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Health & NHS

The NHS crisis: short of nurses and short of money - how will costs be reduced?

The NHS does not, of course, close for the summer holidays - unlike schools.  But August has traditionally been a quiet month in the health service as executives prepare in earnest for the winter ahead and prepare to open their finance directors'  half yearly budget forecast.

This year as nurses take their annual summer breaks, executives have to find cover for them that does not breach the new spending rules on agency nurses.  Money and nurses - and the shortage of both - are inextricably linked in the twists and turns of this NHS crisis.

So let's take a look at these two elements of the crisis.  First nurses.  And the initial point to make about nurses is that the NHS is short of tens of thousands of them.  The second point is that the supply gap in nurse training was supposed to be closed by 2019-20.  But this month it was announced that the shortage will continue beyond 2020.

The reason given for this is the bizarre assertion that the 2020 end date was only achievable if hospital trusts obeyed NHS England's Five Year Forward View plan to reduce 'hospital activity'.  This seems to be 'chopped logic' on a wilful scale: one way hospital activity is reduced is by treating more people in the community - where they need nursing care. In addition, as the NHS knows all too well, the population is ageing and the elderly's conditions are getting more complex and costly to treat.

A money-saving shortage of nurses was identified in the Francis Report as the main cause of the Mid-Staffs scandal - several hundred patients died due to poor care between January 2005 and March 2009 at Stafford Hospital.  

Robert Francis' call for safe nursing numbers has fallen foul of the Treasury's tight funding of the NHS - and contrary guidance on safe nursing numbers seems to come round in time with the warnings about NHS overspending.  Earlier this month, as part of a 'financial reset', the trust regulator tried to show that some hospitals' clinical care bills were too high - too many nurses etc etc.

Last week the former chief of the Royal College of Nursing, Peter Carter, laid the cut 18,000 nurse training places over three years, at the door of the coalition government.  He believes Brexit will be a disaster for healthcare and that "...the Brexit people seriously misunderstood just how dependent we are on people from overseas to staff the health service."

Indeed, the nursing gap has been filled in part by the recruitment of very many EU nationals (especially from Spain, Portugal and Italy) - and with nurses from further afield.

The attitudes exposed - and encouraged - by Brexit campaigners will undoubtedly make recruitment of nurses much, much harder. Immigrant nurses may be loved and valued when they are in uniform, but off-duty they will be as likely as any other immigrant to be shouted at and abused in the street.

News of this new brazenness in anti-immigrant behaviour will precede the recruiters as they travel abroad seeking more nurses to look after all sorts and conditions of British men and women - whatever their attitudes.

One thing is almost certain: nurses' pay will not rise enough (after years of one per cent increases) to make the job of recruiters and those offering training places any easier.

So we get to the money.  At the end of the last financial year the Department of Health escaped Parliamentary humiliation for overspending its budget by some clever accounting wheezes and a major raid on its capital budget.

This year it looks as though there will be a gap - otherwise known as a 'deficit' - of £1.2 billion.  That figure relies on major savings being achieved by Clinical Commissioning Groups and the acute hospitals - and savings means trimming services.

It may also mean a 'reset' for the controversial Sustainability and Transformation Plans (STPs) reorganisation programme.  If savings targets look liable to sudden deficit warnings, then STP plans - due for completion during September - may turn into much more of a programme of reductions in services.  (You will notice the word 'cuts' was not used in that last sentence.  It may have to be dusted off as the autumn proceeds.)


As Jeremy Hunt stays as Health Secretary, the NHS gets a dose of reality

After they had reported rumours he was being sacked, the television headlines said simply ‘Jeremy Hunt remains as Health Secretary'.  They did not mention that the NHS remains in dire circumstances.  Nor did they warn that the sacks of gold promised by Brexit campaigners for the NHS are most unlikely - repeat most unlikely - ever to be delivered.

In fact the situation in the NHS is getting steadily more alarming.  Should anyone think that is 'doom-mongering', listen to Jim Mackey, head of NHS Improvement and probably the second most important person in the NHS. On the day (July 14) Mr Hunt kept his job, he told a conference that the NHS is "in a mess."

Finances are tightening still further, hospitals have posted record deficits, recruitment of staff from overseas is under Brexit threats, the latest way forward - through Sustainability and Transformation Plans (STP) - are taking longer than expected to draft and now the safety of patients is being set against cost.

Members of this government have poured scorn on the Labour government on whose watch the Mid-Staffordshire scandal occurred.  Now this government is telling hospitals which are running deficits that they should not automatically employ staff or improve facilities to meet levels advised by the regulator or standards set by royal colleges.

This latter move has shocked those colleges.  The Health Service Journal quoted Royal College of Nursing chief executive Janet Davies: “This gives completely the wrong message to trusts, whose boards are responsible for the care, treatment and safety of their patients, by suggesting that finances are more important than patient care."

The move will create a new splash of red on hospital risk registers which are already facing a blizzard of new rules - such as caps on agency pay and on management pay - and are still struggling to reduce their deficits.

There are warnings in there air of cuts to services and loosening of targets - the four hour target for A&E waiting times is thought likely to be changed to ease hospitals’ woes.

A reality check is being published by Wiltshire's Clinical Commissioning Group (CCG) in a series of paid, full-page newspaper announcements.  The first one came under the headline "Our challenges".  

The CCG warns of "Future cuts - Annual funding is less than needed to meet demand" and talks about the 'impact of the cuts to social care services'  and points to the "£500million funding gap across Wiltshire, BANES and Swindon for 2017."

The first advertisement quotes Dr Richard Sandford-Hill a GP at Market Lavington Surgery and member of the CCG's board: “Providing health care for an increasingly ageing population is difficult. In my own practice a majority of my routine appointments are attended by people aged over 65, and those people often have complex long term needs."

The CCG's text continues: "The NHS is used to doing as much as it can with ever-stretched budgets.  The shortage of people working in social care means that together with Wiltshire Council, we're doing our very best to make sure we can support people.  And it's not all doom and gloom - we're making some great strides forward to make sure we can properly deal with some of the issues we are facing."

The second advertisement in the series concentrates on explaining 'How we support you to live well' and has a careful guide to choosing the right healthcare when someone is feeling unwell.

On the day Mr Hunt was confirmed in his cabinet post, the much revered King's Fund produced a report on Deficits in the NHS 2016: "There needs to be realism about what the NHS can achieve with the funding allocated for the rest of this parliament."

