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Health & NHS

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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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 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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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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In the midst of its worst financial storm the NHS is hit by a perfect media storm

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.

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Great Western Hospital: as the junior doctors plan their strikes, patient safety and staff shortages still top the agenda

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)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.

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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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