:00:00. > :00:00.Tonight in a special programme we put the
:00:00. > :00:09.region's health care in the spotlight.
:00:10. > :00:11.As budgets tighten and demand rockets, we meet the patients being
:00:12. > :00:30.On the road with Devon's out of hours GPs.
:00:31. > :00:37.We're seeing a 94-year-old chap living alone who
:00:38. > :00:46.has had multiple medical problems in the
:00:47. > :00:47.past, looking at these notes, and may
:00:48. > :00:52.How one of the South West's busiest A is trying to
:00:53. > :00:56.If we can get them up to the unit before nine
:00:57. > :00:58.o'clock, they will be seen by a
:00:59. > :01:00.saving yourself a 12 hour hospital stay.
:01:01. > :01:18.Tighter budgets, more patients, with more complex needs.
:01:19. > :01:22.That's the challenge the NHS is wrestling with,
:01:23. > :01:26.This is A at the Royal Devon and Exeter.
:01:27. > :01:29.We are tracking what happens here at a time when the system is
:01:30. > :01:43.My name is Adam and I'm one of the consultants here.
:01:44. > :01:46.The battle is on to keep patients safe in one of the busiest winters
:01:47. > :01:51.nobody is waiting too long before
:01:52. > :01:59.The doctors call it exit-block, or bed block
:02:00. > :02:04.when patients in A need to be
:02:05. > :02:07.admitted to the hospital but there are no beds.
:02:08. > :02:09.It makes life difficult for Adam Rubin and his patients.
:02:10. > :02:11.We want the best possible care for all of
:02:12. > :02:15.When we have bed blockage and the Department is full
:02:16. > :02:17.it is very difficult at times to do that.
:02:18. > :02:19.when patients in other departments
:02:20. > :02:21.are well enough to leave hospital
:02:22. > :02:23.but there is nobody to look after them at home.
:02:24. > :02:26.In Devon 600 beds per day are occupied by people without any
:02:27. > :02:29.These are beds Doctor Ruben needs for
:02:30. > :02:35.people arriving in the emergency department.
:02:36. > :02:38.Last week or two have been very busy, with high numbers
:02:39. > :02:47.this department is things can change very quickly.
:02:48. > :02:49.In the space of 15 minutes that picture can change to
:02:50. > :02:53.At the moment we are OK, patients are being
:02:54. > :02:56.seen quickly and beds in a hospital
:02:57. > :03:08.It stands for Rapid Assessment and Trriage.
:03:09. > :03:12.That is where paramedics hand over new patients.
:03:13. > :03:13.Beryl Oak is 95 and has just arrived.
:03:14. > :03:26.a handover and when they do I will put a
:03:27. > :03:28.monitor on you to check your blood
:03:29. > :03:31.Doctor Ruben introduced this way of working
:03:32. > :03:33.in Exeter, meaning consultants see
:03:34. > :03:36.In this process we have an opportunity to
:03:37. > :03:37.welcome the patient, do a meet and
:03:38. > :03:39.greet so they meet a very senior
:03:40. > :03:43.member of the team at an early stage.
:03:44. > :03:46.We can tell the patient, forecast and tell what we think is
:03:47. > :03:49.So, you're likely to stay in hospital, that
:03:50. > :03:52.It is one of the top performing emergency departments in
:03:53. > :04:05.the country but even here patients
:04:06. > :04:11.They have come through one week where
:04:12. > :04:12.they have referred 242 people to
:04:13. > :04:13.medical wards, much higher than normal.
:04:14. > :04:16.The waiting ranges from three minutes up to more than 13 hours.
:04:17. > :04:18.This consultant Lewis Jones is chairing the midday handover.
:04:19. > :04:23.Next we have got a plan, spinal, rest of
:04:24. > :04:30.Let's have a quick look at the waiting room as well, Andy.
:04:31. > :04:33.Many of Dr Jones's patients are elderly.
:04:34. > :04:38.I think we have one of the highest rates in all
:04:39. > :04:41.the country, you have a higher volume of patients.
:04:42. > :04:43.Historically would not get that many in an emergency
:04:44. > :04:49.department but then we regularly
:04:50. > :04:57.We try as hard as we can, even to the point
:04:58. > :04:58.of receiving a patient the minutes
:04:59. > :05:02.We can get them up to the medical unit before
:05:03. > :05:04.nine o'clock, they will be seen by
:05:05. > :05:06.tomorrow morning, you are then
:05:07. > :05:08.saving yourself a 12 hour hospital stay.
