GWH shows how the NHS 'to do list' will challenge any winner of the General ElectionPromises, promises, promises - more of this and less of that - the NHS at the heart of anything you care to name. Promises coming thick and fast - with sums of money replete with zeros. That's our General Election experience so far.
Away from platforms, rallies, debates, broadcasting studios and social media, there is still the NHS front line - still under funded, still over-crowded and still short of staff. To get some detail and facts - what we have become used to hearing as a 'reality check' - there was no better place to be this week than the Great Western Hospitals Foundation Trust (GWH) board meeting (December 5).
With so much reality about, it was not somewhere you would find politicians just now - from any political party. And there were no TV or still cameras or spin doctors muscling in on this hospital meeting.
The word most often used during the meeting was 'challenge'. Rising demand is exceeding resources - financial and human resources and beds. At times like these - and with winter pressures building - the struggle to maintain standards is uppermost.
Liam Coleman is the board's chair: "It seems to me that we're suffering a decline against our standards. Are we doing all in our control against these challenges?"
Julie Marshman is GWH's Chief Nurse: "The pressures are taking a toll on the quality of our care."
Charlotte Forsyth is GWH's Medical Director: "We are doing everything we can to reduce corridor care - but with corridor care safety is at risk...Maintaining that high level of care is increasingly difficult."
To take just one example of the continual efforts to maintain standards, three senior executives are engaged in a hands-on review of every patient's length of stay: "Can we trim off our length of stay?"
Success here can produce vital empty beds to take the continual flow of patients needing admission for urgent treatment - many from GWH's Emergency Department (or A&E). Medical Director: "Out of this work there will be champions who will grasp what we are trying to achieve - and take it forward." 'Trimming off at every turn' produces, she assured the board, results.
The GWH board really does face up to reality. The 'patient's story' for this meeting concerned a man with a series of complaints following the death of his wife after a serious lung infection.
Bravely addressing the video camera, 'Michael' said he had not been told what his wife had died from. He wondered whether her infection had been exacerbated by lack of hand washing, phials left on the floor and uncollected meal trays.
It was a complex story as Michael himself had fallen ill and so missed being with his wife when she died - by a few guilt-inducing minutes. His video produced a stream of concerned questions - many seeking evidence that lessons had been learned.
It was all there in the open. A moving and disturbing presentation - with practical 'outcomes'.
One of GWH's 'challenges' that comes with all the extra demand and workforce shortages is, of course, the Trust's finances.
Karen Johnson is GWH's Director of Finance: "On finances we are significantly challenged." The October figures show the year-to-date deficit is £11m - which is £5m above plan. By the end of March the deficit is forecast to reach £21.5m which will be £10m above plan.
It is not as though GWH has not been making savings. Its annual Cost Improvement Programmes (CIP) have saved £29m over the last three years.
However there is a shortfall of £4m in the delivery of this year's CIP. Ms Johnson: "We do have CIP fatigue - I feel - in the organisation." As one non-executive director put it, the easier savings - the low hanging fruit - have been made and "...the remaining fruit is a bit higher."
The figures may be jaw-dropping, but GWH is not alone in its financial constraints - or straits. The South West's NHS system is in 'financial distress'. It is facing a joint deficit of £50m - against £69 across England: "There is performance and financial drift off - productivity is down."
Whether this is just a matter of under-investment in the region or a difficulty in recruiting into the region's more rural hospitals, remains to be seen.
Meanwhile GWH is waiting anxiously to see whether it gets a share of the £2.4m winter pressures money to be handed out by the area's STP. The trouble is the STP has had bids - from hospitals and local authorities - totalling £6.5m. Wiltshire Council has already had a £1m+ winter top up from the government.
There was good news for the board - during October vacancies fell by the equivalent of nearly 40 full time staff. And there are 14 international nurses who are not yet able to undertake the duties they have been employed for because they are waiting to take the Objective Structured Clinical Examination that international nursing recruits must pass.
We have a few days of campaign promises left - promises to take with lots of salt. There is a lesson from health visitor numbers. In April 2011 the coalition government promised '4,200 extra health visitors'.
Despite an expensive recruitment campaign in EU countries (in pre-referendum days), they failed to achieve their promised number. Health visitor numbers did however reach a peak in October 2015. The trouble is that since then numbers have fallen by a third.