The NHS is under intense pressure.
Emergency departments are packed.
It's the most pressure I've felt as a clinician
in my time since I've qualified.
CHANTING: We want fair pay.
Staff say they are at breaking point.
Your NHS, our NHS.
Ambulances are queueing for hours,
it can be desperate for patients.
We sat there and A&E was just absolutely crammed full.
So, what needs to change? I've been meeting doctors and nurses
rethinking health care, picking problems up early...
We've essentially clone 20 consultations in one here.
The more people get a chance to come here, the better.
...and using new technology to take the hospital into the home.
So, can the NHS be fixed?
We're not replacing the hospital,
this isn't about the death of a hospital, if anything it's
the rebirth of the hospital.
Hello, Mrs East.
93-year-old Elizabeth East is being assessed
at the john Radcliffe in Oxford.
How are you doing?
Like many hospitals across the country,
it is being pushed to its limit.
Good morning.
How are you feeling today?
Elizabeth fell at her care home and has a broken arm.
She's already spent nearly five hours in the emergency department.
Now she's being assessed on a special unit run by Dr Jordan Bowen.
You've had a long night, you must be very sleepy.
When admitted to a hospital ward,
frail older patients stay for an average of ten days.
You're feeling cold, are you? Yes, I am. All right.
And this is not a good place for someone like Elizabeth
who is also living with dementia.
One of the treatments already for the way her brain's working
is by trying to normalise her environment,
but we simply can't do in hospital.
Which is why already my intent is to do as much as I can
within her own familiar environment in her own care home.
This assessment unit aims to get people who arrive as emergencies
home the same day.
So, what we try to do is intercept patients who would otherwise
be arriving in the emergency department
or being admitted into the hospital,
and instead be offering them all an alternative to that,
where still they get the same quality of treatment
and yet go home.
Here, they've been very successful,
seeing an average of 7O patients a day.
95% are treated without needing an overnight stay.
Have you been able to get some bloods off her?
They're geared up to get test results back quickly.
Is that all OK?
Elizabeth has problems with her kidneys,
so Dr Bowen adjusts her medication.
Once her arm is treated, she can go back to her care home.
Staff there will monitor her.
Biggest thing is trying to explain to someone who is feeling unwell
why it's OK for them to be at home feeling unwell.
By keeping people recovering safely in their own home,
we think that people get better quicker and return back
to the things that they value sooner than being in hospital.
It's a massive change in thinking.
With the health service under such pressure,
most hospitals are doing this.
But in Oxford, they've gone further
by also providing high level hospital treatment
in people's homes.
The hospital is full at the moment, 110% filled.
There are people in there for 22 hours,
eight hours waiting to be seen.
The clay is very young.
Could we actually get you and the hospital home team to go out?
Yeah, very much so.
Professor Dan Lasserson was one of the first doctors in the country
to provide this kind of home-based medical care.
We can assess you, we can diagnose you,
and with the right support,
we can treat you at home if that's your choice.
We're not replacing the hospital.
This isn't about the death of the hospital,
if anything it's about the rebirth of the hospital.
New technology means he's now able to look after much sicker people
in their own homes.
Professor Lasserson is here to see 91-year-old Ted.
He has heart failure and has been referred to Dan by a specialist.
Hello, my name's Dan. I'm one of the doctors from the hospital.
How are you?
I feel really rotten.
You feel rotten?
Are you getting any pain in your chest?
No.
No, OK, or your tummy?
Last week, Ted fell and paramedics wanted to take him to hospital.
But Ted, supported by his wife and daughter, didn't want to go.
He was always able to do his own medication
up until about three weeks ago.
Hospital at home has given them choice.
It means a doctor, nurse, or paramedic will visit him every day.
Can I undo this? Because I'm going to need to listen to your heart
and your lungs and have a scan of you. Yeah, yeah.
Usually, blood tests, heart monitoring, and an ultrasound scan
would involve separate hospital or GP appointments.
But Professor Lasserson and his team carry all this equipment
in their bags.
The ultrasound scanner even connects to his mobile phone.
That black area is fluid
that's outside the lung and in the chest cavity.
Ancl that bright thing there is the...
Within moments, they can see the cause of Ted's breathlessness.
His heart isn't pumping properly.
...right ventricle,
and this isn't squeezing very well at all, this left ventricle.
Ancl that's the problem.
By quickly uploading the images to the hospital system,
Professor Lasserson can discuss the results
with the heart specialist.
Sean, have you had a chance to look at the images?
Yeah, I've looked at the images.
What do you think?
His LV... His LV isn't bad.
They will keep monitoring Ted and give him a dose
of intravenous drugs.
Professor Lasserson also fits a catheter to help his body
get rid of the excess fluid.
Our key is to get the fluid out of the body, the extra fluid out.
