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.