:05:09. > :05:13.older patients experience a long
:05:14. > :05:18.We discovered 36,000 patients over 80 spent more
:05:19. > :05:20.than 12 hours in A departments this year.
:05:21. > :05:22.That figure has gone up by over 280% in five years.
:05:23. > :05:29.Coming down the stairs and when I came right down
:05:30. > :05:45.And I didn't realise that I had hurt myself.
:05:46. > :05:48.Well, if any of these collapses are the same as the
:05:49. > :05:53.previous ones, I don't think we are
:05:54. > :05:58.going to be of any benefit bringing her in.
:05:59. > :06:01.what value are we going to add to
:06:02. > :06:05.If there is something specific we can do and she
:06:06. > :06:09.The risk of bringing her in and getting a
:06:10. > :06:10.hospital acquired infection and
:06:11. > :06:14.reducing muscle power probably
:06:15. > :06:20.They will do something to it in a moment.
:06:21. > :06:22.Wrap it all up and everything, and
:06:23. > :06:25.then I shall go home to my daughters again.
:06:26. > :06:28.It is what mum wants and I think it is better, for
:06:29. > :06:30.anybody that can stay out of
:06:31. > :06:32.hospital, it is better to be in your
:06:33. > :06:41.One way to take the pressure off A might be
:06:42. > :06:43.to get more people treated closer to home.
:06:44. > :06:46.injuries unit at Homerton Ben Harris
:06:47. > :06:48.is here because he has hurt his hand
:06:49. > :06:52.The role played by small hospitals like this is under
:06:53. > :06:53.review as part of proposed NHS
:06:54. > :06:57.In the minor injuries department they are trying
:06:58. > :07:03.Patients like Ben will be treated by nurses, but what
:07:04. > :07:04.is unusual is that they have the
:07:05. > :07:10.back-up from the emergency department.
:07:11. > :07:13.Doctor Ruben without his scrubs is over from Exeter for the morning.
:07:14. > :07:14.I think that looks like an undisclosed fracture.
:07:15. > :07:22.What do you think we should do with that?
:07:23. > :07:24.Probably strapping again, give it some support.
:07:25. > :07:45.If this facility was not here you would have
:07:46. > :07:49.queue in the emergency department,
:07:50. > :07:51.which for an x-ray, wait to be managed.
:07:52. > :07:54.doorstep, he has the treatment
:07:55. > :07:56.sorted out and all the prep
:07:57. > :07:57.follow-up in place within half an
:07:58. > :08:05.We had quite an influx of sick patients.
:08:06. > :08:10.We now have six patients needing
:08:11. > :08:16.One of the new patients is retired doctor, Judy Daws.
:08:17. > :08:25.What they will do is put two electrodes or my chest.
:08:26. > :08:30.They will give me a brief anaesthetic so
:08:31. > :08:34.I will be unconscious and a current
:08:35. > :08:35.passes through my heart and hopefully that
:08:36. > :08:37.will shock my heart back into a normal rhythm.
:08:38. > :08:40.Then they usually hang onto me for a little while to
:08:41. > :08:41.make sure everything is all right,
:08:42. > :08:43.give me something to eat and drink
:08:44. > :08:45.and then I call a taxi and go home.
:08:46. > :08:47.It is the kind of procedure which
:08:48. > :08:49.used to need an overnight hospital stay.
:08:50. > :08:52.are saving her a hospital admission,
:08:53. > :08:54.so it is good for the patient and
:08:55. > :08:56.also good for the trust, because
:08:57. > :08:58.that is one bed available for
:08:59. > :09:04.It has been a good day, but there are likely
:09:05. > :09:11.In truth we do not know what the answers are.
:09:12. > :09:14.But we have a very good system here and an excellent department.
:09:15. > :09:16.We have good support services in
:09:17. > :09:19.place and it combines to work very
:09:20. > :09:21.well for us for the majority of the time.
:09:22. > :09:31.The emergency team will be hoping the changes deliver on their promise
:09:32. > :09:37.to relieve some of the pressure on places like this one.
