Squaring the circle of the NHS' financial position at the end of the financial year 2016-2017 is proving a complex process - one that changes almost daily and which calls for the proverbial wet towel around the head and a strong cup of coffee.
We will not be encouraged to show any surprise at all when Wiltshire Clinical Commissioning Group (CCG) - which buys primary (GPs etc) and secondary (hospitals etc) health care for all the county's residents - ends the year with a 'surplus' that runs into eight figures. It will be in excess of ten million unspent pounds.
The previous financial year (2015-2016) ended badly with the Department of Health overshooting its total resources. Balancing the Department's books is done by setting those parts of the NHS that are underspent (NHS England's budget and most of the CCGs) against those parts that are overspent (mainly hospitals.)
If the whole system has overspent its agreed financial resources then Jeremy Hunt has to explain himself to the Treasury - and the NHS may simply get less the following year.
This financial year the NHS' finances have been stretched every which way. Basically the hospitals are, as the providers of acute health care, deeply in deficit for 2016-2017 and the commissioners (the CCGs) who buy services from them (and from others) are largely in surplus. That, anyway, was how it looked at the end of the third quarter of the financial year.
So what is this £10m to be left as a surplus on Wiltshire CCG's annual accounts?
Over £5m of it is the one per cent all CCGs have to put by as a 'surplus' - which is returned to them for use the following year. The second £5m-plus is being used as a new way to try and balance the Department of health's books for 2016-2017.
Without getting into all the figures, each year the CCGs have to keep back another one per cent of their resources - known as 'headroom'. This money is held to spend during the year on redesign and transformation costs for local services.
Sensing the financial problems to come, for 2016-2017 the CCGs were required to hold back this one per cent as a 'risk reserve' for the NHS as a whole. It could only be spent with Treasury permission. Across England this 'reserve' adds up to about £800m - which would go part of the way to making up the hospitals' deficits.
Now CCGs have all been told to add this money to their bottom line - making many CCGs' surpluses look alarmingly healthy. How does this help the NHS as a whole?
Wiltshire CGG's Chief Financial Officer, Steve Perkins, explains: "Within all the available resources, there are differing pressures between the providers and the commissioners. This money on our bottom line is in the system - with providers in deficit and commissioners in surplus - this money will balance the books."
That was then. And then was the beginning of last week. Since then new figures have emerged for February which make the challenge of balancing those books look harder still. And there is now only one month left to get things back on track.
Many of the CCG cavalry that had been riding to the rescue of the NHS accountants clutching their underspends, have suddenly gone lame.
As the Health Service Journal reported: "The figures released today (March 30) show that the financial position of the CCGs has worsened by £180m - nearly 50 per cent - in just two months, with approximately a third of groups predicting an overspend at the end of February." (Wiltshire CCG is not among those predicting an end of year deficit.)
Now it looks as though all the CCGs' £800m-that's-not-allowed-to-be-spent may only just bridge the gap. It is going to be a very close run thing - or as NHS England's finance director put it: "tantalisingly close".
Unless the March figures show some serious depletion of funds following February's very high demands for treatment, the result across the whole NHS system could show it is in the black by £34m. Not at all bad out of a total 2016-2017 NHS budget of £120 billion.
The NHS has reached a financial 'precipice' point just as it is about to plunge over the Brexit precipice. As we have reported, the already perilous staffing crisis is threatened with a catastrophic departure of EU clinical and care workers.
And talking of Brexit, that £34m figure is, of course, less than 10 per cent of the post Brexit bonanza the NHS was to expect once we have left the EU - remember the 'Vote Leave' bus and its extra £350m a week for the NHS?
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."