16/01/2017 Inside Out South West


16/01/2017

Is the NHS still a national service - or does where people live matter most when it comes to being treated?


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Tonight in a special programme we put the

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region's health care in the spotlight.

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As budgets tighten and demand rockets, we meet the patients being

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On the road with Devon's out of hours GPs.

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We're seeing a 94-year-old chap living alone who

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has had multiple medical problems in the

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past, looking at these notes, and may

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How one of the South West's busiest A is trying to

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If we can get them up to the unit before nine

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o'clock, they will be seen by a

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saving yourself a 12 hour hospital stay.

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Tighter budgets, more patients, with more complex needs.

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That's the challenge the NHS is wrestling with,

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This is A at the Royal Devon and Exeter.

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We are tracking what happens here at a time when the system is

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My name is Adam and I'm one of the consultants here.

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The battle is on to keep patients safe in one of the busiest winters

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nobody is waiting too long before

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The doctors call it exit-block, or bed block

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when patients in A need to be

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admitted to the hospital but there are no beds.

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It makes life difficult for Adam Rubin and his patients.

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We want the best possible care for all of

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When we have bed blockage and the Department is full

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it is very difficult at times to do that.

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when patients in other departments

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are well enough to leave hospital

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but there is nobody to look after them at home.

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In Devon 600 beds per day are occupied by people without any

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These are beds Doctor Ruben needs for

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people arriving in the emergency department.

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Last week or two have been very busy, with high numbers

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this department is things can change very quickly.

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In the space of 15 minutes that picture can change to

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At the moment we are OK, patients are being

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seen quickly and beds in a hospital

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It stands for Rapid Assessment and Trriage.

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That is where paramedics hand over new patients.

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Beryl Oak is 95 and has just arrived.

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a handover and when they do I will put a

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monitor on you to check your blood

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Doctor Ruben introduced this way of working

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in Exeter, meaning consultants see

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In this process we have an opportunity to

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welcome the patient, do a meet and

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greet so they meet a very senior

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member of the team at an early stage.

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We can tell the patient, forecast and tell what we think is

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So, you're likely to stay in hospital, that

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It is one of the top performing emergency departments in

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the country but even here patients

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They have come through one week where

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they have referred 242 people to

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medical wards, much higher than normal.

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The waiting ranges from three minutes up to more than 13 hours.

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This consultant Lewis Jones is chairing the midday handover.

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Next we have got a plan, spinal, rest of

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Let's have a quick look at the waiting room as well, Andy.

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Many of Dr Jones's patients are elderly.

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I think we have one of the highest rates in all

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the country, you have a higher volume of patients.

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Historically would not get that many in an emergency

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department but then we regularly

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We try as hard as we can, even to the point

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of receiving a patient the minutes

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We can get them up to the medical unit before

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nine o'clock, they will be seen by

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tomorrow morning, you are then

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saving yourself a 12 hour hospital stay.

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older patients experience a long

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We discovered 36,000 patients over 80 spent more

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than 12 hours in A departments this year.

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That figure has gone up by over 280% in five years.

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Coming down the stairs and when I came right down

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And I didn't realise that I had hurt myself.

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Well, if any of these collapses are the same as the

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previous ones, I don't think we are

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going to be of any benefit bringing her in.

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what value are we going to add to

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If there is something specific we can do and she

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The risk of bringing her in and getting a

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hospital acquired infection and

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reducing muscle power probably

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They will do something to it in a moment.

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Wrap it all up and everything, and

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then I shall go home to my daughters again.

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It is what mum wants and I think it is better, for

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anybody that can stay out of

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hospital, it is better to be in your

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One way to take the pressure off A might be

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to get more people treated closer to home.

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injuries unit at Homerton Ben Harris

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is here because he has hurt his hand

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The role played by small hospitals like this is under

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review as part of proposed NHS

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In the minor injuries department they are trying

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Patients like Ben will be treated by nurses, but what

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is unusual is that they have the

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back-up from the emergency department.

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Doctor Ruben without his scrubs is over from Exeter for the morning.

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I think that looks like an undisclosed fracture.

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What do you think we should do with that?

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Probably strapping again, give it some support.

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If this facility was not here you would have

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queue in the emergency department,

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which for an x-ray, wait to be managed.

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doorstep, he has the treatment

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sorted out and all the prep

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follow-up in place within half an

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We had quite an influx of sick patients.

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We now have six patients needing

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One of the new patients is retired doctor, Judy Daws.