:09:38. > :09:39.It's not just hospital patients feeling the strain.
:09:40. > :09:40.In Devon, where there's a huge health funding
:09:41. > :09:43.shortfall, a third out of hours GP surgeries have been shut.
:09:44. > :09:53.Saturday morning in North Devon.
:09:54. > :09:57.On his way to his first appointment
:09:58. > :10:09.We will go on to the moors and see what happens on this beautiful day.
:10:10. > :10:11.Doctor Hughes runs Devon Doctors, the GPs you call
:10:12. > :10:23.We're going to see this 90-year-old chap who lives alone and may
:10:24. > :10:26.This is one of the largest and most rural counties
:10:27. > :10:36.Just finding the patients can prove tricky.
:10:37. > :10:42.That is not where it is. I'm just going to check. I'm going round the
:10:43. > :10:46.front. I do not think there is any entrance there. I'm going to give
:10:47. > :10:54.not look right. That is Mrs Thorne. not look right. That is Mrs Thorne.
:10:55. > :10:57.It is like keystone cops. I cannot find it. The sign says somewhere
:10:58. > :11:04.else. I will have a little luck. Oh, else. I will have a little luck. Oh,
:11:05. > :11:09.it is down here. We were totally confused by the sign. Hello. Good
:11:10. > :11:12.morning. 94-year-old Herbert Symons
:11:13. > :11:23.has had a rough night. Grandad had a bad night. Last night
:11:24. > :11:29.he hardly slept. He has swollen legs. He is complaining about
:11:30. > :11:30.feeling dizzy. Your grandson said you do not like to make a pass. You
:11:31. > :11:35.had some pains in your back keeping had some pains in your back keeping
:11:36. > :11:43.you awake, is that right? I want to see what you are like on your pins
:11:44. > :11:47.in a second. That is not bad, is it? I think you probably have some
:11:48. > :11:48.anaemia. That is why you are not so well in yourself and probably why
:11:49. > :11:53.your ankles are swelling up. Dr Hughes thinks Herbert
:11:54. > :11:55.is OK to stay at home. Visits like this help
:11:56. > :11:57.reassure relatives and I live up in London but try to come
:11:58. > :12:14.down each year for Remembrance Day. We do won three times a day and get
:12:15. > :12:18.started straightaway with plenty of water and a lot of fluid. Check the
:12:19. > :12:22.sugars again at lunchtime. Any changes over the time he is here,
:12:23. > :12:29.call 111 or encouraging to press his buzzer. Thanks for your help.
:12:30. > :12:31.Cheers. Cheers. We probably have doubled the average number of
:12:32. > :12:37.elderly people in Devon compared to most counties. There is a big thrust
:12:38. > :12:41.to not send people to hospital who do not need to be there. But you had
:12:42. > :12:42.to pick the right people to go in and the right people to stay at
:12:43. > :12:45.home. Devon Doctors has been
:12:46. > :12:47.running out of hours care But this year they have
:12:48. > :12:50.to deliver the face-to-face part of the service for around
:12:51. > :12:52.20%, ?2 million, less. More money is going instead
:12:53. > :12:57.to the NHS 111 helpline. Dr Hughes thinks the changes
:12:58. > :13:09.could benefit patients. On the face of it I think patients
:13:10. > :13:15.should get an improved service. I do not think they should experience any
:13:16. > :13:16.reduction in service in terms of reviving a home visit. The really
:13:17. > :13:20.needing it. Devon Doctors also runs the county's
:13:21. > :13:23.out of hours clinics There used to be 15 but one third
:13:24. > :13:29.of them have now been shut. In North Devon the only
:13:30. > :13:31.treatment centre now is in It has taken an hour
:13:32. > :13:39.Kelly Joanna Mitchell and her son They used to be a clinic ten
:13:40. > :13:42.miles away from their home but it was shut
:13:43. > :13:45.as part of the changes. He's like an ox, so it takes a lot
:13:46. > :14:00.to bring him down but we just He has been on high temperatures
:14:01. > :14:10.before and he has been a fine. The doctor is one of four on duty. It
:14:11. > :14:16.has definitely got worse. That has been spreading? Yes, it has got
:14:17. > :14:22.darker. I will call paediatrics and see what they say. OK? OK. I will
:14:23. > :14:28.see you in a minute. The demand for the service has not reduced. Around
:14:29. > :14:30.5000 patients pass through the out of hours surgery doors in Devon
:14:31. > :14:35.every month. As a group of GPs in every month. As a group of GPs in
:14:36. > :14:41.the local area we are very nervous about the changes. There is nothing
:14:42. > :14:51.quite as local for the patients as there was before. OK, thank you.