The King's Fund calls on the government to review the promise of a full seven-day service and believes the government "...has a responsibility to be honest with the public about the consequences of the NHS 'offer', particularly in view of its manifesto commitment to 'protect and improve' the NHS."

The Wiltshire CCG is certainly being honest with the public in its series of advertisements.

Wider planning for Wiltshire's health services:

Amidst all this turmoil, senior NHS leaders in the county are working hard and to very tight deadlines on the STP across Wiltshire, Bath and North-east Somerset and Swindon.

Not everyone is happy with how the STP is being drawn up.  One the most vocal critics is Wiltshire Council's leader, Baroness Scott.  Her unhappiness about the process and the role given to the Council and its staff (first reported by Marlborough.News in April) has now been repeated - even more forcefully.

At the full council meeting on Tuesday (July 12) Independent Councillor Chris Caswill, asked when the plan would be made public so it can be scrutinised by the public.  Baroness Scott: "I would love to know.  This is not being led by this Council."

"I was very disappointed when NHS England changed the the Health and Wellbeing Board (HWB) and the Council being just consultees on it."

"That is not what I think should be happening if we are going to integrate health and social care."  She did say the HWB was getting updates on the planning talks.  But ended her reply: "I haven't seen it yet."


Charity amidst the alien corn

Some will - probably - say it was aliens wot dunnit. Others that very clever crop circle designers have returned to Hackpen Hill with charitable intent and a very large design that goes way beyond the term 'crop circle'.

This pattern-in-the-field is on Weir Farm, Uffcott. Last year James Hussey, who had recently lost his wife to cancer, opened up his crop-circled field at Hackpen to raise money for the Great Western Hospital's Brighter Futures fundraising campaign to build a radiotherapy unit to GWH - bringing cancer care closer to Swindon and the northern population of Wiltshire.

He raised a tidy sum.

You can visit this year's 'circle' - in return for a donation to this fund.


The little machine that's helping doctors tell when antibiotics are NOT needed

Antibiotics, having revolutionised medicine in the twentieth century, now find it hard to keep out of the headlines.  One day it's their crippling cost to the NHS' finances (about £190 million a year), the next day they are being over-prescribed by doctors, and on very bad days it's reports that some ordinary bugs have developed resistance to antibiotics and they're not effective against new breeds of superbugs.

A little machine - pictured on the right - sitting on the bench in a local surgery could become an essential part of the struggle to keep antibiotics effective - and save the NHS some money.

It's the Alere Afinion blood testing system and it has been helping doctors at Great Bedwyn's Old School Surgery since October.  A grant from the Friends of Savernake Hospital and the Community enabled the medical practice to rent one of the machines and set itself up with the equipment needed to make each test.

The test is used for two main groups of patients.  First for those who come in with cold or flu-like symptoms and want - even demand - a course of antibiotics.  The machine will give a very fast read-out of the CRP (which stands for C-Reactive Protein) level in the blood.  

This tells whether the body is suffering from a bacterial infection or whether the condition is viral and will not be cured by antibiotics. Even before they know what is wrong with them, many patients expect antibiotics will cure them.

As Great Bedwyn's Surgery's Practice Manager, Keith Marshall, explains: "There's so much pressure on doctors to prescribe antibiotics, but the more you use them the less effective they become."

The Old School Surgery, Great BedwynThe Old School Surgery, Great BedwynThe second group of patients who will benefit from this new technology are those being tested for diabetes or who have diabetes and need to be tested regularly.  The system will measure the HbA1c levels which are the main indicator for diabetes - measuring how much sugar is attached to blood cells.  

Because our blood cells only last 12 weeks before they are replaced, doctors can use this test to gauge blood glucose levels over the 12 weeks leading up to the test.

The test involves blood from a finger prick being put via a capillary tube into the analysis machine.  Marlborough.News has seen the (anonymised) results of the 80 tests carried out by a nurse at the Old School Surgery between October and the end of January.  

These show that antibiotics were prescribed after only 15 tests.  Of patients tested at the surgery who had lasting coughs, colds and other conditions - which might normally have all attracted a course of antibiotics - 78.75 per cent were shown not to need antibiotics. Two patients were admitted to hospital following tests.

Will the Alere Alfioin system save the NHS money?  The machine costs about £700 a year to rent on a four year contract.  And the equipment for each test costs £4.  For diabetic patients the test is almost instant and saves the costs of blood samples being sent off to a lab.  

For tests to see whether antibiotics should be prescribed the calculation of costs saved is more complicated.  A week-long course of a basic antibiotic can cost as little as £1.20 (not counting dispensing costs.)  

Savings to the NHS will come as much from patients not needing appointments with a doctor as from avoided prescriptions.  But as Dr Hannah Graystone of the Old School Surgery puts it: "This machine is more about using antibiotics appropriately than about saving money."

She explained that it was originally installed as part of the surgery's preparation for the 'winter hit of coughs and colds': "We use it a lot - we've found it very useful."

So what is the likelihood of this machine and its instant testing system getting widespread use in primary care?  Such are the over-tight finances of the NHS that Wiltshire Clinical Commissioning Group were not able to fund its use in Great Bedwyn's surgery.   

If NHS England was really serious about limiting the use of antibiotics and so prolonging their usefulness in fighting patients' infections, they might think a bit harder about funding one of these systems in every one of England's medical practices.  

Bacteria developing resistance to antibiotics is not a new or even an unexpected phenomenon.  Alexander Fleming, who discovered penicillin (one of the first antibiotics), warned it might happen when he accepted his Nobel 1945.

When the system was first operational at the Great Bedwyn surgery it was featured in a report on ITV News.

The AGM of the Friends of Savernake Hospital and the Community is on 11 May - details here.


The NHS is being reorganised - this time quietly and without bothering our sovereign Parliament

We are not supposed to notice it, but the NHS is being reorganised again - and once again it is starting as a top-down process.

Just to recap briefly: before the 2010 election the Conservatives promised 'No more top-down reorganisations of the NHS.'  Within months of coming to power with the LibDems, Andrew Lansley was left alone in the toyshop and began not just a top-down rearrangements of the chairs, but a root and branch reorganisation of key parts of the NHS.

This had not been mentioned in the 'Coalition Agreement' that fluttered across the Downing Street rose garden. But when it came to the crunch in Parliament, the junior coalition partners did little to stop Mr Lansley opening up the NHS to root and branch privatisation - more roots, more branches.

Some of the current problems the NHS is facing can be sourced directly to the Lansley plan - as well as to the decision to make good the promise of 'real term' rises in NHS funding by staying the wrong side of the decimal point.

