"A's not well." "There's times when I feel like halfway through a shift, just walking out, because the pressure is that much." "Accident" "Emergency, the sharp end of the NHS." "Record numbers through an ever-open door." "From a whole hospital point of view, this is the worst year we've had." "Elderly patients stuck in hospital, a system under stress." "I want to go home." "I know you do, darling." "I know you do." "So many patients that targets are missed." "When you're doing everything you can and you are still not hitting your targets, it is frustrating." "And doctors issue a warning:" "We are broken." "We have reached our capacity." "There is no more give." "Accident Emergency has been in crisis and in the news." "Emergency units in England are coming under extra pressure because of a big rise in the number of patients..." "Hospitals in England have declared..." "Accidents and emergency doctors say they're treating 20,000 more patients a week..." "So what's going on?" "Last winter we spent seven days in A at the University" "Hospital of north tease in Stockton." "It was busy " " Tees." "But it was meeting targets." "Last month, we went back." "Across on three." "One, two, three." "Bill, that's." "It you're doing really well." "It's a lot busier than last year." "Everybody's under a lot of strain." "There's a lot of stress going on in the place." "Everybody's trying their best and running around." "Sometimes you feel that you're not getting anywhere." "We filmed here a year ago, coming back, it feels like a different place." "A year, it seems, is a long time in A A staff tell you that the initials really stand for "anything and everything", from a crushed finger." "Fair bit of flood went." "He didn't like the way the end of my finger was kind of loose." "To Princess Fiona with a nose bleed." "My friend rung the NHS line." "The girl on the phone asked if I had any colour in my cheeks." "I said, "I can't answer that at the minute, because I'm green." Winter set in the week we were here." "Has she been pain free?" "Yesment Chest?" "It's the morning meeting in the nurses' station, the nerve centre of the department." "The clinical director," "Andy Simpson, takes the lead, reviewing current cases." "Next is..." "She tripped in the garden this morning trying to put some grit." "She's right handed, had a fractured wrist." "OK, slipped, RTC." "Winter always leads to extra business for A What's happened to you?" "Slipped on the ice." "Yes." "And fell onto my back." "But the falls and winter bugs are no worse than usual." "Throughout the NHS, the pressure started growing long before it got cold." "This winter, we never really got out of the pressures of last winter." "Normally, in the summer, we would see an improvement in performance because the number of people who require admission to hospital, particularly the frail, the elderly and those with breathing problems goes down." "This year, we never really got that recovery." "Year on year, the demand has increased." "This is what's been changing in A, the record number of the frail and elderly they're treating." "Can I grab a syringe, 10 mls." "In adjoining baize, Raymond Smith, who's 37 and Bill Wilson, who's 85." "Raymond was brought in by a career from his residential home." "He's having severe breathing difficulties." "Last year, the total number of patients of all ages arriving at A departments in England, like this one, was 14,600,000." "That's an increase of 3% on the previous year, which does not sound an awful lot." "But it's equivalent to the number of patients that would be seen by seven medium-sized emergency departments." "Now we haven't built or staffed seven more emergency departments in the last 12 months." "We have a rather unwell gentleman in resus, at the moment." "He's come in septic into resus." "Elderly patients often have complex needs." "Since an operation to amputate Bill's leg, he's had recurrent infection Do you mind coming down?" "Is that all right?" "Losing an arm, OK, got it." "Bill's family are anxious to see him." "And to know how he is." "We're trying to figure this out." "He's been in and out of here since August." "They've done everything they can to help him." "He's been in and out of hospital, and of that, you've been in and out of hospital too." "That's been your life?" "It's what you've got to do, there's not a lot else you can do." "This evening, treating a procession of the frail and elderly is that unusual?" "That's a normal situation." "I would expect to see a situation like that on every shift, sometimes several times." "Sometimes you'd never leave resus, just be going from one patient to another to another." "I've been qualified for 25 years." "I've been consultant for 15 years." "From an A point of view, this is the worst year we've ever had." "Raymond was admitted to a ward, but died soon afterwards." "Bill died within days." "Many elderly patients towards the end of their lives may have repeated visits to A What we need to look at is long-term planning for people, because we are getting people from nursing homes, who really don't want" "to come to hospital." "We have had people come to Accident Emergency and they've died in the Accident Emergency department." "It is not a nice