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
region's health care in the spotlight.
As budgets tighten and demand rockets, we meet the patients being
On the road with Devon's out of hours GPs.
We're seeing a 94-year-old chap living alone who
has had multiple medical problems in the
past, looking at these notes, and may
How one of the South West's busiest A is trying to
If we can get them up to the unit before nine
o'clock, they will be seen by a
saving yourself a 12 hour hospital stay.
Tighter budgets, more patients, with more complex needs.
That's the challenge the NHS is wrestling with,
This is A at the Royal Devon and Exeter.
We are tracking what happens here at a time when the system is
My name is Adam and I'm one of the consultants here.
The battle is on to keep patients safe in one of the busiest winters
nobody is waiting too long before
The doctors call it exit-block, or bed block
when patients in A need to be
admitted to the hospital but there are no beds.
It makes life difficult for Adam Rubin and his patients.
We want the best possible care for all of
When we have bed blockage and the Department is full
it is very difficult at times to do that.
when patients in other departments
are well enough to leave hospital
but there is nobody to look after them at home.
In Devon 600 beds per day are occupied by people without any
These are beds Doctor Ruben needs for
people arriving in the emergency department.
Last week or two have been very busy, with high numbers
this department is things can change very quickly.
In the space of 15 minutes that picture can change to
At the moment we are OK, patients are being
seen quickly and beds in a hospital
It stands for Rapid Assessment and Trriage.
That is where paramedics hand over new patients.
Beryl Oak is 95 and has just arrived.
a handover and when they do I will put a
monitor on you to check your blood
Doctor Ruben introduced this way of working
in Exeter, meaning consultants see
In this process we have an opportunity to
welcome the patient, do a meet and
greet so they meet a very senior
member of the team at an early stage.
We can tell the patient, forecast and tell what we think is
So, you're likely to stay in hospital, that
It is one of the top performing emergency departments in
the country but even here patients
They have come through one week where
they have referred 242 people to
medical wards, much higher than normal.
The waiting ranges from three minutes up to more than 13 hours.
This consultant Lewis Jones is chairing the midday handover.
Next we have got a plan, spinal, rest of
Let's have a quick look at the waiting room as well, Andy.
Many of Dr Jones's patients are elderly.
I think we have one of the highest rates in all
the country, you have a higher volume of patients.
Historically would not get that many in an emergency
department but then we regularly
We try as hard as we can, even to the point
of receiving a patient the minutes
We can get them up to the medical unit before
nine o'clock, they will be seen by
tomorrow morning, you are then
saving yourself a 12 hour hospital stay.
older patients experience a long
We discovered 36,000 patients over 80 spent more
than 12 hours in A departments this year.
That figure has gone up by over 280% in five years.
Coming down the stairs and when I came right down
And I didn't realise that I had hurt myself.
Well, if any of these collapses are the same as the
previous ones, I don't think we are
going to be of any benefit bringing her in.
what value are we going to add to
If there is something specific we can do and she
The risk of bringing her in and getting a
hospital acquired infection and
reducing muscle power probably
They will do something to it in a moment.
Wrap it all up and everything, and
then I shall go home to my daughters again.
It is what mum wants and I think it is better, for
anybody that can stay out of
hospital, it is better to be in your
One way to take the pressure off A might be
to get more people treated closer to home.
injuries unit at Homerton Ben Harris
is here because he has hurt his hand
The role played by small hospitals like this is under
review as part of proposed NHS
In the minor injuries department they are trying
Patients like Ben will be treated by nurses, but what
is unusual is that they have the
back-up from the emergency department.
Doctor Ruben without his scrubs is over from Exeter for the morning.
I think that looks like an undisclosed fracture.
What do you think we should do with that?
Probably strapping again, give it some support.
If this facility was not here you would have
queue in the emergency department,
which for an x-ray, wait to be managed.
doorstep, he has the treatment
sorted out and all the prep
follow-up in place within half an
We had quite an influx of sick patients.