Ted can do very little for himself.
So, with him at home rather than in hospital,
most of his care is down to his family.
Do you want this buttoning up, Ted?
His daughter, Jill, returned from her home in France
to help two months ago.
Her mum, Grace, was already struggling.
I'm trying to protect him from going into hospital,
and I'm trying my best to do that.
But it is a strain.
My mum has mobility problems and balance issues,
so, often, all the toileting and washing she can't do.
Ted needs two or three care visits a day.
They're on the waiting list for council support,
butjill has to return home next week,
and with no help, she's worried about how her mother will cope.
Mum needs the support.
She can't carry on doing what she's doing,
what she has been doing.
I'm frightened because...
...if he fell,
and he'd hurt himself badly...
I think I'd just want to sit and cuddle him.
I don't think I'd want to send for anybody.
How important is it that they get some help soon?
It's probably the most important thing in this case, actually.
I think the... The...
Our attempt to get rid of the fluid may not work.
But what may make more difference to him, I think,
is support coming to the home very quickly,
and that will help them as a couple
just focus on being with each other.
The hospital team helped Ted remain at home for as long as possible.
He got some social care, but his family says it wasn't enough.
He died a few weeks later in a hospice.
For hospital at home to work more widely,
families will need support.
About half a million people are waiting
for local authority care services in England.
So they're busy at the moment?
Phenomenally busy. We've seen...
Stephen Chandler runs Oxfords hire County Council.
Oxfords hire is no different.
We are really struggling with the demand.
We've been doing everything you'd expect a good health and care
system to do, commissioning new and innovative arrangements
to help people.
So, we've been doing everything we possibly can.
Yet I would say to you that's still not enough.
In England this winter, a total of £700 million extra
has been put into tackling hospital pressures by the government.
It includes moving some patients into care homes.
For councils, it's a short-term fix that doesn't tackle
the deeper problems,
including 165,000 unfilled care jobs.
We've got to, firstly, address the workforce.
So, that comes from, at the very beginning, positioning social care
in the workforce capacity as being equal to the NHS.
So, social care workers being valued and rewarded
equally in that context.
Care worker Rachel Feather is starting an evening shift
in East Yorkshire.
Each day, there are thousands of patients stuck in hospitals
across the UK, even though they're medically fit to leave.
Many are waiting for the sort of care she provides.
You know, when ambulances are queuing outside a hospital,
you can actually see the pressures on the health and care system.
But here on a cold, dark night, in villages and towns
where people live and need support, those pressures are invisible,
but perhaps even more intense.
Rachel's first visit is to see Shirley.
Are you ready for pudding, Shirley? Did you enjoy that?
Was it nice?
Don't try and pretend you made it!
Aye, I could!
I like the fact that I can come into people's homes,
make them feel safe
and do everything they need.
It's a role that Rachel believes is undervalued.
Carers are classed as unskilled workers, which is unfair.
You know, we're trained in safeguarding, medication.
And, you know, we're really underpaid.
Can I get you anything else before I leave?
On average, a care worker in England is paid a little over £10 an hour,
just above the minimum wage.
People are leaving,
they can go to a local supermarket,
the work isn't as hard,
and they can get the same amount
of money what they would get
from working a 12-hour shift.
With an ageing population,
social care can also be vital
in identifying problems early...
Hello. Hello.
...and heading off emergencies.
How've we been?
You're all right?
In the UK, about 4% of the population
is described as frail.
That's nearly three million people.
Around 40% of all hospital beds
and GP resources
are required to treat them.
In Hull, this one-of-a-kind medical centre
is trying to anticipate and prevent
health problems for frail,
often older people.
In one day, patients see doctors, physios, occupational therapists,
pharmacists and social workers.
The jean Bishop Centre was the brainchild
of Drs Anna Folwelland Dan Harman,
both specialists in elderly care.
We make decisions as a team so a person isn't having to go
to seven or eight different appointments to receive the care
that they require.
83-year-old Mary has come for an assessment
with her daughter, Jackie.
She was referred to the centre
by her GP after falling at home.
Jackie, how concerned were you about your mum last week?
Well, I've never seen her look so frail.
She'd been laid on the floor for a while.
Never mind frail, I looked frightful! Blooming heck.
This is a full body and life MOT,
designed to pick problems up early.
So, what I'm going to be doing in this bit,
we're going to do an ECG, so we'll check your heart over,
we're going to check your weight, your height, your blood pressure,
and your oxygen and pulse.
Then she sees the pharmacist and a consultant.
Usually, doctors only have a partial view of someone's medical history.
So, I'm going to concentrate a little bit more on medical aspects.
Here, Dr Folwell can see Mary's GP, hospital,
and any social care records.
With a longer consultation, she gets a much fuller picture.