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What they will do is put two electrodes or my chest.

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They will give me a brief anaesthetic so

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I will be unconscious and a current

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passes through my heart and hopefully that

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will shock my heart back into a normal rhythm.

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Then they usually hang onto me for a little while to

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make sure everything is all right,

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give me something to eat and drink

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and then I call a taxi and go home.

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It is the kind of procedure which

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used to need an overnight hospital stay.

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are saving her a hospital admission,

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so it is good for the patient and

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also good for the trust, because

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that is one bed available for

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It has been a good day, but there are likely

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In truth we do not know what the answers are.

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But we have a very good system here and an excellent department.

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We have good support services in

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place and it combines to work very

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well for us for the majority of the time.

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The emergency team will be hoping the changes deliver on their promise

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to relieve some of the pressure on places like this one.

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It's not just hospital patients feeling the strain.

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In Devon, where there's a huge health funding

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shortfall, a third out of hours GP surgeries have been shut.

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Saturday morning in North Devon.

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On his way to his first appointment

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We will go on to the moors and see what happens on this beautiful day.

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Doctor Hughes runs Devon Doctors, the GPs you call

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We're going to see this 90-year-old chap who lives alone and may

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This is one of the largest and most rural counties

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Just finding the patients can prove tricky.

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That is not where it is. I'm just going to check. I'm going round the

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front. I do not think there is any entrance there. I'm going to give

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not look right. That is Mrs Thorne. not look right. That is Mrs Thorne.

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It is like keystone cops. I cannot find it. The sign says somewhere

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else. I will have a little luck. Oh, else. I will have a little luck. Oh,

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it is down here. We were totally confused by the sign. Hello. Good

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morning. 94-year-old Herbert Symons

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has had a rough night. Grandad had a bad night. Last night

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he hardly slept. He has swollen legs. He is complaining about

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feeling dizzy. Your grandson said you do not like to make a pass. You

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had some pains in your back keeping had some pains in your back keeping

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you awake, is that right? I want to see what you are like on your pins

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in a second. That is not bad, is it? I think you probably have some

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anaemia. That is why you are not so well in yourself and probably why

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your ankles are swelling up. Dr Hughes thinks Herbert

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is OK to stay at home. Visits like this help

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reassure relatives and I live up in London but try to come

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down each year for Remembrance Day. We do won three times a day and get

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started straightaway with plenty of water and a lot of fluid. Check the

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sugars again at lunchtime. Any changes over the time he is here,

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call 111 or encouraging to press his buzzer. Thanks for your help.

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Cheers. Cheers. We probably have doubled the average number of

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elderly people in Devon compared to most counties. There is a big thrust

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to not send people to hospital who do not need to be there. But you had

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to pick the right people to go in and the right people to stay at

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home. Devon Doctors has been

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running out of hours care But this year they have

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to deliver the face-to-face part of the service for around

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20%, ?2 million, less. More money is going instead

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to the NHS 111 helpline. Dr Hughes thinks the changes

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could benefit patients. On the face of it I think patients

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should get an improved service. I do not think they should experience any

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reduction in service in terms of reviving a home visit. The really

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needing it. Devon Doctors also runs the county's

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out of hours clinics There used to be 15 but one third

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of them have now been shut. In North Devon the only

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treatment centre now is in It has taken an hour

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Kelly Joanna Mitchell and her son They used to be a clinic ten

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miles away from their home but it was shut

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as part of the changes. He's like an ox, so it takes a lot

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to bring him down but we just He has been on high temperatures

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before and he has been a fine. The doctor is one of four on duty. It

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has definitely got worse. That has been spreading? Yes, it has got

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darker. I will call paediatrics and see what they say. OK? OK. I will

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see you in a minute. The demand for the service has not reduced. Around

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5000 patients pass through the out of hours surgery doors in Devon

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every month. As a group of GPs in every month. As a group of GPs in

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the local area we are very nervous about the changes. There is nothing

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quite as local for the patients as there was before. OK, thank you.