We now have six patients needing
One of the new patients is retired doctor, Judy Daws.
What they will do is put two electrodes or my chest.
They will give me a brief anaesthetic so
I will be unconscious and a current
passes through my heart and hopefully that
will shock my heart back into a normal rhythm.
Then they usually hang onto me for a little while to
make sure everything is all right,
give me something to eat and drink
and then I call a taxi and go home.
It is the kind of procedure which
used to need an overnight hospital stay.
are saving her a hospital admission,
so it is good for the patient and
also good for the trust, because
that is one bed available for
It has been a good day, but there are likely
In truth we do not know what the answers are.
But we have a very good system here and an excellent department.
We have good support services in
place and it combines to work very
well for us for the majority of the time.
The emergency team will be hoping the changes deliver on their promise
to relieve some of the pressure on places like this one.
It's not just hospital patients feeling the strain.
In Devon, where there's a huge health funding
shortfall, a third out of hours GP surgeries have been shut.
Saturday morning in North Devon.
On his way to his first appointment
We will go on to the moors and see what happens on this beautiful day.
Doctor Hughes runs Devon Doctors, the GPs you call
We're going to see this 90-year-old chap who lives alone and may
This is one of the largest and most rural counties
Just finding the patients can prove tricky.
That is not where it is. I'm just going to check. I'm going round the
front. I do not think there is any entrance there. I'm going to give
not look right. That is Mrs Thorne. not look right. That is Mrs Thorne.
It is like keystone cops. I cannot find it. The sign says somewhere
else. I will have a little luck. Oh, else. I will have a little luck. Oh,
it is down here. We were totally confused by the sign. Hello. Good
morning. 94-year-old Herbert Symons
has had a rough night. Grandad had a bad night. Last night
he hardly slept. He has swollen legs. He is complaining about
feeling dizzy. Your grandson said you do not like to make a pass. You
had some pains in your back keeping had some pains in your back keeping
you awake, is that right? I want to see what you are like on your pins
in a second. That is not bad, is it? I think you probably have some
anaemia. That is why you are not so well in yourself and probably why
your ankles are swelling up. Dr Hughes thinks Herbert
is OK to stay at home. Visits like this help
reassure relatives and I live up in London but try to come
down each year for Remembrance Day. We do won three times a day and get
started straightaway with plenty of water and a lot of fluid. Check the
sugars again at lunchtime. Any changes over the time he is here,
call 111 or encouraging to press his buzzer. Thanks for your help.
Cheers. Cheers. We probably have doubled the average number of
elderly people in Devon compared to most counties. There is a big thrust
to not send people to hospital who do not need to be there. But you had
to pick the right people to go in and the right people to stay at
home. Devon Doctors has been
running out of hours care But this year they have
to deliver the face-to-face part of the service for around
20%, ?2 million, less. More money is going instead
to the NHS 111 helpline. Dr Hughes thinks the changes
could benefit patients. On the face of it I think patients
should get an improved service. I do not think they should experience any
reduction in service in terms of reviving a home visit. The really
needing it. Devon Doctors also runs the county's
out of hours clinics There used to be 15 but one third
of them have now been shut. In North Devon the only
treatment centre now is in It has taken an hour
Kelly Joanna Mitchell and her son They used to be a clinic ten
miles away from their home but it was shut
as part of the changes. He's like an ox, so it takes a lot
to bring him down but we just He has been on high temperatures
before and he has been a fine. The doctor is one of four on duty. It
has definitely got worse. That has been spreading? Yes, it has got
darker. I will call paediatrics and see what they say. OK? OK. I will
see you in a minute. The demand for the service has not reduced. Around
5000 patients pass through the out of hours surgery doors in Devon
every month. As a group of GPs in every month. As a group of GPs in
the local area we are very nervous about the changes. There is nothing
quite as local for the patients as there was before. OK, thank you.