:14:52. > :14:58.Goodbye. That is Doctor Hughes. The treatment centre keeps in constant
:14:59. > :15:01.contact with GPs on the road. Doctor Hughes is close to his next
:15:02. > :15:05.appointment but transport links in Devon can cause delays. This is what
:15:06. > :15:09.it is like in the summertime with holiday season. I'm not sure what
:15:10. > :15:14.the event is today. It is a massive challenge. When funding formulas are
:15:15. > :15:18.worked out essentially I think it is worked out based on cities like
:15:19. > :15:21.London and Birmingham and do not take into account a 45 minute travel
:15:22. > :15:27.time and getting caught behind a herd of sheep. Another challenge is
:15:28. > :15:33.rising numbers of elderly patients with conjugated health needs. He has
:15:34. > :15:45.a virus, a stiff neck, catheter, bladder cancer and he is not passing
:15:46. > :15:51.much fluid any more. Good morning! Doctor Hughes. You have a lot of
:15:52. > :15:59.horseshoes, haven't you? Geoffrey Barker has been housebound for over
:16:00. > :16:06.one week. Hello. Mr Barker? Hello, Jeffrey. How are you doing? I feel
:16:07. > :16:14.like I want to be sick. I keep bringing up a lot of mucus. From
:16:15. > :16:21.your chest? From my chest. Jeffrey's wife is his sole carer. When he is
:16:22. > :16:28.not well he takes to his bed the stop he will be their two or three
:16:29. > :16:31.days. -- takes to his bed. He was walking like this with his head and
:16:32. > :16:43.he would not move it. It has continued from there. If I cannot
:16:44. > :16:46.get some care for him today, that will not meet his needs, then he has
:16:47. > :16:53.to go to hospital. Ideal for you, I think. He arranges a care package.
:16:54. > :16:57.Good news. I think they can help. They will telephone you. It is
:16:58. > :17:04.somebody called the rapid response team and they will bring some help
:17:05. > :17:09.in. We have got a 50% hit rate this morning of arriving at the right
:17:10. > :17:17.place. So if we get this one, we are on 66%. What do you think? Do we
:17:18. > :17:24.know where this one is? Hello, Devon Doctors. Back at the treatment
:17:25. > :17:27.centre, the patients are coming in thick and fast. Most are here for
:17:28. > :17:31.minor problems but clearly this is a service in demand. I slipped down
:17:32. > :17:39.the stairs last night and did something to my coccyx. Ulcers on
:17:40. > :17:42.the tongue. Take a deep breath in. He has had this for Sundays. We've
:17:43. > :17:48.had a rough night and I think it is a chest infection. We will have a
:17:49. > :17:53.look. Here we go. Good boy. I have injured my shoulder. Agony through
:17:54. > :17:57.the night. Most of what I have done is just reassuring people and giving
:17:58. > :18:00.advice as to when to seek help if they get worse. Feeling a bit rough,
:18:01. > :18:05.isn't he? Changes to the out of isn't he? Changes to the out of
:18:06. > :18:09.hours service are part of a trial until March. At that stage the
:18:10. > :18:19.number of GPs on the road could be reduced to one. The concern is if it
:18:20. > :18:24.goes down to one, we may be delaying treatment to the sickest of our
:18:25. > :18:28.patients and they are the people we're busting housebound when they
:18:29. > :18:34.are unable to come in. He heads back to base. Five visits this morning in
:18:35. > :18:41.total. Which for Saturday morning is about average. A good morning's
:18:42. > :18:46.work. Out of hours care is just one service having to change in the face
:18:47. > :18:49.of an unprecedented NHS overspent. Those on the front line are trying
:18:50. > :18:53.to adapt but they are feeling the pressure. The workload is through
:18:54. > :18:58.the roof. The workforce is disappearing in droves. People are
:18:59. > :19:00.finding maybe Australia, Canada, New Zealand, offer a better work and
:19:01. > :19:05.life balance for them. Literally this morning I had an e-mail from
:19:06. > :19:12.somebody wanting me to come and work in Canada. Are you tempted? I looked
:19:13. > :19:15.up exactly what they are offering and it looks like tundra and polar
:19:16. > :19:21.bears, so I think not for the moment!
