NHS and the 'winter crisis' in our hospitals - beds, beds and beds - and, of course, funding
If you've been watching BBC2's amazing series Hospital, you won't really need to read much of this. On second thoughts, if you do read this you can see what the NHS' problems look like far away from the gigantic Imperial College Healthcare NHS Trust in London - to which we will return.
The Wiltshire Clinical Commissioning (CCG) board meeting held this week was dominated by a report on the "Urgent care system pressures - December". A paper gave detailed analysis of the five weeks November 28 to January 8: it is, as one of CCG director said, "...very fragile out there."
The four-hour treatment or admission target for A&E was missed by all three hospitals that serve Wiltshire - Salisbury, GWH and RUH/Bath - see graph below. The misses in most of the weeks were worse than last year's.
GWH recorded the worst performance - in week two they were at 62 per cent against the target of 95 per cent of people attending A&E being seen, treated and either sent home or admitted to a bed within four hours.
During the period attendances at the three hospitals were up on the previous year: GWH up 1.8 per cent, RUH up 2 per cent and Salisbury up a whopping 4.5 per cent. That explains some of the problem.
The rest is undoubtedly down to the delayed transfers of care - once known as 'bed blockers', and now more properly known as DTOCs. These are patients well enough to be discharged, but who need further NHS care, care home places, social care packages or help from relatives.
When they cannot leave hospital at the back door, people coming into the front door - A&E especially - who need to be admitted for treatment cannot get beds. The reasons for DTOCs are many - including such reasons as outbreaks of 'flu in care homes.
The meeting agreed that problems with social care, although significant, were an overused excuse. Many DTOCs were down to NHS problems.
One such problem is that some patients' families are over insistent on their right of choice - causing delays and not realising that hospital is not the best place for well people, relatives or otherwise, to linger. As the CCG's Interim head, Tracy Cox, put it: "People aren't prepared to have difficult conversations with the public."
However, it was also said that the shortage of beds should not be used as a default reason for DTOCs. This is a generalisation. GWH are on record as saying that year round they are short of 43 acute care beds - which rises each year to a 78 bed shortage during February.
GWH was built as a smaller hospital than Swindon's Princess Margaret which it replaced - and Swindon's population has risen hugely since it was opened.
How far is the NHS funding stretching in Wiltshire? The CCG's figures look set for a good end of year outcome. But a little surprise came in the finance report where a figure of £596,000 has appeared as the cost of market rents now being charged by the national NHS Property Services company.
For the moment this hole is being plugged by extra funds from the Department of Health - a temporary measure which may leave a real hole in budgets for future years.
This very mini-crisis may become to be seen as a bit like a Treasury inflicted PFI - but with PFI the maintenance costs are included in the annual fee to the owner of the PFI contract.
If leases are not very tightly drawn, how will local NHS executives persuade the national owner of their property to spend money to maintain buildings properly? This will become even more important when the government decides to sell off NHS Property Services Ltd - as was foreseen in the Lansley reforms.
If you have not been watching BBC2's Hospital you will have missed the amazing sight of a man with a very bad arm tremor showing medical staff the tremor had been cured while still lying in the scanner where he had undergone ground-breaking, experimental non-invasive brain surgery using ultrasound beams.
He was up and away home within hours - not a blocked bed in sight. Astonishing - and an obvious way forward if the NHS can ever afford the necessary sophisticated equipment and highly trained staff.