I think this was your second fall, wasn't it?
Third this year. Oh, third this year. She had one in June outside.
Yeah, so for...
Treating people who've had falls is estimated to cost the NHS
more than £2 billion a year.
Dr Folwell believes Mary's blood pressure pills
may be having unintended consequences.
Because what's happening with your blood pressure, I think,
is it's been really well controlled.
But when you're standing, it is dropping,
and that can make you feel a bit woozy or dizzy.
We worry about that because then that makes you
more at risk of falling.
We're not the experts, so we just take what we're given
and then... Cos I haven't had them changed for ages.
No, you've been on it a long time.
It's nice to have the opportunity, really, to talk about it.
Because when you go to the GP's,
you just don't have time to ask questions.
Time has been key for this. Hmm.
How often in a normal hospital run or in a GP's practice
would you have this sort of time to go through things with someone?
I think that would be really unusual, not for want of desire.
I mean, we've essentially clone, like, 20 consultations in one here.
Some will say, well, actually the NHS can't afford to have someone
such as yourself spending so much time on one patient
when there are so many people who have needs.
I think we can't afford not to do things slightly differently.
We need to be able to do both.
We're never going to get on top of the reactive work
if we're not doing preventative, proactive work, as well.
Just this one up, and the door's open.
Dr Folwell reduces Mary's blood pressure medicine
and stops another medication altogether.
It's a small change that helps Mary and the NHS.
How much money can be saved by looking at medication?
Over the last four and a half years, we've consistently demonstrated
a greater than £100 per patient per year cost saving
in terms of the reduction in those medications, where the risks
outweigh the benefits, which can then be reinvested into other areas
of the health system.
The centre believes if this was adopted across the health service
in the UK, an estimated £270 million could be saved on medication alone.
Mary also sees the centre's social worker
who can assess if she needs more help at home.
It's our role, Mary, to just find out
how you're managing with everything at home.
Don't do the things I used to do,
like chopping trees down, lifting up stones and things like that.
Something like this, maybe a couple of years ago,
if she'd have accessed it then she wouldn't have gone through
what she's gone through the last couple of years.
And she might not have had the falls.
She might not have had the falls.
What do we want?
Fair pay!
When do we want it? Now!
As winter deepens, pressure on the NHS intensifies.
HORNS HONK
There have been national strikes.
Staff want more pay.
They say they're struggling with the cost of living,
exhausted from the pandemic
and the demand on services is unrelenting.
Safe staffing! Saves lives!
Across England in December, record numbers of patients arrived
in emergency departments.
Amongst the worst was Hull, where nearly two thirds
were waiting longer than the four-hour target to be seen.
When 91-year-old Richard was feeling unwell,
the overstretched GP practice sent him and his daughter Alison
straight to the emergency department.
Our clad was sat 23 hours on the chair
and we sat there and A&E was just absolutely crammed full.
But it was... Tt was a simple blood test and antibiotic.
Now, the jean Bishop medical team is investigating his problems further.
Hello, Richard. Hello, dear.
I've been asked to come out and see you about some tests the doctors
have requested. Right, come in.
Blood tests found a serious problem.
Their intervention prevented another trip to the emergency department.
Richard could have collapsed at any time.
His salt levels in his bloodstream had dropped dangerously
and could be fatal if not treated.
So we had a planned admission the next clay,
straight on to the Frailty Assessment Unit
at Hull Royal Infirmary, which was much better for Richard
and for his daughter, for Alison, but also for the system.
Two weeks later, I go with Dr Harman to see Richard.
Because you've had a tough time of it.
A worrying time, really. Yeah.
Yeah, it's been really difficult.
He's given a full check-up, including an ultrasound scan.
So, there you go. Ten out of ten.
Absolutely over the moon.
Yeah, yeah. I feel great.
Might even go for a run now!
LAUGHTER
Since the centre opened four years ago,
they've treated more than 12,000 mainly elderly people.
Researchers found all needed fewer GP and hospital visits,
but the biggest impact has been anticipating and preventing
problems among the frailest patients.
Those patients that are deemed to be frequent flyers, so three or more
emergency department attends in the last six months,
we've reduced those attendances by over 50%.
And, you know, that's not by chance.
We can invest time and energy into trying to prevent that episode
of acute care ever being needed.
Then... Then it pays for itself,
both in time, but financially as well,
but more importantly from the patient's perspective.
So if ideas like this can ease NHS pressures and improve patient care,
why aren't they being rolled out elsewhere?
One of the things that's really important
is it's got facilities in here...
Amanda Bloor runs the organisation that plans and delivers
health and care in Humber and North Yorkshire.
I really want to make sure we learn all the lessons
we can from the jean Bishop Centre, and actually the other services
that integrate to that.