:19:22. > :19:24.new concerns around the so-called postcode lottery
:19:25. > :19:28.Does where you live now matter more than ever when it comes
:19:29. > :19:34.Chris Jackson has been investigating.
:19:35. > :19:36.The NHS is facing the most significant financial challenge
:19:37. > :19:42.There are fears the service we have grown up with is
:19:43. > :19:50.Absolutely there is a postcode lottery.
:19:51. > :20:06.So is the NHS in danger of ceasing to be a National
:20:07. > :20:11.Where everyone is entitled to the same care?
:20:12. > :20:13.It's treating more patients but is it becoming a
:20:14. > :20:15.postcode lottery, where access can depend on where you live?
:20:16. > :20:36.It feels like my bones are actually screaming
:20:37. > :20:38.33-year-old Ben Franklin has hepatitis C.
:20:39. > :20:40.The virus can cause life-threatening liver damage.
:20:41. > :20:50.I've been off sick and could possibly lose the flat over my head.
:20:51. > :20:52.There are new drugs that could potentially cure Ben's hepatitis.
:20:53. > :20:59.All I got was "Wait", basically, because my
:21:00. > :21:07.That made me want to go out and just get
:21:08. > :21:11.absolutely wasted and ruin my liver just so they would treat me.
:21:12. > :21:21.But I wouldn't be surprised if anybody else wouldn't.
:21:22. > :21:23.The money is there for just over 10,000 treatments.
:21:24. > :21:28.It is claimed that means there are no queues in parts
:21:29. > :21:30.of the North and long waits in places like London.
:21:31. > :21:32.Two people with exactly the same state of liver
:21:33. > :21:34.damage could present themselves in different
:21:35. > :21:38.in one they'll be able to walk in and get hepatitis C treatment
:21:39. > :21:41.In another part of the country they may
:21:42. > :21:44.go there and be told, "Sorry, you're going to have to wait."
:21:45. > :21:49.NHS England told us it was regularly reallocating
:21:50. > :21:57.unused hepatitis C treatments to places with waiting lists.
:21:58. > :22:00.The number of patients treated will increase by 25% next year.
:22:01. > :22:03.The fact that it's down to money, that upsets
:22:04. > :22:11.So Ben is taking the risk of treating
:22:12. > :22:18.himself with cheaper copies of the new drug.
:22:19. > :22:29.The fact that I've had to pay for my treatment, it's
:22:30. > :22:46.I'm just tired of being tired, basically.
:22:47. > :22:48.Ben is hoping the generic drugs will cure
:22:49. > :22:56.The hepatitis C trust estimates around 1,000 people in
:22:57. > :23:02.Britain may have bought the drugs abroad.
:23:03. > :23:04.If you go outside there are halos around light.
:23:05. > :23:13.Gloria MacShane has cataracts in both eyes.
:23:14. > :23:24.Go up or down stairs with any kind of confidence.
:23:25. > :23:27.Cataracts are supposed to be treated within 4.5 months of referral.
:23:28. > :23:30.Gloria lives in the north-east and says she has been waiting seven.
:23:31. > :23:34.Because there's such potential for accidents and there is
:23:35. > :23:44.If Gloria had lived in Luton her wait
:23:45. > :23:46.could have been as little as 15 days.
:23:47. > :23:48.Absolutely, there is a postcode lottery.
:23:49. > :23:50.It is not about clinical need, it is about
:23:51. > :23:53.some places in England having poor systems,
:23:54. > :23:58.budget pressures and de-prioritising cataract surgery.
:23:59. > :24:02.That doesn't feel too national to me.
:24:03. > :24:09.Gloria expects to get her operation later this month.
:24:10. > :24:11.It really makes me angry because I think that it's
:24:12. > :24:18.Clinical Commissioning Groups, or CCGs, control health budgets.
:24:19. > :24:20.It is claimed some are delaying treatments
:24:21. > :24:23.like cataract surgery by slowing down referrals.