Goodbye. That is Doctor Hughes. The treatment centre keeps in constant
contact with GPs on the road. Doctor Hughes is close to his next
appointment but transport links in Devon can cause delays. This is what
it is like in the summertime with holiday season. I'm not sure what
the event is today. It is a massive challenge. When funding formulas are
worked out essentially I think it is worked out based on cities like
London and Birmingham and do not take into account a 45 minute travel
time and getting caught behind a herd of sheep. Another challenge is
rising numbers of elderly patients with conjugated health needs. He has
a virus, a stiff neck, catheter, bladder cancer and he is not passing
much fluid any more. Good morning! Doctor Hughes. You have a lot of
horseshoes, haven't you? Geoffrey Barker has been housebound for over
one week. Hello. Mr Barker? Hello, Jeffrey. How are you doing? I feel
like I want to be sick. I keep bringing up a lot of mucus. From
your chest? From my chest. Jeffrey's wife is his sole carer. When he is
not well he takes to his bed the stop he will be their two or three
days. -- takes to his bed. He was walking like this with his head and
he would not move it. It has continued from there. If I cannot
get some care for him today, that will not meet his needs, then he has
to go to hospital. Ideal for you, I think. He arranges a care package.
Good news. I think they can help. They will telephone you. It is
somebody called the rapid response team and they will bring some help
in. We have got a 50% hit rate this morning of arriving at the right
place. So if we get this one, we are on 66%. What do you think? Do we
know where this one is? Hello, Devon Doctors. Back at the treatment
centre, the patients are coming in thick and fast. Most are here for
minor problems but clearly this is a service in demand. I slipped down
the stairs last night and did something to my coccyx. Ulcers on
the tongue. Take a deep breath in. He has had this for Sundays. We've
had a rough night and I think it is a chest infection. We will have a
look. Here we go. Good boy. I have injured my shoulder. Agony through
the night. Most of what I have done is just reassuring people and giving
advice as to when to seek help if they get worse. Feeling a bit rough,
isn't he? Changes to the out of isn't he? Changes to the out of
hours service are part of a trial until March. At that stage the
number of GPs on the road could be reduced to one. The concern is if it
goes down to one, we may be delaying treatment to the sickest of our
patients and they are the people we're busting housebound when they
are unable to come in. He heads back to base. Five visits this morning in
total. Which for Saturday morning is about average. A good morning's
work. Out of hours care is just one service having to change in the face
of an unprecedented NHS overspent. Those on the front line are trying
to adapt but they are feeling the pressure. The workload is through
the roof. The workforce is disappearing in droves. People are
finding maybe Australia, Canada, New Zealand, offer a better work and
life balance for them. Literally this morning I had an e-mail from
somebody wanting me to come and work in Canada. Are you tempted? I looked
up exactly what they are offering and it looks like tundra and polar
bears, so I think not for the moment!
new concerns around the so-called postcode lottery
Does where you live now matter more than ever when it comes
Chris Jackson has been investigating.
The NHS is facing the most significant financial challenge
There are fears the service we have grown up with is
Absolutely there is a postcode lottery.
So is the NHS in danger of ceasing to be a National
Where everyone is entitled to the same care?
It's treating more patients but is it becoming a
postcode lottery, where access can depend on where you live?
It feels like my bones are actually screaming
33-year-old Ben Franklin has hepatitis C.
The virus can cause life-threatening liver damage.
I've been off sick and could possibly lose the flat over my head.
There are new drugs that could potentially cure Ben's hepatitis.
All I got was "Wait", basically, because my
That made me want to go out and just get
absolutely wasted and ruin my liver just so they would treat me.
But I wouldn't be surprised if anybody else wouldn't.
The money is there for just over 10,000 treatments.
It is claimed that means there are no queues in parts
of the North and long waits in places like London.
