On Wednesday (March 29) the Prime Minister will trigger Britain's departure from the European Union. This will undoubtedly leave the estimated 57,000 EU nationals who work in the NHS feeling even more unsettled and anxious than they have been since June.
We know that Brexit is already having an impact on the NHS. During 2016 2,700 EU nurses left the NHS - compared to the 1,600 EU nurses who left in 2014. And only 96 nurses joined the NHS from other EU countries in December 2016 - compared to 1,304 who joined last July.
A morning spent at the Wiltshire Clinical Commissioning Group (CCG) board meeting offers ample evidence of the way the NHS is already, in pre-Brexit times, struggling with recruitment - and the shortage of staff is also hitting social care which in turn affects the NHS.
1) It was the impossibility of recruiting two GPs to the Marlborough and Pewsey GP surgeries that has caused their merger. Now, "due to unforeseen GP shortages", the Smallbrook surgery based in the Warminster Community Hospital has collapsed - leaving its 4,300 patients unsettled and anxious.
This surgery - which in December had been rated 'Good' by the regulator - lost one GP to maternity leave and then two partners suddenly left. Recruiting one doctor - let alone three doctors - in a hurry proved, understandably, impossible. The surgery has now been 'integrated' - temporarily? - with the Westbury Group Practice.
Smallbrook is still open for three hours a day with priority for appointments given to those who cannot travel to Westbury. The CCG are working on more permanent plans to make sure those 4,300 people have a full and local GP service.
2) The Avon and Wiltshire Partnership (AWP), which provides the county's adult mental health services, shows a scary example of the endemic recruitment shortfall. Their teams in Wiltshire have 117 vacancies - a vacancy rate of about 22 per cent.
3) There was some wry laughter during discussions on the ongoing 'crisis' in A&E and the missed four-hour-wait target. The CCG Board heard that capital money was available to meet NHS's insistence that GPs should be placed at A&E 'front doors' to act as a first line of triage. The elephant stalking that room was simply: "Where are they going to find all those doctors?"
4) The CCG and Wiltshire Council's Better Care Plan work to keep the elderly out of hospital and, if they do have to go into hospital, to get them back home faster, will be supported from April 1 by an experimental scheme involving 30 Rehab Support Workers - a new role.
The plan is for them to help people during their first ten days at home and, over a year, should effect 1,091 timely discharges from hospital. In the first year they will be costing £1.2million.
Seven of those thirty recruits have come from Wiltshire's Help to Live at Home providers - leaving them, in turn, short of seven staff who should also be helping patients get home from hospital - and at a time when their work is getting harder.
A report to the CCG Board stated: "Help to live at Home providers are experiencing increased acuity and are delivering more hours of care, supporting the same number of clients".
As one CCG director put it, when it comes to recruitment "We are all fishing in the same pond."
5) Virgin Care which last April took over community health services for Wiltshire's 110,000 nought-to-eighteen year-olds, is also having recruitment problems. In January their nursing vacancy rate rose by eleven per cent.
In the last quarter of 2016 they were short of six whole-time-equivalent school and community nurses and currently have clinical vacancies equivalent to 22 whole-time-equivalent posts.
That is probably enough examples to show how great a problem Wiltshire faces. Why is Wiltshire affected so much by these shortages? Recruitment plans and staff retention plans abound. To some extent it is true that "We are at the mercy of the market." But it may be much more of a cultural issue.
AWP appears to have no problems of recruitment for its services in the Bath and North East Somerset area. Presumably the cultural and night-life of Bath solves their problem.
Facing the closure of Smallbrook Surgery, one Warminster town councillor was quoted as saying: “The town council doesn’t have much on a say on healthcare, but what we can do is do our best to make the town a more attractive place to live - to encourage more GPs to want to come and work here.”
Locally these staff shortages may be partly due to cultural and partly to housing costs. The problem may be partly a matter of rates of pay and, more generally, of government imposed pay restraint.
But as Brexit proceeds and EU nurses, doctors and surgeons (and for that matter those from beyond the EU) feel even less welcome in Britain than they have been made to feel since the EU referendum, then recruitment and staff retention could well become the next great problem that threatens to break the NHS.
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 onyourmind.org.uk 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)
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.
GWH'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.
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.
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."
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.
St John's Academy: healthy mind, healthy lifeThe last in a three part series of reports on the treatment of children and young people's mental health problems - in Wiltshire and in the Marlborough area.
One former pupil of St John's Academy we spoke to said they had found CAMHS "Brilliant - with its friendly waiting room and willingness to suit your timetable - very different to what was available at school. But when I needed more serious help there was a huge gap - going to a hospital felt like a big step up. It's scary - lots of long names and corridors."
Attitudes in secondary schools are changing - and schools will, as we have seen, be at the centre of the new CAMHS regime for Wiltshire. I met with St John's Academy's Assistant Vice Principal in charge of safeguarding, Miss Maeve McNeill, and with the school's part-time counsellor, Rona Muller, to discuss mental health issues - especially anxiety and panic attacks.
At St John's they were very open and keen to discuss the issues. Why did they think there was such an increase in pupils wanting help? "Twenty years ago there just weren't so many issues. Now there's a greater awareness of the issues and discussion in the media and on social media."
"Much of it is anxiety - quite often at a low level. There's a lot of tension in the world and they pick up on it. They're connected all the time to 24-hour news - they will know instantly that something has happened - and they worry more about what they hear or read. There may be family tensions too. It's an intense time of life. But teenage years are hard enough without these kind of issues."