This new reorganisation is called STP - an NHS acronym that sounds unfortunately as though it belongs to a sexually transmitted disease.  It stands for Sustainability and Transformation Plans.

STP involves two basic notions:
1.  It creates units that are larger than the Clinical Commissioning Groups (CCGs) which Lansley created to replace Primary Care Trusts (PCTs).  These new areas are called 'planning footprints'.

2. Lansley concentrated on the commissioning of health care and left hospitals at the mercy of rising demand, lack of trained staff, commissioners trying to save money and two regulators each with different priorities.  This time it is very different:

Although the Lansley legislation was called the Health and Social Care Act and included the formation of local Health and Wellbeing Boards to promote integration, he did not properly build bridges between health and social care.  And anyway his colleague at the Treasury was busy reducing - if only indirectly - local councils' social care budgets.

STP 'footprints' will include not only the commissioners (CCGs) but also acute hospitals and local authorities - with all the latter's social care responsibilities.  They aim at real integration.  But they will not include any of the private providers which have a growing stake in the NHS.

On paper these STP 'footprints' look suspiciously like re-heated Strategic Health Authorities - one of the many NHS bodies Lansley abolished.

Wiltshire will join Swindon and Bath and North East Somerset (BANES) to become an STP 'planning footprint'.    The great advantage of the 'footprint' the Marlborough area finds itself in, is that it includes all three acute hospitals (RUH, Salisbury and GWH) which serve Wiltshire's population.

Another advantage of this new system is that Wiltshire CCG are quite a distance along the road to transformation - notably with the rising success of their policies to treat many more of the old and frail at home rather than in hospitals.

A probable disadvantage for this STP footprint is that it yokes together three very different cultures (mainly urban and mainly rural) and demographics.

A broader disadvantage of the whole STP scheme is that it may be seen as a distinct slap in the face for the 'clinical leadership' of the CCGs.  They have been driving change in the CCGs and, under the Lansley regime, replaced the commissioners of the PCTs who were referred to by many politicians as nothing but bureaucrats - or worse.

The speed with which NHS leaders and local authority leaders now have to move to achieve this nation-wide reconfiguration is eye-watering.  The timetable of key stages began last week (week beginning February 29) and ends in July.

The power these footprints will wield comes from the capitated budget each will receive.  But this will almost certainly provide them with their main problem: as the population ages and treatments get more costly, affordability will become the watchword.  They will have to decide on reductions in treatments they can afford.

And, unless people are properly informed and prepared, that will open them up to a welter of local 'rationing' controversies and they will have a lot of explaining to do to patients, families and their MPs.

However, do not get too alarmed: because STP is not put in place by legislation but by NHS dictat it may not create permanent structures.   If they do not work, they can be shunted off to a rehabilitation home.

Each 'footprint' area has to have "a named person who will be responsible for overseeing and coordination their STP process" - this could be a CCG chief officer, the chief executive of a hospital or of a local authority.

The letter spelling out 'the process' is from the heads of the six main, national NHS organisations - NHS England, Care Quality Commission, Health Education England, NICE, Public Health England and a new body - NHS Improvement.

This new kid on the block is symptomatic of the sleight of hand with which this reorganisation is being carried out.  NHS Improvement joins together the Trust Development Authority and Monitor which each regulated different layers of England's hospitals.

However, joining them together would require primary legislation - and that might frighten the horses.  So they have simply been yoked together under one boss, but still with separate offices and staffs. Many people hope that NHS Improvement will work towards real improvements rather than merely delivering the slaps on the wrist associated with its forebears.

The chief problem will be sorting out the governance of STP: who reports to whom and who can force change on what, and how to deal with a complex cocktail of conflicts of interest. Another issue will be that while the CCGs and hospitals carry on their vital day jobs, there will need to be some sharing of staff and resources towards the greater good of the 'footprint' - and ultimately themselves.

Another issue will undoubtedly be fitting various existing oversight and other committees into this new 'footprint' geography.  For example the Health and Wellbeing Boards (of which there are three in our 'footprint' - joining each CCG to its local authority) may well become redundant. That would be tricky as they were created under Lansley's Act of Parliament.

As the NHS letter to all heads of CCGs, hospitals and local authorities, spells out engagement and communication will be one of the main jobs the STP will have to achieve:

"If we get this right, then together we will:
•    engage patients, staff and communities from the start, developing priorities through the eyes of those who use and pay for the NHS.
•    develop services that reflect the needs of patients and improve outcomes by 2020/21 and...close gaps across the health and care system...
•    mobilise local energy and enthusiasm around place-based systems of health and care, and develop partnerships, governnance and capacity to deliver.
•    provide a better way of spreading and connecting successful local initiative, providing a platform for investment from the Sustainability and Transformation Fund..."

So we will be watching this space to see whether STP is the cure or the disease.  We should all expect to hear about STP sooner rather than later as one of its key aims will certainly be telling 'those who use and pay for the NHS' what the service can no longer afford and what services will be combined or moved elsewhere.

This Friday (March 11) a cross-party (not, we note, 'all-party') NHS Bill will be debated in Parliament.  This aims to bring back the NHS as a national universal service and get rid of the expensive, chaotic internal and external market.  

In other words it seeks to de-Lansley the NHS - ending fragmentation and privatisation.  Were that to pass it might do more in the short term to save the NHS than hurtling forward with STP.


Hotkidz Clinic: pilot scheme for out of hours care of unwell children gets thumbs up

On the day the nation awoke to hear and read about the dreadful blunders that led to the death from sepsis of one-year-old William Mead in Cornwall, Wiltshire Clinical Commissioning Group's board meeting (January 26) was told about a ground breaking pilot in Salisbury for out of hours care of unwell children by GPs.

The scheme provides health advice and treatment for minor illnesses and injuries and gives parents a local alternative to A&E when their child is ill and their surgery is closed. If necessary, parents are advised to make a same-day appointment at the Salisbury Walk In centre.    

The aim is to provide "A service dedicated to treating children in a safe environment during the out of hours period by local GPs."  And they have had no problems filling the shifts to staff the pilot.

The pilot runs till the end of March and in its first five weeks 85 children have been seen with only one being referred to hospital:  "It's so much easier to eye-ball a child.  You can use all the diagnostic templates there are, but eye-balling gets the best results."

This scheme has already helped reduce the pressure on A&E. Dr Chet Seth, who is a director of Wilcodoc which is running the pilot, and a CCG board member, explained that one advantage of this new Hotkidz Clinic service in keeping children out of hospital emergency departments is financial.