:24:24. > :24:25.Others are requiring patients to lose weight before
:24:26. > :24:32.getting operations like hip replacements.
:24:33. > :24:34.Postponing an operation in these circumstances can
:24:35. > :24:48.Whilst the CCGs say it can be clinically
:24:49. > :24:50.justified, the Royal College of Surgeons says it can't.
:24:51. > :24:52.There is very good evidence people are now
:24:53. > :24:54.not getting elective operations, which they desperately sometimes
:24:55. > :24:56.require simply because of financial restrictions.
:24:57. > :24:58.It is up to the clinicians to decide who should have
:24:59. > :25:01.Therefore a bureaucratic system producing a
:25:02. > :25:08.blanket ban we think is morally wrong.
:25:09. > :25:10.It is also claimed new systems for vetting appointments
:25:11. > :25:12.with specialists are another form of rationing.
:25:13. > :25:18.Why are they treating their patients with such contempt?
:25:19. > :25:21.Last month MPs complained about a private company being paid ?10 for
:25:22. > :25:25.This is rationing by the back door and
:25:26. > :25:31.has the potential to compromise safety.
:25:32. > :25:34.The same private company overseas referrals in North Tyneside.
:25:35. > :25:36.We spoken to doctors who say the system is putting patients
:25:37. > :25:41.The GPs, who fear speaking out, have told us that cancer
:25:42. > :25:49.I tried to get a patient referred to a dermatologist.
:25:50. > :25:50.The referral Management service said it was a
:25:51. > :25:57.It was a nasty, invasive skin cancer.
:25:58. > :26:03.They are putting up barriers, using delaying tactics.
:26:04. > :26:08.It is getting between the doctor and the specialist.
:26:09. > :26:11.In a statement North Tyneside CCG said there was no
:26:12. > :26:16.evidence the system caused additional risk or delay.
:26:17. > :26:24.the system and made directly to hospital.
:26:25. > :26:27.The number of referrals back the GPs in England has risen by
:26:28. > :26:36.You can see the details of our research online.
:26:37. > :26:39.Shortage and regional difference were always part of the NHS.
:26:40. > :26:40.Today the differences could get much worse.
:26:41. > :26:43.The NHS is under an unprecedented level of pressure at
:26:44. > :26:47.If it does not get more funding waiting times are going to
:26:48. > :26:49.get longer, the quality of patient care is going to suffer.
:26:50. > :26:52.We will see different decisions taken in
:26:53. > :26:54.different parts of the country and different services being available
:26:55. > :27:02.One of our most prominent medics is clear.
:27:03. > :27:08.I think it matters because it leads to
:27:09. > :27:12.inequality in health care, that is the problem.
:27:13. > :27:17.Some people will get health care for free and others will not.
:27:18. > :27:20.In a statement the Department of Health told us that
:27:21. > :27:24.far from rationing more people than ever are getting prompt treatment
:27:25. > :27:27.and more cancer patients are being seen every day and that
:27:28. > :27:35.We asked the Health Secretary and NHS England for
:27:36. > :27:40.The people actually paying for NHS services, the clinical
:27:41. > :27:47.It is a National Service with local variation based
:27:48. > :27:50.Demographically populations vary significantly from
:27:51. > :27:51.town to rural, from county to county.
:27:52. > :27:54.It is very important we commission and respond to the needs
:27:55. > :27:59.It is about making sure the pathway is correct.
:28:00. > :28:01.We do not want to squander any money.
:28:02. > :28:07.We have limited resources so it is really important
:28:08. > :28:10.we spend most effectively and get the best value for our population.
:28:11. > :28:12.For those forced to take their own action,
:28:13. > :28:19.rationing appears all too real.
:28:20. > :28:25.That's all for this week, but do join me next Monday, when Nick
:28:26. > :28:30.Baker's all sea having a whale of a time with these fellows.
:28:31. > :28:42.This is what it is all about. We have got a pod of dolphins right
:28:43. > :28:43.underneath the bowel. What I love watching, it doesn't get any better
:28:44. > :28:52.than this. That is next week. I will than this. That is next week. I will
:28:53. > :29:06.see you then. Hello, I'm Louisa Preston
:29:07. > :29:09.with your 90 second update. 30 British tourists shot
:29:10. > :29:12.dead in Tunisia in 2015.