There are worries too about achievement and exams - these may be internal school or parental pressures to excel or they may be pressures they put on themselves when they realise they need good results to get a good job or move into further education.
Wiltshire's lead commissioner for CAMHS had identified for me a further and interesting cause of the rise in teenage mental health issues: lack of sleep. Whether it is chatting via social media, watching television in their bedrooms or playing computer games, sleep time is being lost.
The Marlborough area is not yet on Wiltshire's programme for secondary school Thrive Hubs. But St John's Academy has Rona Muller, and can also call on two part-time mentors. She has her own room, which was included in the design for the new school buildings: "We're very lucky that it is a very nice room - conducive to counselling!"
Rona Muller sees students during the school day - the average is about five one hour sessions and she swops appointments around so students do not miss the same lessons again and again. Appointment times are delivered in envelopes - for privacy: "We do respect students - we're very discreet."
A poster for an the online services designed for teenagersSt John's are also lucky to have the area's CAMHS unit so close by - at Savernake Hospital. Sometimes CAMHS staff from Savernake Hospital work with pupils in the school and sometimes go to their home: "It's a very bespoke service and they now work more closely with schools."
Since September, teachers have seen an improvement in the service provided at Savernake. Before there had been too much 'bouncing back' of students who did not meet the CAMHS severity threshold: "There's especially been an improvement in turn-around time - it's down now to two or so weeks from referral to being seen."
There are still, of course, varying degrees of 'awkwardness' about mental health problems: "The key to being successful with our young people is knowing them as individuals." Only then can open discussions between teacher and student take place.
While year seven students at St John's - in their first year at secondary school - have a separate regime, students up to year eleven are in mixed age tutor groups and see their own tutor every morning. Sixth formers are grouped together. These arrangements make mentoring schemes easy to arrange.
St John's Academy has found an innovative away to help students at the early intervention level. Currently there is not the time or the resources in school to address all the needs of those suffering panic attacks or anxiety - conditions that do not automatically qualify for CAMHS treatment.
It was the students themselves - in a recent survey - who asked for help with these mental health issues. And it was Wiltshire Council's area Youth Facilitator, Helen Bradbury, who canvassed students and suggested the school apply through the Area Board for a grant from Local Youth Network funding to run a pilot programme of weekly 'mindfulness' sessions.
The sessions with a specialist practitioner will teach techniques and exercises to calm the mind and through self-awareness help students manage their stress and anxiety. The school will support this with an hour a week of one-to-one work with the practitioner.
During the pilot, the school will evaluate the effectiveness of the programme subjectively, with a questionnaire at the beginning and end of the programme.
St John's asked for a grant of £5,000. In January, the Marlborough Area Board approved a grant of £3,500 to fund the pilot for the rest of the academic year - with £500 of the grant put for a proper evaluation of the pilot. And they wanted this work to become part of the school's budget and spread to other schools in the Academy Trust.
St John's reckons that about five per cent of their students need some attention for mental health issues. That equates to about one student in every class.
Wiltshire's lead commissioner for CAMHS explains: "Locally, the bulk of the CAMHS caseload is made up of teenagers - mainly anxiety, low mood and depression." The problems are not so serious or numerous at primary school level - but early intervention is the watchword.
Marlborough St Mary's Primary school is still operating on its two sites - and due to move together into the new school in September. At the moment they do not employ a counsellor.
Headteacher Anne Schwodler told Marlborough.News: "CAMHS offer a very useful service but along with everyone else have very limited funds to cope with the increasing demand for mental health services and it is therefore sometimes quite difficult to get support when it is needed."
The number of pupils who need support for emotional problems has been rising, but it is difficult to give a percentage as the level of need varies widely: "We have children in Key Stage 1 and Key Stage 2 - pupils between five and seven years old - who need some support with emotional needs for a variety of reasons."
"We have trained Emotional Literacy Support Assistants on both sites who work with children one-to-one or in small groups to support children with emotional issues."
One of the Prime Minister's plans is to offer every secondary school in the country mental health first aid training over three years. With 'early intervention' the watchword on the lips of politicians and commissioners, it might be advantageous if this was extended to primary schools as well.
In development: part of the home page of the new On Your Mind website
CASEBOOK THREE: Names have been changed throughout these accounts of CAMHS at work
A third parent who lives in Wiltshire but outside the Marlborough area and has shared her experiences with Marlborough.News, confirms that CAMHS do not always cope well with pre-existing conditions that turn into or come to include a definable mental health problem.
We will call her Jenny: she sees her teenage son's depression, anxiety and suicidal thoughts as quite separate from his ongoing autism and aspergers: "I just couldn't get through to them how he needed handling differently due to the autism, but that it wasn't necessarily the main cause."
"The CAMHS were lovely people. I did find the young girl we spoke to a bit unsure of how to approach a child with autism. She did keep saying that some of the negative feelings were caused by the autism, but did not say how to help him."
"Six sessions were nowhere near enough to get a testosterone filled austistic teenager with anger and suicidal issues back to 'normal'. It wasn't even long enough really for them even to get to know each other, to form a trust."
"He also," Jenny says, "lies." He will lie to create the easiest path: "His keyworker knows this and we have spoken quite often about it. But in six sessions the CAMHS worker just did not know him well enough to help him."
"He is still bad now, last week we went back to the doctor and he has pretty much demanded more sessions, but it's the school that has to implement this and I don't think they have the clout to get it done. The doctor did say she would write to the school if it helped - but that my son needed help and needed it now."
Healthwatch 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.
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 "...at 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?
GWHThe 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.
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 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.