At acute hospitals paediatric assessments in emergency departments are charged to the CCG as an admission.

Hotkidz Clinic flyer (as this pilot does not apply to the Marlborough area we have removed the phone number)Hotkidz Clinic flyer (as this pilot does not apply to the Marlborough area we have removed the phone number)As with any new services, getting the word out is proving a challenge.  But, with support from the CCG's communications team, they are making good use of school bag messages, social and traditional media. 

They need more referrals from NHS111.

When asked whether there are plans to replicate this scheme elsewhere in Wiltshire, Simon Burrell who heads the CCG's north and east locality which includes Marlborough, came back with a quick:  "There are now!"

Given that what is good for Salisbury may not be so applicable in rural areas, this led to a brief discussion about hubs for out of hours services - given that with costs and staffing constraints, it is simply not possible to 'keep the lights' on in all surgeries 24/7.

Dr Burrell: "It depends on how far people are willing to travel - or should be expected to travel."  And Chris Graves of Healthwatch Wiltshire asked: "How do we help them to travel? We need to be building in alternatives to get you where you need to be."

In rural areas, travel for patients will become a central part of the NHS debate as more and more services are delivered away from the major hospitals and cannot all be 'close to home'. 

And it comes at a tricky time - as subsidised bus routes are under threat and the RUH hopper bus service is no longer funded by Wiltshire Council.


Will the cap fit? GWH faces up to the squeeze of recruitment versus capped agency costs


As NHS hospitals across England enter the winter months - and put their plans to work round strikes by junior doctors on hold - staff shortages are still high on their agenda.  Staffing - especially nursing staff - is being squeezed from both ends.

There are serious recruitment problems throughout the NHS and finance directors are watching every day's costs.  And from November 23 they have the additional pressure of a government imposed cap on how much they can pay agency nurses.

The money spent of agency staff across the NHS in England during July-September was £1.9 billion - or 7.7 per cent of the national NHS pay bill.  Great Western Hospitals Foundation Trust (GWH) have been working to cut their agency costs by 30 per cent from last year's level and their spend for October came to to 3.7 per cent of their pay bill.

GWH currently have 87 nursing vacancies.  In the first week of the agency pay cap they missed the limit on 87 nursing shifts.  But they had only had a weekend's notice that the cap was coming into force.

This intervention by the government in the marketplace for nurses is by no means certain to have the impact ministers want.  One director told the Trust's board meeting this week:  "I don't think it's going to have the kind of benefits people are predicting."

An experienced senior NHS manager and now a consultant to NHS Trusts, went further - his view featuring in this Health Service Journal headline: Fears agency cap will be 'train crash'.  

NHS authorities have said the cap poses 'significant risks' for patient safety and performance, but that the 'balance of clinical risks' support taking action on agency costs.

The difference in pay between the capped hourly rate of £28.80 per hour (for daytime shifts) and the prices paid for some agency nurses can be as much as £10 per hour.  GWH managers believe that at November levels they will breach the cap for nurses' pay an average of 62 times a week.

The capping regime will get tougher next year.  The cap rachets down from that £28.80 per hour to £25.20 on February 1 and to £22.32 on April 1.

Nurses are not the only agency staff employed by GWH.  They are currently employing four consultants from agencies who are breaching the £129.62 per hour cap.  Already there are stories about overseas doctors working for agencies seeing their pay reducing and deciding to return home.

GWH's chief executive, Nerissa Vaughan, told this week's board meeting that since 2013 the Trust has recruited 570 nurses, 47 midwives and 102 doctors - which means they have 198 more permanent staff caring for patients.  

Marlborough News Online asked Oonagh Fitzgerald, GWH's director of human resources, where those other 521 people had gone.  Nurses can retire at 55 without damaging their pensions: "Turnover has crept up over the last years - across the NHS."

One factor has been the one per cent pay rise over the last government and into this one.  And that pay rise is not what it seems as increased pension contributions have eroded the one per cent.  Some staff do leave to join the higher paying agencies.

Some nurses do get annual increments as their experience increases.  But 27 per cent of GWH's nurses are at the top of their pay scale - and so only get the one per cent rises.

When it come to planning ahead Oonagh Fitzgerald has a good local source of newly trained nurses who come through the Oxford Brookes University training college in Swindon.  She hopes to recruit about eight in every ten nurses trained there - many of them already living locally.

The NHS (through the Health Education England) buys places at the Swindon arm of Oxford Brookes University: 67 this year, 120 next year and a rise to 132 for 2017 and 2018.  Interestingly the average age of applicants for those places is running at 29 - it may be their second career or they are returning to work after having children: "They are making", says Oonagh, "a proactive choice - and so are most likely to become good nurses."

To close the immediate gap GWH is again recruiting overseas.  As their economies revive, the EU countries - mainly Ireland, Spain and Portugal - are not proving such good recruitment areas.  The relief overseas recruits bring in boosting staff numbers is sometimes shortlived as the pull of families and the strangeness of England lead some to realise they have made the wrong choice and they return home.

GWH 's last visit to Spain and Portugal - where forty NHS Trusts had been over the last two years - was not so productive.  They saw 35 applicants and accepted six: "We have," Oonagh explains, "high standards for people working with our patients."

Next year they may go further afield - to India and the Philippines.  The Home Secretary lifted visa restrictions in October and put nurses on the shortage occupation list.  But Mrs May's decision is now under review - and GWH have been putting their case to the review that visa restrictions should not be put back in place.

Shortages in other areas are not affecting GWH so much.  Unlike some areas of the NHS, they are not short of midwives.  But the age profile of their midwife team is 'at the high end' - which may bring future problems. And GWH reflects the national shortage of doctors specialising in the care of the elderly.



Changing of the guard for Wiltshire's NHS - just as Brexit poses new problems for health services

Deborah FieldingDeborah FieldingHaving steered Wiltshire's Clinical Commissioning Group (CCG) as its Chief Officer through its first - and pretty difficult - four years, Deborah Fielding has left to return to her home territory of Essex and a new NHS commissioning role.  Her place will be taken by Finance Director Simon Truelove - until he leaves in September.

Marlborough.News went to see her on her last day at Wiltshire CCG's Devizes headquarters - we wanted to find out what her legacy would be and what the future holds for the CCG itself.  And she had important news about NHS111.

The very next day we got evidence of a major part of her legacy: from July 1 the county's adult community health services are in the hands of a partnership or joint venture between the three major hospitals that serve Wiltshire (RUH in Bath, GWH in Swindon and Salisbury Hospital) under the title Wiltshire Health and Care.  

