The NHS goalposts are on the move again - how will Wiltshire's NHS be affected?
You wake up one morning to hear the BBC's Laura Kuenssberg telling her sleepy-eared audience that the government are about to 'unpick' some of or some parts of the Conservative-led Coalition's great NHS restructuring.
Then you remember you are going to the board meeting of the Wiltshire Clinical Commissioning Group (CCG) (Tuesday, May 22). Will they be in a state of panic? Will it be a case of turkeys waiting for Christmas?
CCGs were the main plank of what is known as the Lansley 'reforms' - as enshrined in the Health and Social Care Act 2012. Andrew Lansley MP was, at the time, Secretary of State for Health and had a bumpy time getting it through Parliament.
CCGs replaced Primary Care Trusts and were designed to put 'clinicians' in charge of commissioning services for their local populations. On Tuesday, were the members of the CCG board in a state of shock at Laura Kuenssberg's scoop? Not a bit of it. They had other things to worry about and several interesting new and patient friendly developments to talk about.
Their Chairman, Dr Richard Sandford-Hill did say there would soon be a Green Paper from the government, which would show the 'direction of travel for CCGs': "The goalposts are always moving in the NHS."
The Lansley restructuring was widely criticised for its complexity - as the King's Fund illustrated in its somewhat satirical Alternative guide to the new NHS in England [left]. The trouble is that as the Lansley model's success has been mixed and as the government starved the NHS of funding in the face of increasing demand, more structures were imposed - without Parliamentary authority - on top of already complex structures. There is a lot of scope for 'unpicking'.
The most obvious of these post-Lansley additions are the Sustainability Transformation Partnerships - STPs. The STP covering Wiltshire also takes in Bath & North-East Somerset and Swindon. It has a Chief Exec and he has a staff. The STP is in deficit by £20million because it includes three acute hospitals and almost all NHS hospitals in England are in deficit - largely as a result of what Lansley did but also did not do.
Some CCGs have been strong-armed into merging or forming some sort of co-habiting arrangement. Others have merged voluntarily as their funding or their geography proved unworkable. Mergers are still on the government's agenda.
It has been becoming more and more apparent that at a time when there was a looming doctor shortage and immigration rules were being tightened, it was a bit silly to have doctors sitting in CCG board meetings all day and driving miles to committee meetings or away days.
However, the latest 'must do' from central control is 'integration' - integrating the CCG's responsibilities for health with those of local authorities to bring seamless working on health AND social care. The main problem is the proper use of funds that both organisations hold and the consequent governance issues.
Integration drives a coach and horses through much of the Lansley Act of Parliament. So the linking up is said to need a degree of 'informality' - which, when disaster strikes, the courts will just hate. What it will do to the power of the clinicians and CCGs remains to be seen.
The first step towards integration in Wiltshire will be the (somewhat delayed) appointment of a single person to be - take a deep breath - jointly Accountable Officer of the CCG and the Council's Corporate Director of Adult Social Care. At the Wiltshire CCG board meeting the Interim Chief Officer, Linda Prosser, announced that the Governing Body of the CCG had signed off "...the governance arrangements for integration and the details of the joint post at its March meeting."
Part of the problem in sorting out where the goalposts are going - let alone reporting it - is that most of the decision-making is carried out in secret and with no published minutes. Halfway through May, we learn that in March the CCG asked Baroness Scott for 'some assurances from the council on specific matters...'
She has now replied to their letter. And, as the board meeting was told, the reply will "...be considered formally by the Governing Body in the private session today."
Some people say that integration is simply a way to fund social care by stripping even more money for social care out of local NHS budgets than is the case already. Others are already saying that this is a way to introduce one of the other new structures that have been trialled in parts of England - the ACO or ACS = Accountable Care Organisation or System.
Broadly this hands over the entire commissioning and administration of health services for an area - be it an STP area or a CCG area or perhaps even a local authority area - to a single organisation. It is an American idea that is deemed not to have been a huge success in the land of its birth.
It is seen by many people who work in the NHS and work to understand the NHS, as a quick way to a great deal more privatisation of the NHS.
What Laura Kuenssberg's scoop does show is that politicians who cheer when the NHS does well or favours their own constituency and remain silent as the NHS struggles on, have realised that voters are getting pretty fed up waiting for appointments - whether to see their doctor or a hospital specialist or a surgeon.
One of Lansley's aims that has withered on the many boughs of his restructuring, was to reduce the number of NHS managers. It was recently revealed that the NHS now has more senior managers than it had in 2010. Lansley's restructuring was said to have cost £3 billion - mainly in redundancy payments. Are more redundancies on the way?