Chippenham in Wiltshire has a model community hospital. There are minor injuries and maternity units; beds for elderly mentally ill patients and for hospice care; beds for patients of local GPs and beds for consultants' referrals. Come spring, there will be a new unit for stroke victims.
The hospital fits the town's re-found prosperity. With a big Dutch gable over its archway entrance, it seems more like a private housing scheme and you certainly wouldn't recognise it as the former local workhouse. Clinical and nursing care are generally held to be excellent.
There is, though, a downside: through no fault of the hospital, at least a quarter of its patients are stuck in a benign servitude, more like Victorian times than the present. These are elderly men and women who, though assessed as medically fit for discharge, could not manage on their own and so await transfer to nursing or residential homes. In the ugly jargon, they are "bed-blockers".
Wiltshire social services does not have funds to satisfy the demand for residential places. For months, the trapped patients lie or sit or shuffle in hospital wards; talking, fretting or dreaming of release. The beds they needlessly occupy cost the NHS £166 a day; yet for less than a third of that - about £350 a week - they could be in residential care.
This bottleneck delays admissions in Chippenham and causes ripples in hospitals in other small towns and in Bath. And it is by no means unique: in similar hot spots across the country, the government's best laid plans for keeping the NHS show on the road this winter are threatened by a shortage of social services funding for residential and nursing home care.
Anne Keat, a sister at the Chippenham hospital, is "desperately concerned". She says: "Several patients have been waiting since early summer. Hospitals have no entertainment; there's nothing for them to do. We're having patients who die before they get to a nursing home. We've had several in the last few months."
Nick Whyatt, head of a local, seven-partner GP practice, has a patient who's been waiting since January for a move from hospital to nursing home. Whyatt describes the knock-on effect of bed-blocking. "Two weeks ago, a deeply unconscious old lady was found by a neighbour," he says. "Normally, I'd admit her to a GP bed. Our beds were blocked; she wasn't really fit for a long ambulance journey but we had to send her 13 miles to St Martin's [Bath]. She took their last bed, so their next patient would have to go to the Royal United [also in Bath], where one of their acute medical beds would have to be used for the next elderly patient."
Patient flow has been "buggered up" by lack of social services funding for nursing and residential homes, says Whyatt, who stresses that he sympathises with social workers' dilemma. Wiltshire social services, he asserts, has a policy of only paying for one new client when two clients come off its books.
According to Keat's estimate, 36 out of 89 beds in Chippenham were blocked earlier this month. The position fluctuates, but she and Whyatt fear what will happen as winter takes its toll.
A graver picture of the whole county - 119 bed-blockers in early November - comes from Dick Barton, who chairs Wiltshire Registered Care Homes. And his figure, he maintains, does not include those waiting for medical assessments.
What is alarming in Wiltshire is that, for all the planning and cooperation between health and social services, and for all the government's extra NHS funds, the next four months are going to be tricky. Just how tricky is open to interpretation.
Jeremy Hallett, chief executive of Wiltshire health authority, says there are problems, but, thanks to extra funding and several new initiatives, "this winter we'll be in a better position than in previous winters".
But Phil Day, a general manager of Wiltshire health care trust, insists: "The situation is worse than it was at last winter's peak, and unless social services can find the funding, it will get worse."
There are different takes on what causes it too. The first reason Hallett mentions for bed-blocking is that patients, or their relatives, do not accept the first offer of a residential place if it is too far away. Funding shortages he ranks second.
And Ray Jones, Wiltshire's director of social services, says the waiting time for such a place is "up to about three months". If any elderly person has had to wait in hospital since the beginning of the year, he maintains, it is not because of financial limitations: social workers cleared the backlog at the start of the financial year in April.
Many of the complexities of the circumstances in Chippenham have necessarily been condensed. It is not quite accurate to describe the social service policy as "two out, one in", as Whyatt does. Jones prefers this description: when any money is freed up, 50% goes to offset the department's deficit, and 50% is available for spending.
What is undisputed is that all professionals are advancing the best case - as they see it - to ameliorate the difficulties. Chippenham, with its hospital serving a town of 32,000 and a rural catchment of 70,000, is a microcosm of the much vaunted, albeit patchy, moves to integrate systems of social and health care.
The theory is fine: step up domiciliary support, and more of the elderly will not need long stays in hospital, or in care homes. A rapid response rehabilitation team covering Chippenham and two small market towns nearby, was set up two years ago and is being expanded this winter. Extra support staff are being trained to work in physiotherapy and occupational therapy, under the supervision of qualified professionals. Where there is a need for night sitters, to relieve carers, volunteers trained by Help the Aged will be brought in.
All of this is on the horizon. For some, however, it will come too late. Every day, Fred Barrett, a 74-year-old former farm worker, visits his wife, Violet, 85, in the Chippenham hospital.
"She can't walk about; she can't do nothing," says a stoical Barrett, as he waits by the phone for news that a place has been found for his wife in a local nursing home. He's been waiting now for six months.
Electoral risk of catching a cold
Unprecedented steps are being taken to try to stave off an NHS winter crisis. The danger for the government is that trouble in the hospitals could jeopardise victory in a spring general election.
The Department of Health says it is spending an extra £630m in anticipation of winter pressures, including £150m on critical care. An extra 343 critical care beds should be open in England. In addition, £63m is being invested in "step down" or "intermediate" care for patients ready to leave hospital but unable yet to cope at home. Some £12m of this has gone on additional staff.
For the first time, flu immunisation has been available free to all people over age 65. Local winter planning groups have been set up across the country and their plans have been vetted by the department. Central monitoring arrangements are in place, with advice teams of health and social care professionals ready to swoop on trouble spots.
David Brindle
