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Health & NHS

NHS nursing crisis: Lili is from Romania & works at GWH - but the flow of EU nurses has now dried up

Lili Baleanu is a Romanian nurse working at Great Western Hospital - one of the steeply declining number of EU nurses to arrive since the Brexit referendum.

Lili graduated as a nurse in Romania in August last year and arrived at GWH in late November. She passed the obligatory English language test (the IELTS - more of which later) and will become a fully registered nurse in a matter of days - getting her Pin number from the Nursing & Midwifery Council (NMC).

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STP WATCH: Did anyone notice? NHS Sustainability and Transformation Plans have become Partnerships - and permanent

 

There was a bit of noise during the election campaign around the government's latest move in the continual and discreet reorganisation of the NHS - the STPs aka Sustainability and Transformation Plans.  This noise of protest centred on rumours of cuts some STPs are going to make.

This kind of noise will get very loud indeed as the plans of some of England's 44 STPs focus on money saving closures of services and buildings - all in the name of sustainability with reduced funding.  But in case we got frightened by 'plans', the STPs have had their 'P' changed to the cosier and much more user friendly 'Partnership'.

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“The Doctor will see you now’”…but in the future? Maybe not

The general election brings - as usual - a wealth of promises and opinions about the NHS.  There is not, however, much talk about the GP crisis.  

About ten per cent of NHS doctors (not all of them GPs) are EU nationals - so unless the post-Brexit status of EU nationals to remain is not fixed soon, the shortage of GPs could get a lot worse.  A poll in February found that nearly two out of three EU doctors in the NHS were considering leaving the UK.

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Young people want better access to mental health services in Wiltshire 

Zoe Tonks & Elley-May Timmins with the Young Listeners report - ready to present it to the Wiltshire Health & Wellbeing Board (Photos: Tim Gander)Zoe Tonks & Elley-May Timmins with the Young Listeners report - ready to present it to the Wiltshire Health & Wellbeing Board (Photos: Tim Gander)A group of Wiltshire young people are on a mission to change the way mental health services are run for their peers and will be presenting a report to Wiltshire’s Health and Wellbeing Board next Thursday (May 18).

Young Listeners from Healthwatch Wiltshire spoke to 174 children and young people in the county to find out how they felt about using health and care services.

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A Wiltshire GP practice disappears as staff shortages hit NHS and social services

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.


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NHS funding crisis: Wiltshire's part in plan to balance Department of Health's end of year accounts

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?

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A crisis in children's mental health? How is Wiltshire coping? Part Three: How Marlborough's schools respond to mental health issues

St John's Academy: healthy mind, healthy lifeSt 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 teenagersA 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 websiteIn 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."

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