16/01/2017 Inside Out South West


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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.


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