They were commissioned by the CCG after a long and careful tender process: "The joint venture gives us the opportunity to continue collaboration."  She sees this collaboration as key to the Sustainability and Transformation Plans (STP) she has been working on with Bath and Swindon CCGs and the three hospitals during her final months in Wiltshire.

"The STP could be the solution.  I think it could be a real opportunity for Wiltshire.  There's unparalleled collaboration. Not everything can be commissioned at local level."

However STP will alter the position of CCGs in the NHS organisational hierarchy: "The role of the CCG is changing.  I think the CCG has a really important role in developing primary care and community based services.  Eventually those services will become Accountable Care Organisations (ACOs) - commissioners and providers.  The CCG will be needed to manage and monitor ACOs. But it'll become smaller."

"We have", she says, "improved collaboration across the system".  She came to Wiltshire for the CCG's start-up period and her first task was to prevent Wiltshire having three separate CCGs - both the south and west of the county wanted to go their own way - on their own.

She and her team set-up one CCG for the county with a three locality structure: "We developed a common strategy that could be implemented locally - depending on local conditions - based around integrated teams of health professionals serving populations of around 20,000."

How have these changes to the NHS in Wiltshire come about: "Partly economic necessity, partly leadership - including the leadership of our GPs.  We're lucky in Wiltshire to have such good primary care."  One result will be a new building to house Devizes urgent care service - the application for planning permission will be made in September.

From time to time during her four years relations between the CCG and Wiltshire Council have been strained - sometimes very strained, for instance over the ownership of NHS funding: "Relationships have been repaired. We have to work through the challenges. The government haven't helped by funding social care particularly badly."

She says Council leader Baroness Scott has the needs of the people in mind: "Strategically working together is not difficult - because we both work through localities and both want Wiltshire patients treated within Wiltshire.  The population needs to become paramount - at the local level."

The controversial contract for the NHS111 telephone service for Wiltshire comes up in 2018: "We are working on a more integrated urgent care structure which will include 111.  It will be more locally sensitive and make better use of clinical skills and new technologies - so patients are directed to the right place at the right time."

"Safety is not the biggest problem with the current service - if anything they're over cautious - sending more people into A&E."

We spoke to Deborah Fielding during that strange gap in contemporary history between hearing that Gove wanted to be the new Prime Minister and that Johnson realised he could not be the next Prime Minister.  So Brexit was much on our minds and will be hovering over the NHS for years to come.   What would the impact of leaving the EU be for the NHS?

Deborah Fielding says there are two really big and important things that affect the care you will get - money and people - and both are put in jeopardy by Brexit: "If Britain goes into recession there will be less money for the NHS - there is no doubt about that."   The people part is all about the workforce: "The NHS is dependent on our European workforce and that's dependent on the free movement of people."

Then our talk turned to a photo [see below] that had been whizzing around social media that morning.  It shows the surgical team a hospital in England.  Just one member is a British citizen (of Pakistani origin), the rest are all European (that's European as in 'from the EU').


The NHS crisis: controversial changes may be coming to Wiltshire's health services - sooner or later?

Later this month leaders of the new NHS grouping that includes Wiltshire, go to London to hear the official response to their draft Sustainability and Transformation Plan (STP) that will also cover Swindon and Bath & North-East Somerset.  This so-called 'footprint' for the STP reorganisation is known in NHS-speak as BSW.

This response matters as an approved STP brings with it extra funding from a £2.1 billion central fund for the NHS in England.  In the first month of the new financial year, Great Western Hospitals Foundation Trust was £100,000 adrift from its target.  And that included a month's share of the promised STP funding - without that money they would have been £788,000 in deficit.

The majority of Trusts across England finished the last financial year in deficit.  As the graphic [below left] from the Health Foundation shows, this situation has been deteriorating over the past four years

BSW's plan is at a formative stage and its workings are largely below the radar - though it is said to be "all consuming" as regards Wiltshire CCG's executive team.  There are some hints as to what will be coming Wiltshire's health services way in the near-ish future.

[Click on image to enlarge it][Click on image to enlarge it]The NHS Chief Executive, Simon Stevens, floated the idea of 'combined authorities' that could emerge from decisions made under the STP.  These would probably unite commissioners and providers - for instance a CCG and one or more hospital trusts.  

Another set of initials introduces the Integrated Care Organisation (ICO) - joining social care departments and hospitals.  An ICO in Salford is already being formed and 400 council staff have been moved to the Salford Royal Foundation Trust's payroll.  At least stabling them with the hospital trust rather than the local Council will avoid further politicising health services.

One thing is certain: STPs will involve 'controversial changes' - so much so that Stevens has promised 'safe harbour' for NHS leaders who make those decisions.  This means, it seems, that NHS national bodies will sign those leaders up for a period of 'three, four, five years' - so they can survive in the face of any fierce public or political firestorm in reaction to their decisions.

Perhaps that is what the CCG's outgoing Chief Accountable Officer, Deborah Fielding, meant when she told her board (May 24): "The next couple of years are going to be really difficult for CCGs."

In some recent minutes of Wiltshire CCG committees there are hints at how stringent (some would say ruthless) the STP regime is going to be.  Talking about human resources matters, one executive notes that " would be even more important to support staff with the advent of the STP and the Accountable Care Organisation."

Does this mean the CCG or the STP grouping have decided to go down the Accountable Care Organisation (ACO) route?  A CCG can contract a single ACO (made up of hospitals, charities and private companies) to arrange and provide all health care for the CCG's population.  And, with the CCG's responsibilities then reduced, its staff is slimmed down accordingly.

At a CCG meeting in February there was a warning too about other members of the STP grouping: "The Committee discussed the STP and it was reported that Swindon and BaNES have an estimated funding gap of £70million for 2016/17.  An action plan needs to be in place by June 2016 to address this gap."

And discussing 'affordability' of services and the CCG's budget, the Chief Finance Officer said: "...with the 2016/17 population growth, it was essential that more people were kept out of hospital.  It was necessary to reduce hospital capacity in order to keep admissions down."

Does this fit the 'by-pass' theory of supply and demand?  In terms of traffic management, if you build a new by-pass it will fill up with cars.  But the theory does not explain where the cars were before the by-pass was built.  

If this theory is applied in reverse to a reduction in hospital capacity - that is closing wards or even hospitals - it presumably means that with fewer hospital beds there will be fewer people needing to be in hospital.   

But the theory certainly does not explain where those people who are now ill enough to be admitted to hospital will go when there are no beds for them.  Not everything can be treated at home.