place to end up dying." "Zblt public never sees the -- the public never sees the stress A staff work under every day." "You can hear the crying in the background?" "Sometimes we wish we could share with people in the waiting area, because all they see is nothing happening, but in actual fact, we're busy trying to resuscitate people, behind closed doors." "We come out of there exhausted to see them with their spraned ankle." "I've trapped my thumb in a door." "I think it's broken or got infected." "I've been here for hours and nobody's bothered to tell me anything." "There's lots of doctors and nurses treating people who are much more severely unwell back there." "Oh, yeah, I understand that completely." "Other people have been in and out within five or ten minutes, that's all." "According to official figures, about 40% of the people arriving at A could have been treated elsewhere." "People who are using the NHS the way it wasn't designed to be used." "They want now, instant fix." "They want it done yesterday." "They don't care who does it." "They want it done now." "A is open for business 24/7." "Some staff told us that they thought the NHS's new 111 phone advice system was sending too many patients into A" "Would you consider yourself severely ill?" "What have you been able to do today?" "My view is that we get too many patients sent to Accident" "Emergency via 111." "The whole point of 111 was to actually send patients to different place rather than Accident Emergency." "Isn't is 111, which is meant to be part of the solution, part of the problem?" "Categorically not." "More people are phoning 111 in a year than going to" "A departments." "What we know is that of those people who phone 111," "I Would Do Anything For Love otherwise have dialled 999 for an ambulance or gone to A, 60% are now offered a treatment that is better and actually avoids them doing either of those things. 111 can only refer people to other parts of the NHS, if they're open." "Sometimes, especially at the weekend, there may be no alternative to A This is not to blame 111, this is a call to increase the number of services and the numbers of days per week those services are" "available so that NHS 111 can direct people to the most appropriate place, not the only available place." "That is broke and it should be put in a cast." "Patients who are drunk and abusive are part of the daily round in A Mostly staff grin and bear it, but not always." "This is the third time I've been treated like this." "Last time she come in, she was verbally abusive because we wouldn't get her transport home." "She was very intoxicated." "We got the police to escort her off the department." "Sister Nicola Donachie has been in A for 18 years." "She says she's never been worked so hard." "Very low tolerance to her staying, if she's going to be abusive again." "Zero tolerance." "Are you going to be quiet?" "I will be quiet, but I don't want to talk to you." "I'm not going to treat you." "Take me back to the police station." "You caused this injury by kicking the door." "Exactly." "Not only are they drunk, nine times out of ten, they're not very nice drunks either." "We get a lot of abuse from them." "Just down the corridor, a patient has been brought in with a head injury." "As soon as I've treated you..." "How's it going to be?" "!" "She'd been drinking too." "Who's you?" "I want Gregg!" "I can hear you three doors down." "I'm hungry officer." "All I want is a little cheese sandwich." "What's the problem?" "I haven't got a problem." "Scenes like this are nothing unusual in A The NHS in England estimates the total cost of harm from alcohol at 3. ?" "3.5 billion a year." "And hospital admissions are rising." "Nice and still for me, Stuart." "Stuart, just relax." "Until they're sober, they haven't got capacity." "They can't make judgments for themselves." "We have to keep them in hospital until they're sober." "It's the morning after." "Stuart spent the night on a ward." "He's sobered up." "Have you got a problem with alcohol?" "Yes." "Are you an alcoholic?" "Yeah." "It takes a fair bit of all their time, doesn't it, when you come in?" "I suppose so, yeah." "It does, yes." "A departments also see people with mental health problems." "Some turn up so often staff call them "regulars"." "Sister Donachie knows this patient well." "Oh, bless you." "You two have got to know each other well over the years." "What do you usually bring me?" "Bag of sweets." "Bag of sweets." "Have you been here before?" "Yeah, many, many times." "Can you give me some idea of how many times, five, six, ten?" "About 120." "What's brought you here?" "It's either been pain." "I suffer with a lot of pain." "I've done a lot of damage over the years." "This isn't a social network, it's a hospital." "No, I think it is a social network." "We become friends." "I think they come because they're lonely and they have nowhere else to go, the majority of them." "Could you imagine your life without coming here?" "Yeah." "You could?" "I've done that for the past eight weeks." "But that's not that long." "It is for me." "That's very, very good for me." "In Stockton, we saw A staff treating old people with complex medical needs, but we saw something else as well." "Elderly