members of the security forces confronted crowds demanding the resignation of president dina boluarte. the latest reports say a building is on fire in the city centre. now on bbc news, panorama. the nhs is under intense pressure. emergency departments are packed. it's the most pressure i have felt as a clinician in my time since i qualified. all: we want fair pay! staff say they are at breaking point. all: your nhs, our nhs. ambulances are queueing for hours. it can be desperate for patients. we sat there, and e&a was just absolutely crammed full.

so what needs to change? i've been meeting doctors and nurses rethinking healthcare, picking problems up early... we've essentially done 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, only about the rebirth of the hospital. hello, mrs east? 93—year—old elizabeth east is being assessed at thejohn radcliffe in oxford. how are you doing? like many hospitals across the country, it has been pushed to its limit. good morning. hello. 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 is being assessed on a special unit run by drjordan 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. how about — are you feeling cold, are you? yes. all right. and this is not a good place for a person like elizabeth who is also living with dementia. it is trying to normalise her environment, which we simply can't do in a 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. 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 have been very successful, seeing an average of 70 patients a day — 95% are treated without needing an overnight stay. can you get some bloods off her? they're geared up to get test results back quickly. are you 0k? 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. the biggest thing is trying to explain to someone who is feeling unwell why it is 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 — iio% filled. people are in there for 22 hours, eight hours waiting to be seen. could we get you and the hospital team to go out? yeah. 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 is your choice. we are not replacing the hospital. this isn't about the death of a hospital or anything, it's about the rebirth of a hospital.

new technology means he is 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 — i feel really rotten. you feel rotten? yeah. are you getting any pain in your chest? no. no? 0k. oryourtummy? 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?

cos i'm going to need to listen to your heart and 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 and then outside the lung and in the chest cavity. that bright thing is the... within moments, they can see the cause of ted's breathlessness. his heart isn't pumping properly. and this isn't squeezing very well at all, this left ventricle, and that is the problem. by quickly uploading the images to the hospital system, professor lasserson can discuss the results with the heart specialist. have you had a chance to look at the images? yes, i'm looking at the images. what do you think?

his lv — his lv isn't there. they will keep monitoring ted and give them 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. there you go. 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. mum — 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 is worried about how her mother will cope. mum needs support. she can't carry on what she's doing — or what she has been doing. i'm frightened because... ..if he fell, and he'd hurt himself badly, i think i'd just sit down and cuddle him. 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 will make more difference to him i think is support coming into 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 500,000 people are waiting for local authority care services in england. so, very busy at the moment? phenomenally busy. we've seen... stephen chandler runs oxfordshire county council. oxfordshire's no different. we are we a re really we are really struggling with the demand. we've been doing everything you'd expect a good healthcare 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 is 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 carejobs. we've go 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 queueing 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. you ready for pudding, shirley? did you enjoy that? was it nice? don't try and pretend you like it! 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 are 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. ..and heading off emergencies. how have you been? you're all right? in the uk, about 4% of the population is described as frail — that's nearly 3 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. thejean bishop centre was the brainchild of doctors anna folwell and 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 afterfalling at home. jackie, how concerned were you about your mum last week? well, i've never seen her

look so frail, like she'd been laid on the floor for a while. didn't look frail, i looked frightful. bloomin' 'eck! 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 is an ecg. 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 fulwell 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. she had one injune outside. treating people who've had falls is estimated to cost

the nhs more than £2 billion a year. doctor folwell believes mary's blood pressure pills may be having unintended consequences. yeah. because what's happening with your blood pressure is it has been really well—controlled. but when you are standing, it is dropping, and that can make you feel a bit woozy and dizzy. hovel we worry about we worry about that because it makes you more at risk of falling. we are not the experts here, we just take what we're given. but i haven't had a change for a long time. you haven't in a long time. it is nice to have the opportunity 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. how often, in a normal hospital run, or in a gp�*s practice, would you have the sort of time to go through things with someone? i think that would be really unusual. not for want of desire,

but we have essentially done 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 are never going to get on top of the reactive work if we are not doing preventative proactive work, as well. just this one, and the door is open. dr fulwell 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 4.5 years, we have consistently demonstrated that 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 be then 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 help at home. it is our role to find out how you are managing everything at home. trees down. laughter. moving stones and things like that. e something like this maybe a couple of years ago, if she had access to it then, she wouldn't have gone through what she has 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? when do we want it? now! as winter deepens, pressure on the nhs intensifies. there have been

national strikes. staff want more pay. they say they are struggling with the cost of living, exhausted from the pandemic, and the demand on services is unrelenting. cheering. 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. i was sat 23 hours on the chair, we sat there and a&e was just absolutely crammed full. yeah. but it was a simple blood test and antibiotic. now, thejean bishop medical team is investigating his problems further.