Seen from GWH - at the northern end of the BSW 'footprint' - there is a very different view of hospital capacity - see separate story.


Great Western Hospital asks for support as its emergency department fills up again

Here is a window onto the problems facing the Great Western Hospital in Swindon - the hospital that serves many patients from the Marlborough area.

Last Wednesday (March 16) the hospital announced:  "Patients may be waiting for longer than normal when visiting the Emergency Department at the Great Western Hospital today."
"The hospital is extremely busy and as of 10.30am this morning, around 100 patients were waiting to be seen, with 220 being the average number of people attending the Emergency Department each day."  
"We are doing everything we can to treat patients in a timely manner - however less urgent patients may be waiting longer than we would like."
The number of people attending GWH's Emergency (or A&E) Department has increased by almost 20 per cent over the last five years and approximately 100 patients each day who attend the Emergency Department now need to be admitted to hospital.
The hospital staff are asking people to help them: "We are doing everything we can to provide safe and high quality care during this challenging time, however there are lots of things local people can also do to support us."
"If you need urgent healthcare, but your condition is not critical, you might be seen sooner at one of the many other healthcare services available throughout Swindon and Wiltshire."

There are other ways to get timely help or treatment:
SEQOL Urgent Care Centre
:  The Urgent Care Centre, which is on the Great Western Hospital site, is open 24/7 and is the place to go if you need medical assistance and have been unable to get an urgent GP appointment. Contact 01793 646466.

SEQOL Children's Clinic: 
The clinic, which runs from Monday to Friday between 8am and 8pm,  for youngsters, toddlers and infants suffering from common colds, aches or pains but not life-threatening conditions, that are unable to get an appointment with their own GP. 

Contact: 01793 646466 to speak to a specialist nurse who will make an appointment time with you at either Moredon Medical Centre or at:

Swindon Health Centre in Carfax Street, Swindon is open daily between 8am and 8pm and can help to treat people suffering from minor injuries and illnesses, such as sprains, strains, ear care, eye care as well as urine and chest infections. 

Pharmacist : 
Your local pharmacist is also an alternative when you want quick help for a minor condition, such as flu, aches, pains, upset stomachs and skin conditions. Most are open late and can even offer you private consultations. 

Out of Hours GP Service: 
Make sure you are registered with a local GP. The out-of-hours GP (01793 646466) can offer advice over the phone, as well as arranging home visits. 

The NHS 111 is available for medical advice over the phone

The Emergency Department
at at GWH is for critical or life-threatening situations where immediate medical attention is needed, such as breathing difficulties or chest pain, sudden severe pain or heavy loss of blood, for example. In a medical emergency call 999 immediately and ask for the ambulance service.

GWH is also asking people to look out for elderly friends, relatives and neighbours and encourage them to seek help early on.  If they start to feel unwell - even if it's just a cough or cold - then get help from your pharmacist quickly before it gets more serious.
Finally, GWH is asking relatives and friends to help them get patients Home for Lunch:  

At any one time around 30 of the patients in the 450 beds (which are - on average - in use at GWH on any day) are well enough to leave.

Discharges can be delayed for a number of complex reasons, often in relation to on-going care needs, however they are asking relatives and friends to ensure patients can leave in a timely and well-planned way, helping to free up beds so staff can start treating more seriously ill patients.

There are many things relatives and friends can do to make sure patients get out of hospital at the right time:

    •    Be involved in discussions around the patient’s recovery and on-going care needs, so that arrangements can be made early on
    •    Make arrangements to be available at the time of discharge
    •    Make the home comfortable for the patients return
    •    Arrange help around the home
    •    Arrange transport and clothes to leave hospital in
    •    Put the heating on if needed
    •    Stock the patient's home with basic food and any medicine they might need.


How a patients group has surveyed views on Marlborough's doctors and are helping the practice


Members of the PPG at one of their first meetingsMembers of the PPG at one of their first meetingsThe week's news headlines reported a rise in dissatisfaction with the NHS in England. This news item came from a survey of Britain during the 2015 General Election campaign.  A time when politicians made free with criticisms of and promises about the NHS.  

Among those surveyed many did not live in England and even if they did may not have experienced the NHS recently or even at all. And the survey used a sample that has been tweaked to destruction for margins of error.  So much for that survey.

A much more relevant survey was carried out during September and October last year by the Marlborough Medical Practice's Patient Participation Group (PPG) to test patients' views on their experience of the Practice.

When Marlborough News Online met with representatives of the PPG our first question was "How did your survey go?" - "Extremely well".  They had aimed to get 100 responses: "That would have been really good."  

But they got 470 responses.   Most were very pleased and positive indeed with their experience at the practice.  The responses contained, a PPG member said:  "An astonishing amount of feedback - most of it positive. Over eighty per cent either positive or constructive."

PPG members handed out questionnaires at the surgery's flu jab clinics and at Tesco - where one woman told them: "I don't need to fill one in I'm very happy with the surgery."

The survey was also available online.  PPG members have decided that some of their questions could have been better phrased and some people skipped placing various elements of the surgery's current and possible future services in order of priority.

However, that question did reveal one important point.  While patients are in favour of the surgery opening for appointments on Saturdays, they were against Sunday opening.  This fits with national surveys and blows something of a hole in the government's expensive policy for a seven-day health service.

The practice doctor who is a member of the PPG, Dr Jenny Campbell, says the survey has had a really positive response from the partners: "We've had a really positive discussion about the issues it raises.  Seeing everything from the patients' viewpoint is important.  Some of them are small things - the niggles - and being able to change them is just great."

Among the niggles revealed by the survey are the locked doors to the waiting room (doors the doctors never use so do not see the problems caused to those with pushchairs or who are disabled) and the fact that the surgery is thought by some to be closed completely during the lunch hour (it is not, but a notice implies it is.)  These and other points are now on the 'Action List'.

One fact revealed by the survey is that too few people know they can book appointments online - and not enough people use this new facility which cuts down waiting at busy times for 'phone calls to be answered.

Some points raised by the survey are beyond immediate cure - such as parking.  Others are 'urban myths' that the PPG can help dispel.

Some issues are, of course, much more difficult to resolve. The survey showed people value continuity - i.e. seeing the same doctor at every appointment - but also want choice of their GP.  As absolutes these are considered to be mutually exclusive and incompatible.

Dr Campbell explains: "There is a lack of understanding about how the system works."

The PPG agrees with doctors that spreading the word about new NHS developments, about on line services, about the difficulties practices across the country are having in recruiting doctors and about restricted NHS resources.  