people arriving not because they're ill, but because those caring for them can no longer cope." "It is Saturday night." "Kathleen has been brought in." "She is 89, and lives at home with her daughters." "Sorry, Nick, can we get a better Kathleen in room six, please?" "Your mother lost her husband a few months ago?" "We lost my dad seven months ago." "And you are worried that your mother has not been eating?" "Yes, very much so." "You have been unhappy?" "My family has made me happy, but I have not been happy myself, really." "And that is why you have not been eating?" "I would say that, yes." "Do you think you did the right thing?" "Yes." "By calling 999 on a Saturday night and bring her to this hospital?" "Yes." "Couldn't cope." "Not the way she was tonight." "Kathleen is not ill, but she has come to a place for the acutely unwell." "The A" "Doctor focuses on her social welfare." "We can't do anything now." "Come morning, we will get some people to look at you, and they will see what you can do at home and what you can't do and what kind of help you need, all right?" "And maybe we can sort out some carers to make it easier." "You are not a burden on your family, so I don't want you thinking that." "It just might make it easier at home for you and everyone." "Thank you very much." "That is all right." "Has anyone told you what nice white teeth you have got?" "Thanks, no one has told me that." "Stop flattering me!" "In the small hours of the following morning, another patient arrives at A who no one thinks is ill." "If we left him at home, he is not eating and it is possible that he would not have made it." "This is" "George, as you know." "Hi, George." "He is a bit death. -- deaf." "A young friend of his has brought him in." "So why tonight, all of a sudden?" "He never goes into the shower." "His room is minging." "I try to get him in the shower, and he just punches us." "I am just doing to pop these stickers on you, George, OK?" "Nice and still, George." "George, who has not had an accident or an emergency, has become A's business nonetheless." "He is just very deaf." "I would say he has got capacity." "He will need the help of social services, but for now, it is the NHS that work out for him." "Is he here because he is ill?" "No." "He does not seem to have any medical problems." "I could baby in a basket, he has been brought here in the small hours of the morning -- like a baby?" "Yeah." "And he will be admitted into a hospital bed, probably." "But that is not going to be easy." "Bed throughout the hospital are at a premium." "The skills of the bed management team have never been needed more." "He is allocated to an empty bed, Karen." "Have you ever known this hospital this full before?" "In my time, I have not seen so many extra beds open, no." "They have opened up 56 extra beds, but they are full as well." "Can I get an update, please?" "Her business is freeing up beds, and she hands them down throughout the hospital." "How far do you think you walk everyday?" "Not sure." "Maybe a couple of miles, I guess." "Hello?" "It is Carolyn." "And just after the side room that is coming up." "Oh, what is there a change in the plan?" "Anything else coming up?" "It is very stressful." "Obviously, you are worrying about getting patients home before it gets too late." "And you are also worried about the patients that are on their way in and that you need to create capacity for." "Often, a hospital bed that could otherwise be free is occupied by an elderly patient who no longer needs hospital care." "Mum, have a drink." "Well done." "Jane" "Abraham has dementia." "She was admitted straight onto a hospital ward from her care home. # Our hearts are on fire." "She was well enough to leave hospital before Christmas, but in mid-January, she is still here." "There is a tiny bit left." "Prolonged hospital admissions are costly and also costly to Jane, because she is at risk of infection is just from being in hospital." "We can only protect her so much." "I want to go home." "We will, as soon as you are strong." "But because Jane's medical and nursing needs have increased, she can't go back to the care home where she lived before." "And this is where a hospital can become reliant on the actions of others - social services and families themselves." "We are an acute ward." "We are very busy." "In a nursing home, it will obviously be more relaxed." "Her daughters have been struggling to find a new care home." "We are really concerned about my mother." "We desperately want her out of here." "I feel like there is a big blog somewhere -- a big blog between the" "NHS and what happens to somebody afterwards." "They spend hours on the phone and the internet, trying to find a suitable home for their mother." "It is unfamiliar and stressful work." "Could I speak to the manager, please?" "It is Bridget Lowry about Jane Abraham." "We have been ringing the various organisations to try and get it sorted." "It has been a long haul." "So it is definitely not going to be today?" "Could it be tomorrow, possibly?" "Thanks very much." "Bye-bye." "The family think they should have had more help from social services, but the local authority insist that they have done everything that was required of them." "Can