Two people with exactly the same state of liver
damage could present themselves in different
in one they'll be able to walk in and get hepatitis C treatment
In another part of the country they may
go there and be told, "Sorry, you're going to have to wait."
NHS England told us it was regularly reallocating
unused hepatitis C treatments to places with waiting lists.
The number of patients treated will increase by 25% next year.
The fact that it's down to money, that upsets
So Ben is taking the risk of treating
himself with cheaper copies of the new drug.
The fact that I've had to pay for my treatment, it's
I'm just tired of being tired, basically.
Ben is hoping the generic drugs will cure
The hepatitis C trust estimates around 1,000 people in
Britain may have bought the drugs abroad.
If you go outside there are halos around light.
Gloria MacShane has cataracts in both eyes.
Go up or down stairs with any kind of confidence.
Cataracts are supposed to be treated within 4.5 months of referral.
Gloria lives in the north-east and says she has been waiting seven.
Because there's such potential for accidents and there is
If Gloria had lived in Luton her wait
could have been as little as 15 days.
Absolutely, there is a postcode lottery.
It is not about clinical need, it is about
some places in England having poor systems,
budget pressures and de-prioritising cataract surgery.
That doesn't feel too national to me.
Gloria expects to get her operation later this month.
It really makes me angry because I think that it's
Clinical Commissioning Groups, or CCGs, control health budgets.
It is claimed some are delaying treatments
like cataract surgery by slowing down referrals.
Others are requiring patients to lose weight before
getting operations like hip replacements.
Postponing an operation in these circumstances can
Whilst the CCGs say it can be clinically
justified, the Royal College of Surgeons says it can't.
There is very good evidence people are now
not getting elective operations, which they desperately sometimes
require simply because of financial restrictions.
It is up to the clinicians to decide who should have
Therefore a bureaucratic system producing a
blanket ban we think is morally wrong.
It is also claimed new systems for vetting appointments
with specialists are another form of rationing.
Why are they treating their patients with such contempt?
Last month MPs complained about a private company being paid ?10 for
This is rationing by the back door and
has the potential to compromise safety.
The same private company overseas referrals in North Tyneside.
We spoken to doctors who say the system is putting patients
The GPs, who fear speaking out, have told us that cancer
I tried to get a patient referred to a dermatologist.
The referral Management service said it was a
It was a nasty, invasive skin cancer.
They are putting up barriers, using delaying tactics.
It is getting between the doctor and the specialist.
In a statement North Tyneside CCG said there was no
evidence the system caused additional risk or delay.
the system and made directly to hospital.
The number of referrals back the GPs in England has risen by
You can see the details of our research online.
Shortage and regional difference were always part of the NHS.
Today the differences could get much worse.
The NHS is under an unprecedented level of pressure at
If it does not get more funding waiting times are going to
get longer, the quality of patient care is going to suffer.
We will see different decisions taken in
different parts of the country and different services being available
One of our most prominent medics is clear.
I think it matters because it leads to
inequality in health care, that is the problem.
Some people will get health care for free and others will not.
In a statement the Department of Health told us that
far from rationing more people than ever are getting prompt treatment
and more cancer patients are being seen every day and that
We asked the Health Secretary and NHS England for
The people actually paying for NHS services, the clinical
It is a National Service with local variation based
Demographically populations vary significantly from
town to rural, from county to county.
It is very important we commission and respond to the needs
It is about making sure the pathway is correct.
We do not want to squander any money.
We have limited resources so it is really important
we spend most effectively and get the best value for our population.
For those forced to take their own action,
rationing appears all too real.
That's all for this week, but do join me next Monday, when Nick
Baker's all sea having a whale of a time with these fellows.
This is what it is all about. We have got a pod of dolphins right
underneath the bowel. What I love watching, it doesn't get any better
than this. That is next week. I will than this. That is next week. I will
see you then. Hello, I'm Louisa Preston
with your 90 second update. 30 British tourists shot
dead in Tunisia in 2015.
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.