Is the NHS healthy now it's reached middle-age?

In fact the NHS is more notorious now than ever. Everyone is always talking about it, its problems and where the money to keep it in style should come from.

In the first part of a two part series as part of NHS Week, MARGARET SMITH takes a look at aspects of the service in South Bucks.

Hospital targets are misleading

ALL hospitals are set targets to reduce the number of people waiting for routine operations like hip replacements, varicose veins and cataracts the length of time they wait, and the time they wait to see a hospital consultant before their operation.

Wycombe Hospital beat all its targets in the year ending in April. Last year saw the lowest number on the list for seven years and no patients waiting for ops more than 15 months, compared with the 18-month maximum.

The number of outpatients kept waiting more than 13 weeks for an appointment with a consultant fell by more than a third.

Figures are checked each month and are still on the right lines, says hospital chief Roy Darby.

Hitting targets is a headache and it can seem that the only thing that matters is getting there.

Mr Darby described the difficulties as a triple whammy. Doctors referred more patients, and staffing problems reduced the number of beds available, as did the fact that older people were kept in hospital when they could be discharged, because of delays in finding places for them to go.

To avoid getting into hot water with the Government, hospital chiefs have to manage their lists carefully. If they always treat the more urgent cases first they run the risk of letting the less urgent cases come up to the 18-month danger period. On the other hand hospitals have been accused of packing in non-urgent operations just to cut their lists.

"It's a question of balance," said Mr Darby. "But we have a time limit to deliver and if you don't have a system of dealing with it, you breach it."

The artificiality of waiting lists is shown by the fact that the South Bucks Trust had a very good waiting list position some years ago. But because it was out of sync with the rest of the county it had to scale down by closing beds.

The Government is putting extra money into getting waiting numbers down. Last year the trust got £750,000 extra and it is getting £450,000 this year.

The money paid for more staff so that more beds remained open, and more operations were carried out. The trust also paid for private beds and places in nursing homes, again to free up hospital beds.

Staff and house prices a big issue

STAFFING is still a big issue for the NHS and a recruitment fair has been taking place at Wycombe Hospital all week to try and get qualified staff back and new ones in.

It is not such a problem in community-based services such as district nursing and health visiting, probably because these jobs are done by older women settled in the area.

But it is difficult to recruit nurses in acute medicine and surgery. There is a shortage of therapists and midwifery, though OK at present, will have problems as people retire.

It is a question of house prices in this area qualified people cannot afford to buy - as well as pressure of work and the fact women no longer gravitate towards health service careers.

Chief executive Roy Darby said: "We are 100 trained nurses short at present, mostly in acute and surgical." He said that medical and surgical wards were generally full; their patients needed a lot of care and there was lots of pressure on the nurses.

He said: "What happens is that nurses find it stressful and either leave or don't apply for jobs, so that those who are left are under even more pressure and you get into a downward spiral."

Things were not helped by the fact that new graduates now said they would not go into a job paying less than £25,000.

This week a decision is expected about the trust's bid for government money to make it easier for its nurses to get on the home ownership ladder. If the bid is approved a housing trust will buy homes and allow key workers to part buy and part rent them.

"We shall be disappointed if we don't get it," said Mr Darby.

Practitioners ease pressure

SISTER Julie Welch is an emergency nurse practitioner at Wycombe Hospital which means she has been trained to take over some of the work from doctors in the hospital's accident and emergency department.

Julie and two other nurse practitioners see their patients through from assessment to treatment to discharge, and ease the hours of waiting in A & E for the large numbers of patients who need treatment, but are not urgent cases.

Being 'not urgent' can mean waiting four hours or more for minor treatment. Doctors cannot give priority to a sprained wrist or stitch a minor cut, when there is a heart attack or road accident victim who may die within minutes without help.

'Non urgent' means 'back of the queue' and the notice in A & E even asks patients to consider whether they need to be there.

Hospital chief executive Roy Darby said the hospital's A & E Department was under severe pressure, not because of major staff shortages, but from the sheer numbers of patients coming in through what was in effect the hospital's front door.

He said: "Nurse practitioners are trained to go beyond nursing. They will be able to deal with lots of minor injuries, which in the past have been done by doctors."

The hospital has been running a pilot scheme for the past year.

Dr Tanya Malpass, one of three consultants in A & E, explained. "We needed to help the patients who were the highest volume the walking wounded, people with cuts, bruises and sprains.

"We have to prioritise our activities and see first the people who are seriously ill. They take lots of resources, and waiting times for the walking wounded are going up and up. It used to be one to two hours. Now it's three to four and it can be longer."

Now the pilot scheme is over, the hospital is taking on an extra two nurse practitioners so there should be one available seven days a week. The nurses who are all experienced in A & E will also continue to help the doctors with the more serious cases.

Cleaning up operations

SOUTH Buckinghamshire NHS Trust is getting another £85,000 this year to spend on cleaning up its hospitals at High Wycombe and Amersham.

The trust, like others in the country, was given £100,000 last year for the same thing. Handing out the cash was one of the first things the government did after publishing its 10 year NHS plan. Hospitals were to be given green, amber, or red lights according to their cleanliness.

The trust took a lot of stick when a government appointed Patient Environment Action Team came round and gave the hospitals the thumbs down and a red light. A subsequent inspection after the money had been spent, put the trust on amber.

Chief executive Roy Darby said the first inspection team had arrived when new building was going on at Amersham and he said it was not really about dirt, but about the patient environment, though it did give the trust a bench mark to work to.

"We were in the middle of PFI [Private Finance Initiative] and when they came back the second time we had completed it and our score went up."

It was spent at Wycombe Hospital, on toilets, carpeting, lifts and signage.

Mr Darby said: "But £100,000 doesn't go that far and we could have spent it many times over."

Governments are keen on targeting money on specific things and then making local councils and trusts and clubs bid for it. No win, no cash and time wasted putting the bid together.

For example the trust failed in its bid for cash to enlarge and improve the day nursery at Wycombe Hospital for the children of the hospital's staff.

Mr Darby said he could see the government's point of view but said: "From our point of view it may be we think the money might be better spent elsewhere."