The jean Bishop Centre has been up and running for about four years.
There are huge pressures now, there is urgency,
so why aren't we seeing this happening more often?
I don't think that taking it and dropping it elsewhere
is exactly the right solution.
Ancl I think we've got to empower teams of staff in different places
to say, what's the right solution here for our population?
Hello, my name's Claire.
I'm one of the nurses on the virtual ward.
Across England, the NHS is encouraging hospitals
to free up beds by treating more patients at home.
It says its virtual wards initiative will ease demand and improve care.
Hello.
Ah! Good morning. How was your night?
Doctors and nurses monitor the patient's health at home.
It's focused on more routine patients
who'll be visited if needed.
NHS England says last month 10,000 people were treated in this way.
Hi, Dan. How are you?
In Hull, the target is for about 300 patients to be cared for like this
by the end of the year.
What are the barriers to this?
Staffing, training, funding is an issue.
You're essentially talking about a small hospital in the community
and I think any place would struggle to deliver those numbers
under the current operating models that we have.
And it's a very tough environment for people to change
the way they're working.
In Oxford, some of the hospital staff
also joined the national strikes.
What is staff morale like
and how does that fit with what you're trying to do?
Morale is low, you're right.
But it's also unevenly distributed.
So, the morale in our particular work is high,
because we are involved in
changing an approach.
There's an energy and excitement around that.
Members of the team are learning new technologies and new ways
of doing things that they wouldn't do
if they'd stayed in their traditional roles.
I came to see your lung on your...
Here, Yun Ody is being trained to carry out some tasks
usually done by doctors.
If you see how far you are from the chest as a barrel,
so it's that way.
She's one of the hospital at home team and will soon qualify
as an advanced nurse.
Tell me about the equipment that you're using out on the road.
We go out, we either bring the laptop or iPad
and iPhone, go out, so we can communicate using hospital systems.
We've got point of care bloods machine,
that can do the bloods at the patient's home
and we've got results in two minutes.
That's so clever. Yeah, it is.
We love gadgets!
And increasing the skills across the health and care workforce
is critical for delivering this kind of hospital at home care.
You used to work on busy general wards.
What are the things you find work better this way?
I find I got more time to spend with my patient and I listen to them
and I know what they need.
And what difference does that make?
I think made the patients think we listen to them
and they're always thinking,
"Oh, you deliver much nicer care to me,"
and that means a lot to them.
And the health service of the future will need to work better
for a much wider range of patients.
As well as people living to an older age,
there are more young people with complex health conditions.
How's him? He's not been too bad.
Yun has come to see Will and his mum, Wendy.
He's the Oxford team's youngest patient.
Did you enjoy your birthday yesterday?
Will's just turned 19.
He has a rare genetic muscle condition.
He's doing computer studies at college and wants to be there,
not in hospital.
The last time that Will had to go into hospital to stay...
How tricky was that?
It was horrible.
And you couldn't sleep.
For someone who is an adult like Will, but is actually
still quite young at heart... And it felt...
It felt inappropriate to his needs.
I think it was noisy, it was scary.
It wasn't as scary as the other one. No, it wasn't scary.
It wasn't scary? Oh, OK. I was for you, but not for me.
It was for me! It might be scary for me.
If potassium levels in Will's blood drop too low,
it affects the rhythm of his heart,
and that's when he ends up in hospital.
Last year, he spent a total of 16 nights there
and had 18 outpatient visits for blood checks.
Now, that happens at home.
Everything falls apart when your potassium's low, doesn't it?
That's right.
The news is good.
Results are fine, great.
Yes. Ancl we can come to check it again, say two weeks?
But Will also needs nursing care night and day.
With one in ten nursing jobs in England unfilled,
finding nurses to visit is really difficult, leaving his family
to provide nearly all of his routine care.
We're only averaging about, I think, one to two days a week at most,
usually one. So, there's a big gap in those services.
It is a big gap and it's...
Month on month, year on year, it is quite exhausting.
The government says there are record numbers of doctors, nurses
and other staff working in the NHS, that it's tackling the pressures
and investing up to £7.5 billion in social care over two years,
as well as improving training and recruitment.
Change can be difficult in an organisation the size of the NHS,
particularly at a time of crisis.
But the doctors and nurses we've met believe building more services
around patients at home is better for them,
better for staff and inevitable.
All change gets resisted and it's... I think it's a complex business
to understand how you can innovate and change
in a stressed environment.
But I think often that's where that innovation is most needed.
How we want our health care service to be is personalised, responsive
and still being able to make a difference,
not just at the health care level,
but also at the thriving and quality of life level.
To achieve that,
solving deep-rooted staffing shortages will be key.
If that doesn't happen, the danger is the health and care system
continues to lurch from crisis to crisis.