hello, richard. i've been asked to come out and see you about some tests doctors have requested. come in. blood tests found a serious problem. the intervention prevented another trip to the emergency department. richard could have collapsed any time. his salt levels in his bloodstream had dropped dangerously, it could be fatal if not treated, so we had a planned admissions the next day, straight onto the frailty assessment unit at royal infirmary, which was much better for richard and for his daughter, alison, but also for the system. two weeks later, i go with dr harman to see richard. because you have had a tough time of it. a worrying time, really full stop in my career. it has been, it's been really difficult. - he is given a full checkup, including an ultrasound scan. there you go, ten out of ten. absolutely over the moon.

yeah, great. i 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 four a—lister patients. —— the frailest patients. for those patients that are deemed to be frequent flyers, so three or more emergency department visits in the last six months, we have reduced attendance is by over 50%, and that is not by chance. if we can invest time and energy into trying to prevent that episode of acute care ever being needed, than 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 has facilities and here. amanda blore runs the organisation that funds and delivers health and care in north yorkshire in humber. we really want to make sure we learn all the lessons we can from thejean bishop centre, and actually the other services that integrate into that. thejean bishop centre has been up and running for about four years was that there are huge pressures now, there is urgency, so why aren't we seeing this happening more often? i don't think taking it and dropping it elsewhere is exactly the right solution, and 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 is claire, i am one of the nurses on the ward. across england, the nhs is encouraging hospitals to free up beds by treating

more patients at home. it says its virtual awards initiative will ease demand and improve care. hello. good morning. how was your night? doctors and nurses monitor the patient�*s health at home. it is focused on more routine patients who will 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. we are essentially talking about a small hospital in the community, and i think anyplace 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 are working.

in oxford, some of the hospital staff also join the national strikes. what is staff morale like, and how does that fit with what you're trying to do? morale is low, you are right, but it is also unevenly distributed. so the morale in our community work is high, because we are involved in changing an approach. there is an energy and excitement about that. members of the team are learning new technologies and ways of different dynamics that they would not do if they stayed in their traditional roles. here, this nurses being trained to carry out some tasks usually done by doctors. if you see how far you are, the chest is a barrel... she is one of the hospital at home team and will soon

qualify as an advanced nurse. tell me about the equipment you are using out in the road. we either use the laptop or ipad so we can communicate using hospital systems. we have a machine that can deal with the bloods at home and get results in two minutes. that's so clever. it is. we love gadgets! 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? ifound i have more time to spend with my patient and listen with them and know what they need. what difference does that make? the patients think we listen to them and they are 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 is he? he has not been too bad. she has come to see will and his mum, wendy. he is the oxford team's youngest patient. did you enjoy your birthday yesterday? will has just turned 19. he has a rare genetic muscle condition. he is 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, it felt inappropriate to his needs. i think it was noisy, it was scary, it wasn't as scary as the other one? it wasn't scary. yeah it wasn't scary, oh, 0k. it was for me. if potassium levels in will's blood drop too low, it affects the rhythm of his heart and that is 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 level is low, doesn't it? that's right. the news is good. great. then we can come and check it again in 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 are only averaging about, i think, one to two days a week at most, usually one. so there is a big gap in their services? it is a big gap. 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 is 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 have met believe building more services around patients at home is betterfor them, better for staff, and inevitable. all change gets resisted and it is a complex business to understand how you can innovate and change in a stressed environment. but i think of the matter is where that innovation is most needed. how we want our health care to be, personalised, responsive, and still being able to make a difference, not just of health care level, but also at a thriving and quality 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.

this is bbc news. i'm monika plaha. our top stories: the actor alec baldwin is to be charged with involuntary manslaughter after a fatal shooting on the set of the film rust. growing pressure on nato countries to send more tanks to ukraine. we have a special report from the front line. explosions very active front lines this morning. very close to soledar, seized by the russians in the last few days. reports of more deaths and more protests as antigovernment demonstrations continue in peru.

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