Very quietly the NHS for our area is once again being reorganisedFor one or two moments we'll stop worrying about A&E waiting times, staff shortages, the numbers of fit patients stuck in hospital beds... Instead we will try to understand how and why the NHS in Wiltshire is being reorganised - again.
At an extraordinary - and public - meeting of the Wiltshire Clinical Commissioning (CCG) board (November 13) it was agreed to accept one of four options for a new structure that stretches beyond Wiltshire. Among those attending were four Wiltshire GPs and one member of the public - your reporter.
Small and local were beautiful in the eyes of the coalition government's 2012 Health & Social Care Act with the CCGs placed in pole position and in charge of most of the NHS budget. Now bigger and less local is back in fashion.
Briefly, the CCGs for Wiltshire, Swindon and Bath & North-East Somerset (BANES or B&NES for short) will come under one Accountable Officer - described as being "more of a chief executive". They will have a "single management team and streamlined governance." However the three CCGs will remain separate - they are, after all, legal entities under the Act.
The new "chief executive" will also head up the STP (Sustainability and Transformation Partnership) that comprises the same area as the three CCGs - and is known as BSW. And which may well morph into the new 'single management team'.
The meeting was told this reorganisation was not being done to save money, but to improve treatment and care in the wider area. However the CCG's Chairman did tell the meeting: "There will be an expectation from NHS England there would be cost savings in this."
Although not a statutory organisation and begun as something of a 'workaround', the STP has been taking on staff and has been pretty busy. They have, for instance, worked with the hospitals to improve the treatment of stroke patients - and have very satisfactorily improved results to show for it.
But it's quite hard to sus the BSW/STP out. It has a rudimentary website and no public board meetings - you can't even be sure it has a board. It does issue occasional online newsletters.
From these we learn Tracey Cox was appointed in August as BSW's interim leader - it is a job share as she is still Accountable Officer for BANES CCG.
We also learn that - at the last count - BSW has a Financial Lead, a Chief Digital Officer, a Digital Programme Manager, a Director of Financial Recovery, a Director of Transformation, a Programme Manager and a Communications and Engagement Manager.
In October they were joined by Dame Angela Pedder, attached for three months as "Strategic Adviser to help BSW's Executive Board through the next stages of its development." Oh, so they have an Executive Board. And they have a Chairman - Wiltshire Councillor Jerry Wickham.
It is not clear yet what will happen to these STP staff, but they may become part of the new and overarching management team. The problem for staff at the CCG and STP is that the new "chief executive" can't be in post until the end of January - and he/she needs to decide the exact shape of the new structure and its personnel. An uneasy couple of months for them.
These changes follow the U-turn on the CCG's integration with Wiltshire Council. It got stopped in its tracks. (BANES' Council and CCG are already fully 'integrated' on health matters.)
The meeting was told that among the 'high level risks' these changes bring are reputational damage to the county's NHS, 'loss of engagement with partners (e.g. Council members)', instability within the workforce and that the CCG's agenda will not be delivered because 'staff are distracted by wider agendas'.
One of the problems of the current NHS is the lack of accountability (the CCG is run by clinicians and the public cannot vote them off if the CCG is failing) and lack of transparency. It is not clear whether the new 'management team' will meet in public or publish minutes of its meetings - 'streamlined governance' says probably not.
Where does this new order for CCGs leave the Wiltshire Health and Wellbeing Board (set up under the Act as a Wiltshire Council committee)? Will the Healthwatch teams for the three CCGs have to merge?
What will the new organisation be called - will it take over the initials of the STP and be known simply as BSW? Or will it be the BSW Integrated Care System. When things get really big in the NHS they become 'systems'.
When the (fairly) new Health Secretary Matt Hancock was about to make his first speech he tweeted a flip-chart scrawl of his early priorities - pictured left. At the top was 'Workforce' - he was right there. Britain's three best known health policy think tanks have now warned that the service could be short of 350,000 key personnel by 2030.
We were only distracted from the normal NHS headlines - including workforce shortfalls - for a very short time: the day after Wiltshire CCG's meeting, it had to announce the closure of a GP surgery in Melksham.
GPs at the Bradford on Avon and Melksham Health Partnership "...have been unable to recruit enough clinicians following the retirement of three full-time GP partners." They have asked permission to close their St Damian's branch surgery.
Whether or not the result of reorganisations, earlier this year the number of managers in the NHS was back up to pre Health and Social Care Act levels. And that at a time when the NHS in England has some 100,000 vacancies - a number that's quite a challenge for Mr Hancock and the CCGs and STPs etc etc...