collaboration where there has been competiveness - for instance acute hospitals vying for 'business'. But how far collaboration gets beyond sharing 'back office' staff and costs remains to be seen.
The eminent King's Fund tells us: "STPs must also cover better integration with local authority services." A similar line comes from an NHS Manager writing anonymously and entirely sensibly in the Guardian.
'She' puts a very positive spin on the STP process: "The benefits of STP could be huge...we must bring health and social care services together..." How this is can happen when Wiltshire Council has only been a 'consultee' on the BSW STP board is unclear.
NHS England is determined we should not think of the STP boards as new organisations within the NHS. Who then makes the final decisions?
Presumably if the clinicians on the more locally responsive - and empowered by statute - CCGs do not like a closure or a money-saving reduction in service ordered by the STP, they will vote it down. Though if they do, they may face some sort of penalty - or perhaps they will all be blacklisted from future MBE handouts.