Wiltshire's NHS: the new chairman of the Clinical Commissioning Group looks ahead
Despite its current state of rolling crises, the NHS is changing. Perhaps the changes are the reaction to crisis. But we do not often get to understand just what those changes entail and how they may affect us.
The Wiltshire Clinical Commissioning Group (CCG) - which holds the budget for the great majority of Wiltshire health services - is itself changing and also facing changes within the wider NHS organisation.
Following the retirement of Dr Peter Jenkins, the Wiltshire CCG has a new chairman - Dr Richard Sandford-Hill. He has been a CCG board member for four years and will continue to work at Market Lavington Surgery where he has been as senior partner since 2006.
Talking to Dr Sandford-Hill it is absolutely clear that he is wholly committed to the NHS.
As he explained to marlborough.news, he sees some problems ahead about the declared intention to integrate health and care services provided by Wiltshire Council and Wiltshire CCG: "We are progressing this - without a doubt. We both look after the same people - it makes sense we work together - now we're working out how."
They have agreed a joint appointment for someone to be the CCG's Accountable Officer (or CEO) and also be head of the Council's adult social services. There are practical problems - "Where do you go on Monday morning?" - and, perhaps more importantly, governance and finance problems.
The Council's leader, Jane Scott, who is very keen on this integration, is elected. The CGG is not - although Dr Sandford-Hill was chosen - or elected - as chairman by the county's 50 GP surgeries.
Both sides need to work out who this joint person is accountable to: "I'm a great believer in teamwork. But this joint appointment is not a straightforward model - we do have a governing body. The governance needs to be sorted out."
One step the CCG is taking is to appoint a Director of Strategy - a CCG post "Basically to mind the ship - to enable the joint approach to work properly."
Later this month the board will discuss a new paper giving more assurance about money and exact roles: "Whatever we agree will be good for the NHS in Wiltshire - not just for the sake of integration."
One of the main headaches Dr Sandford-Hill and his CCG colleagues face is the state of the GP service in the county. Closures and mergers - like the Marlborough-Pewsey merger - take time and cost money.
How many surgeries in the county are considered to be vulnerable? "Ten or twelve". And he explains how one practice lost three salaried GPs simply because Swindon has 26 GP vacancies and an agency there was paying more than the Wiltshire practice could afford.
This year the CCG has spent £250,000 supporting vulnerable surgeries - for next year they are budgeting £330,000 in support for these surgeries.
Which brought our conversation round to the CCG's finances: "It's always tough - we're on target for this year. Next year it's going to be harder. We should be transparent. I don't think we engage enough with the public. We need to have open and honest conversations: this is what we're doing and why - what do you think?"
All that takes up doctors' valuable time and costs money. He knows there is a downside to such openness: "It all becomes emotional as it has with IVF. We've reduced it to one cycle. Do we pay for more - or do we fund a by-pass or cancer operation? There needs to be a genuine debate - we can't afford everything."
One of the prime areas for integration to have a real impact on the NHS is on getting people out of hospital once they are medically okay to leave - delayed transfers of care (DTOCS for short.) The CCG has provided many millions of pounds to the joint NHS-Council Better Care Fund which was supposed to sort out the DTOC problem - and has not done so.
Dr Sandford-Hill says the main cause of DTOCS goes back in some form to social services and community care: "The problem we've got as a society is that carers aren't valued. We need a nationwide workforce plan for carers and have got to make it an attractive job to do - and sell it."
This may involve giving carers more responsible jobs to do - as well as the necessary mundane jobs. With training they could take blood pressure, take blood for tests, change dressings and so on. It has not helped that so many carers are now employed by private firms on tight financial contracts who cannot afford training or apprenticeships.
Hovering over the CCG - and Wiltshire Council - is the STP (now promoted from Sustainability and Transformation Plan to Partnership - one of 44 STP 'footprints' across England.) It covers Wiltshire, Swindon and Bath & North East Somerset and is known as the BSW STP.
Ten days ago Chris Bown was appointed to lead the BSW STP and, after sometime lost in the long grass, it now has a team of people working on health services for the wider area - a bit like the old Strategic Health Authorities which were abolished in March 2013: "The STP had not got much traction - now it's more foot to the floor than we have been."
The increasing activity of the STP will have an impact on the CCG: "From the commissioning side, you'll see the CCG shrink a bit."
But Dr Sandford-Hill is keen to see the STP succeed - especially if it overcomes the market system which has to some degree set commissioners against providers - or, for example, the CCG against the acute hospitals - and vice versa.
"We need to start working as a system - to get round the market system. I don't think it's worked that well. Instead of opposing each other, how do we work better - putting the patient at the centre of a sustainable system?"