As pressures on the NHS continue to grow and its funding does not keep up with demand, people in Wiltshire will need to understand what services are available and where they are.  The PPG say they believe they can help people to understand how the system is changing.

The PPG's Chair, Amanda Giles, pointed out that they were still in at a formative stage: "We need to help maximise what we can get from the practice - and we have to understand what doctors have to do besides seeing patients at the surgery and help everyone understand that."

And Dr Campbell said: "If at the end of the day people understand the limitations we have to work with - that would be a real success for the PPG."  

The NHS will be changing over the coming years as funding dips again and people need to know from their PPG how they can still get the best out of the service.

The full and short versions of the survey report can be found here.

Missed appointments:

One area where the PPG are spreading the word is on missed appointments, which hamper the service the practice can give and waste time.  During 2015 patients did not attend 2,221 booked appointments at the Marlborough Medical Practice.

That is an average of 8.5 no-shows every day or eight appointments that could have been booked by a patient who really wanted or needed to show up.

The Marlborough Medical Practice has about 12,000 patients on its books - the number varies.  Last week the count was 11,642 registered patients.  Making sure that number of patients can get appointments when they need them or when it suits them - fitting round working hours, school hours and so on - is difficult enough without all those no shows.


When winter comes can pressure on the NHS be far behind - except it's now a government secret

About this time last year, Marlborough News Online began an occasional series of reports highlighting the winter pressures on England's NHS hospitals - with special reference to the Great Western Hospital, which serves the Marlborough area.

After last winter, the pressures hardly reduced when spring arrived and demand for NHS hospital services kept on growing.  And now it's winter again.  But this time the figures are not being released as they were last year.

We will not now get weekly figures on A&E waiting times, cancelled operations, beds closed by norovirus outbreaks, or delayed transfers of care (DTOCs aka blocked hospital beds.)  This winter's weekly figures were due to start on December 11.

But now only figures for cancelled operations, patients waiting over four hours in A&E and DTOCs will be released - and only released on a monthly basis and with a six-week delay.  NHS England says it is 'seeking to minimise the bureaucratic burden on frontline hospitals and GPs'.

That is a really lame reason - or excuse: the figures will be collected and collated anyway - it's just the person who presses the 'send' button who will have for an extra cup of tea.  You can tell it is an excuse by the use of the weasel phrase 'frontline hospitals' - are not all NHS hospital's 'frontline'?

At the GWH board meeting today (January 7), the directors learned that in November the emergency department treated 89.3 per cent of patients within the 4-hour wait target - the standard is 95 per cent.   In the autumn GWH had hit the target percentage several weeks running.

Achieving targets are not the hospitals only problem.  There is also the combined problem of the national nursing shortage and spiralling costs for agency nurses.  

The GWH board members have before them a paper on nurse recruitment.  This is a vital part of the GWH's strategy to cut its deficit and still keep patients safe.

Nursing numbers have been hit by the coalition government's disastrous cut in training places, years of low pay rises, the lure of agency pay scales and growing numbers nearing retirement age. Now hospitals are also having to take into account the dichotomy between safe staffing and a capped spend on agency nurses.

Part of the answer has had to be recruitment of nurses from overseas - running the gauntlet of Home Office entry rules, costs of recruiting overseas (which some national newspapers find offensive) and finding nurses with the right English, the right qualifications and a desire to work in England that will not prove too short-lived.

GWH's recruitment plans for 2016-2017 had been costed at £300,000.  But this new paper adds another £221,400 to those the costs.

Costs are not the only hurdle.  New rules come into force on January 19 to make sure overseas nurses have the 'appropriate' level of English language skills. The new level is equivalent to a master's level qualification and it is thought that only about five per cent of the overseas nurses who have joined GWH would have passed this new and stringent test.

The economic revival in Spain and Portugal and these new language rules will mean fewer suitable candidates will be found within the EU.  So the GWH Board is being asked to agree an extended  recruitment programme outside the EU - with a focus on the Philippines.

The quality and quantity of nursing recruits from the Philippines will be 'considerably higher' than from the EU, but the recruitment costs involved will also be higher and the time taken to get each nurse into post will be longer.

In order to cope with the increasing demand on hospital services and keep within the agency caps, GWH believes it will need to recruit ten EU nurses in each quarter of the next financial year - a total cost of £100,000.  They also forecast the need to increase their recruitment during the year of non-EU nurses from 35 to 70 - raising those recruitment costs from an estimated £212,430 to £421,400.

Once these nurses have been at GWH for fourteen weeks, their salary and recruitment costs will make them cheaper than agency nurses.

The paper signs off with this statement: in order to have a full complement of registered nurses at GWH "...a similar international recruitment strategy will be required until 2020 when the number of nurses within the UK is expected to match the demand."



Has the NHS' financial crisis been caused by reduced funding levels over the last five years or by policies?

As winter approaches, bringing fresh pressures to hospitals and GPs surgeries, doubts are being raised about the NHS' ability to survive at present funding levels.

Hospital Trusts are facing large deficits and some Clinical Commissioning Groups are not going to make their end of year targets.  Now the Department of Health is asking how much capital spending could be delayed till 2016-17.   A raid on capital budgets shows how serious this crisis is getting.

In October the King's Fund issued a stark judgment on the government's funding of the NHS:  the decade to 2020 could see the longest reduction in the share of the economy devoted to health care in Britain for seventy years.

The King's Fund analysis was clear: "The 10 years up to 2020-21 are likely to see the largest sustained fall in NHS spending as a share of GDP in any period since 1951."

At the last two elections the Conservative Party promised to raise the annual grant to the NHS by more than inflation.  And during the coalition government they kept their promise - just.  However, a plus-or-minus one per cent increase over general inflation flew in the face of 'health service inflation' of four per cent or more - depending where you are in England.

The reasons for this higher level of NHS inflation are many: the growing population, raised expectations of care, new treatments, increasing numbers of the old and frail, more people with long-term illnesses, more complex procedures, more expensive drugs...

Earlier the independent Health Foundation had raised very similar concerns.  They showed that this decade will see - even with all the promised £8 billion increase in NHS funding by 2020 - the lowest real-term growth in funding since the NHS was established in 1948.

And it may get lower still as the extra £8 billion was promised only if the NHS delivered £23 billion in savings.  No one believes those savings are achievable and as yet there is absolutely no whisper as to when the £8 billion will appear.

So what does our Member of Parliament mean when she writes cheerily in the local newspaper:  "...this government has guaranteed record funding for our precious NHS, paid for by a strong economy..."