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Goodbye. That is Doctor Hughes. The treatment centre keeps in constant

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contact with GPs on the road. Doctor Hughes is close to his next

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appointment but transport links in Devon can cause delays. This is what

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it is like in the summertime with holiday season. I'm not sure what

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the event is today. It is a massive challenge. When funding formulas are

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worked out essentially I think it is worked out based on cities like

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London and Birmingham and do not take into account a 45 minute travel

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time and getting caught behind a herd of sheep. Another challenge is

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rising numbers of elderly patients with conjugated health needs. He has

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a virus, a stiff neck, catheter, bladder cancer and he is not passing

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much fluid any more. Good morning! Doctor Hughes. You have a lot of

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horseshoes, haven't you? Geoffrey Barker has been housebound for over

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one week. Hello. Mr Barker? Hello, Jeffrey. How are you doing? I feel

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like I want to be sick. I keep bringing up a lot of mucus. From

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your chest? From my chest. Jeffrey's wife is his sole carer. When he is

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not well he takes to his bed the stop he will be their two or three

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days. -- takes to his bed. He was walking like this with his head and

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he would not move it. It has continued from there. If I cannot

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get some care for him today, that will not meet his needs, then he has

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to go to hospital. Ideal for you, I think. He arranges a care package.

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Good news. I think they can help. They will telephone you. It is

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somebody called the rapid response team and they will bring some help

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in. We have got a 50% hit rate this morning of arriving at the right

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place. So if we get this one, we are on 66%. What do you think? Do we

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know where this one is? Hello, Devon Doctors. Back at the treatment

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centre, the patients are coming in thick and fast. Most are here for

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minor problems but clearly this is a service in demand. I slipped down

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the stairs last night and did something to my coccyx. Ulcers on

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the tongue. Take a deep breath in. He has had this for Sundays. We've

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had a rough night and I think it is a chest infection. We will have a

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look. Here we go. Good boy. I have injured my shoulder. Agony through

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the night. Most of what I have done is just reassuring people and giving

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advice as to when to seek help if they get worse. Feeling a bit rough,

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isn't he? Changes to the out of isn't he? Changes to the out of

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hours service are part of a trial until March. At that stage the

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number of GPs on the road could be reduced to one. The concern is if it

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goes down to one, we may be delaying treatment to the sickest of our

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patients and they are the people we're busting housebound when they

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are unable to come in. He heads back to base. Five visits this morning in

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total. Which for Saturday morning is about average. A good morning's

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work. Out of hours care is just one service having to change in the face

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of an unprecedented NHS overspent. Those on the front line are trying

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to adapt but they are feeling the pressure. The workload is through

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the roof. The workforce is disappearing in droves. People are

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finding maybe Australia, Canada, New Zealand, offer a better work and

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life balance for them. Literally this morning I had an e-mail from

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somebody wanting me to come and work in Canada. Are you tempted? I looked

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up exactly what they are offering and it looks like tundra and polar

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bears, so I think not for the moment!

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new concerns around the so-called postcode lottery

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Does where you live now matter more than ever when it comes

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Chris Jackson has been investigating.

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The NHS is facing the most significant financial challenge

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There are fears the service we have grown up with is

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Absolutely there is a postcode lottery.

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So is the NHS in danger of ceasing to be a National

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Where everyone is entitled to the same care?

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It's treating more patients but is it becoming a

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postcode lottery, where access can depend on where you live?

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It feels like my bones are actually screaming

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33-year-old Ben Franklin has hepatitis C.

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The virus can cause life-threatening liver damage.

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I've been off sick and could possibly lose the flat over my head.

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There are new drugs that could potentially cure Ben's hepatitis.

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All I got was "Wait", basically, because my

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That made me want to go out and just get

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absolutely wasted and ruin my liver just so they would treat me.

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But I wouldn't be surprised if anybody else wouldn't.

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The money is there for just over 10,000 treatments.

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It is claimed that means there are no queues in parts

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of the North and long waits in places like London.

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Two people with exactly the same state of liver

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damage could present themselves in different

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in one they'll be able to walk in and get hepatitis C treatment

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In another part of the country they may

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go there and be told, "Sorry, you're going to have to wait."

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NHS England told us it was regularly reallocating

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unused hepatitis C treatments to places with waiting lists.

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The number of patients treated will increase by 25% next year.

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The fact that it's down to money, that upsets

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So Ben is taking the risk of treating

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himself with cheaper copies of the new drug.

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The fact that I've had to pay for my treatment, it's

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I'm just tired of being tired, basically.

:22:30.:22:46.

Ben is hoping the generic drugs will cure

:22:47.:22:48.

The hepatitis C trust estimates around 1,000 people in

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Britain may have bought the drugs abroad.

:22:57.:23:02.

If you go outside there are halos around light.

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Gloria MacShane has cataracts in both eyes.

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Go up or down stairs with any kind of confidence.