you see my dad?" "The hospital admits that a failure in communication on its part has contributed to the delay." "In another room in the same ward is George." "He is the old fellow whose friends thought he could not look after himself at home." "How are you feeling?" "Champion." "You can't do better than that." "So what are things like the Georgia at home?" "With his permission, I went to look at his room." "This is where he has been living for years." "It is not difficult to see why his friends think he can't cope." "Meanwhile, until everyone sorts out what to do about him, he is being cared for by the NHS." "Enjoy your meal." "More than a quarter of the days that patients spending hospital in England after they are medically fit to leave are down to arranging social care." "There is a disconnect between NHS and social services, and that hurts pressured hospitals." "It is not a disconnect, there is a good connection, but it has got to be better." "Social care have had a tougher time than we have, and we recognise that the ability for the health system to be efficient is dependent on the social care and community services." "That is why extra money has been put into that by the government." "The harder it is to get patients out of hospital, the more the traffic jam tails back to an already overstretched A Yet the staff are still meant to meet the same official waiting time targets, treating and then admitting" "or discharging 95% of their patients within four hours." "You are doing everything you can and everybody is pulling together, and you are still not hitting your targets." "It is frustrating." "Last year, we saw staff busting a gut to keep the red warning light is off the computer screen and meet the target, and they were succeeding." "But now, week by week, like many hospitals, Stockton is failing." "For the last quarter, we have just managed to achieve the target of 95%." "But on some days, we do fail and have too many breaches." "In this quarter, barring a miracle, you will fail." "What is it like to give it your best shot and still know you are heading for failure?" "Well, nobody likes to fail." "We do our best to achieve the target, but if we do fail, it will not be for lack of trying." "Some staff sounded quite unapologetic about failing to meet the targets." "You are "failing"." "Yeah, and I think that is a good thing." "It is good that you are failing?" "If no one knows how bad the situation is, how on earth will we get help?" "If the system is broken, we want that to be highlighted." "That is the increased pressure on A department is causing not just a failure to meet targets, but something more serious?" "Here on the A front line, they are worried about whether they can continue to do their job properly." "We have all felt that danger of there being someone in the department who might be unwell, and we might not have a handle on exactly how unwell they are simply because we are spread so thin." "The clinical director in A is worried about patient safety as well." "Once you have overloaded a system to a point where you have no beds in the hospital, where you have no rooms left in resus and beer asked to come in, you must put people at risk in some way. -- when people are still coming." "When a service is under pressure, that is inevitable, but nevertheless, we do make sure we have the staff thing we need in place to make sure that most patients, when they come into hospital, are not put at risk." "Stockton is officially recognised as a good hospital." "Its frail and elderly patients, who are arriving and being admitted in such numbers, are treated with great care." "We are going to go home." "After over a month in hospital, Jane Abraham left to go to a new care home her daughters had found for her." "Kathleen, admitted into A on Saturday night, is now in the hospital's rehabilitation unit." "You are going to start doing your exercises but the physio is giving you." "I will to you one thing." "She is bossy." "Mum is a lot better." "George, brought in because he was not coping on his own, is still in hospital while his future care needs are sorted out." "But even this good hospital is labouring under heavy burdens, and its staff in A say they can't take much more." "There are times when I feel like, halfway through a shift, just walking out, because the pressure is that much." "Would you have said a year ago, there are half -- times halfway through my shift when I feel like chucking it in?" "No." "The man in charge of acute care in England says reform has already begun." "We are trying very hard to make sure that the system is coping, and I believe the NHS is currently coping, but we have an unsustainable system, and I agree that it is something that will have to change." "Because the patients are being put at risk?" "Because the system demand means that at the moment, the model we have to deliver care will increasingly find it difficult to do safe care." "We are broken." "We have reached our capacity." "There is no more give." "So the diagnosis at the end of a week in A is clear." "This most exposed and politically sensitive part of the NHS is in need of urgent care." "Ten minutes!" ".." "Six and a half!" "MUSIC:" "Flight of the Bumblebee by Rimsky-Korsakov"