It's a record all right - but the wrong sort of record.   Even Health Secretary Jeremy Hunt told the Health Select Committee of the House of Commons last month that the financial pressures on the NHS are "...the worst they've ever been in its history."

It is a clear fact that as cuts to local authorities' budgets hit social care, huge sums of money from the NHS budget were diverted to social care: this is called the Better Care Fund.  This policy was supposed to help save the NHS money as the old and frail were kept out of expensive hospital beds and cared for more economically in or close to their homes - community care.

The headline from Healthwatch Wiltshire's report on patients' experience of Better Care Fund treatment is very positive: "The good news is that we found that the majority of the people we spoke to (77 per cent) said that they were ‘extremely likely’ or ‘likely’ to recommend the care that they received to friends or family if they needed the same care."

While it is indisputable that many older people in Wiltshire are welcoming this care, the Better Care Fund is not yet having the beneficial impact on NHS budgets that it was supposed to have.  

At the latest meeting of the Wiltshire Clinical Commissioning Group's governing board, reports found much to cheer about as the Better Care Fund started to provide better care out of hospital.   

For example a four per cent reduction has been achieved in emergency admissions of patients aged over 65.  Another example was the costly Urgent Care at Home programme which "...continues to receive a high level of referrals over a seven day period with high confidence that admissions are being avoided."  And delayed transfers of care of those ready to leave hospital are down.

This is real progress under the Better Care Fund flag.  But it is not yet the required transformation in care.  It is progress in services provided through the CCG and the Council that has been bought, it must be noted, with extra funding.

There is a slight fog around these results as, before the Better Care Fund was thought of, the CCG got there first with their own plans to bring care closer to home - based in the community rather than in hospitals.

However, the CCG's board meeting was also presented with a great splash of red against all the Better Care Fund projects in the list of financial savings the CCG must make.  The Director was reported as being only 30 per cent confident that the CCG would deliver 2015-2016's savings: a sum set at £2,785,000 or a reduction of 978 hospital admissions.

Is this all about the Better Care Fund 'bedding in', 'ironing out the creases', learning as they go along, having a cumulative impact - and so on?  Or is there a fundamental flaw in the theory behind the Better Care Fund?

If you keep the old and frail away from hospital treatment, are you just patching them up for the time being?  Does this mean that when they eventually do have to go into hospital they need longer and more complex (i.e. more expensive) treatment?  Will there always be a cohort of these elderly patients who do need this sort of costly hospital treatment?  

CCG data definitely demonstrates that those being admitted to hospital now are more in need of complex - more expensive - treatment.  But it also shows that people are able to stay longer in their homes rather than be admitted to hospital early and have all the problems of leaving hospital again.  Do the costs involved in this 'equation' balance out?

Some will argue that the real problem is that funding for social care has been stripped to the bone - and the NHS budget is, in one way or another, having to pick up the pieces - and the bills. 

There have been reports that the government wants to continue with the Better Care Fund - although NHS England want its funding frozen at this year's level for 2016-17.  They must hope that in the longer term its impact will be beneficial not just for patients, but for the NHS as a whole.  

Even before the General Election, Jeremy Hunt was telling the Health Service Journal that some of the promised £8 billion extra over the next Parliament would be paid out via an 'accelerated and extended' Better Care Fund to help cash strapped social services.    And now we hear that social care organisations are lobbying hard to receive a cut of that £8 billion.

While the Better Care Fund carries on - having many positive effects - front line services in the NHS as a whole threaten to become 'worse care',  'under-funded care' and in some cases 'unsafe care'.

There are other health service records being broken: our politicians have to remember that we now spend a lower share of the country's Gross Domestic Product on health than Greece or Portugal.  Britain's figure - according the Organisation for Economic Co-operation and Development - is similar to those for Finland and Italy, but well below that for Germany and France.

The government seems intent on chipping away at the money the NHS spends on front-line services.  Many of the much trumpeted savings on 'bureaucracy' and managers, have been lost to hugely increased costs of open procurement processes, consultants and legal advice.

You can follow the only too logical steps from the government's imposed cap on public pay - leading to some nurses leaving the NHS because their pay has fallen so far behind - leading some of them to work with better pay for agencies - leading to hospitals struggling with inflated agency costs to replace those missing NHS nurses.  
A policy designed so the Chancellor can point to the money saved by the pay cap - but politicians seem in denial that it has to be spent elsewhere.

Another sleight of hand raid on front line NHS budgets - from the biggest trust hospital, through the average GPs' practice, to your neighbourhood care home - is coming with the Care Quality Commission's charges.  Not many people know that the CQC charge fees to all health care providers they inspect.

To cut government spending, the Treasury is making the CQC recover all its costs from its regulation fees.  So the CQC just puts its charges up again (after last year's nine per cent rise.)

Some providers could see their CQC fees rise by 300 per cent. And care home fees would rise by 23 per cent a year.  The CQC may stagger these increases over two or four years.  But the raid on frontline care costs will still cause cuts in services, in staff or perhaps in building maintenance.  Robbing Peter to pay George...?
Is there another slice about to be taken off NHS funds?  The Local Government Association wants to get its hands on more NHS money. It wants some of the money already paid to CCGs to cope with winter pressures.  

Across Engloand, the attempt to integrate social and health care in the shape of co-operation between local authorities and CCGs has produced an absurd free-for-all tug- of-war over bits of the NHS's supposedly ring-fenced budget.

Which brings us to the cuts to the public health budget.   It has now been separated from the NHS budget (protected from cuts) and so it can now be cut by the Chancellor with apparent impunity.  

It is estimated the £200 million cut to public health spending in the current year will have consequential costs for the NHS of £1 billion over this parliament as more people fall sick - more will smoke, more will become obese, skip vaccinations and so on. Where’s the saving?  

And as we are looking at records, this cut in public health funding certainly counts as one: It is the first time in its history that the public health budget has been cut.  

Politicians cannot pretend to have been caught out by this NHS crisis.  Last December the independent King's Fund forecast the NHS would spend the next five years lurching from crisis to crisis - only this time each year will be worse than the last.  

And exactly a year ago the Commons' public accounts committee discovered figures showing that NHS bodies ended 2013-2014 with a combined surplus of £722 million - one third of the £2.1 billion recorded in the previous twelve months.  

The time for tweaking at the edges must be over.  One suspects that on November 25 finance directors in every corner of the NHS will watch the television broadcast of the Chancellor's spending review from behind their sofas.


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