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Cataracts are supposed to be treated within 4.5 months of referral.

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Gloria lives in the north-east and says she has been waiting seven.

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Because there's such potential for accidents and there is

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If Gloria had lived in Luton her wait

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could have been as little as 15 days.

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Absolutely, there is a postcode lottery.

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It is not about clinical need, it is about

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some places in England having poor systems,

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budget pressures and de-prioritising cataract surgery.

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That doesn't feel too national to me.

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Gloria expects to get her operation later this month.

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It really makes me angry because I think that it's

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Clinical Commissioning Groups, or CCGs, control health budgets.

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It is claimed some are delaying treatments

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like cataract surgery by slowing down referrals.

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Others are requiring patients to lose weight before

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getting operations like hip replacements.

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Postponing an operation in these circumstances can

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Whilst the CCGs say it can be clinically

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justified, the Royal College of Surgeons says it can't.

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There is very good evidence people are now

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not getting elective operations, which they desperately sometimes

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require simply because of financial restrictions.

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It is up to the clinicians to decide who should have

:24:57.:24:58.

Therefore a bureaucratic system producing a

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blanket ban we think is morally wrong.

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It is also claimed new systems for vetting appointments

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with specialists are another form of rationing.

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Why are they treating their patients with such contempt?

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Last month MPs complained about a private company being paid ?10 for

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This is rationing by the back door and

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has the potential to compromise safety.

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The same private company overseas referrals in North Tyneside.

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We spoken to doctors who say the system is putting patients

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The GPs, who fear speaking out, have told us that cancer

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I tried to get a patient referred to a dermatologist.

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The referral Management service said it was a

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It was a nasty, invasive skin cancer.

:25:51.:25:57.

They are putting up barriers, using delaying tactics.

:25:58.:26:03.

It is getting between the doctor and the specialist.

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In a statement North Tyneside CCG said there was no

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evidence the system caused additional risk or delay.

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the system and made directly to hospital.

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The number of referrals back the GPs in England has risen by

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You can see the details of our research online.

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Shortage and regional difference were always part of the NHS.

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Today the differences could get much worse.

:26:40.:26:40.

The NHS is under an unprecedented level of pressure at

:26:41.:26:43.

If it does not get more funding waiting times are going to

:26:44.:26:47.

get longer, the quality of patient care is going to suffer.

:26:48.:26:49.

We will see different decisions taken in

:26:50.:26:52.

different parts of the country and different services being available

:26:53.:26:54.

One of our most prominent medics is clear.

:26:55.:27:02.

I think it matters because it leads to

:27:03.:27:08.

inequality in health care, that is the problem.

:27:09.:27:12.

Some people will get health care for free and others will not.

:27:13.:27:17.

In a statement the Department of Health told us that

:27:18.:27:20.

far from rationing more people than ever are getting prompt treatment

:27:21.:27:24.

and more cancer patients are being seen every day and that

:27:25.:27:27.

We asked the Health Secretary and NHS England for

:27:28.:27:35.

The people actually paying for NHS services, the clinical

:27:36.:27:40.

It is a National Service with local variation based

:27:41.:27:47.

Demographically populations vary significantly from

:27:48.:27:50.

town to rural, from county to county.

:27:51.:27:51.

It is very important we commission and respond to the needs

:27:52.:27:54.

It is about making sure the pathway is correct.

:27:55.:27:59.

We do not want to squander any money.

:28:00.:28:01.

We have limited resources so it is really important

:28:02.:28:07.

we spend most effectively and get the best value for our population.

:28:08.:28:10.

For those forced to take their own action,

:28:11.:28:12.

rationing appears all too real.

:28:13.:28:19.

That's all for this week, but do join me next Monday, when Nick

:28:20.:28:25.

Baker's all sea having a whale of a time with these fellows.

:28:26.:28:30.

This is what it is all about. We have got a pod of dolphins right

:28:31.:28:42.

underneath the bowel. What I love watching, it doesn't get any better

:28:43.:28:43.

than this. That is next week. I will than this. That is next week. I will

:28:44.:28:52.

see you then. Hello, I'm Louisa Preston

:28:53.:29:06.

with your 90 second update. 30 British tourists shot

:29:07.:29:09.

dead in Tunisia in 2015.

:29:10.:29:12.

Is the NHS still a national service - or does where people live matter most when it comes to being treated? Jemma Woodman meets patients and clinicians who say rationing is fracturing the NHS, as the south west decision-makers struggle to balance the books.


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