Special investigation: Shropshire Star exposes the NHS crisis through the eyes of those who work in the health service

The country's cherished National Health Service has gone straight from an unprecedented pandemic, into the most pressurised healthcare environment since its creation in 1948.

Today we highlight the crisis through the eyes of those that are living it every day – from GPs to 999 call handlers, paramedics, nurses and consultants right the way through to those working in social care.

All aspects of healthcare have been under immense strain, as staff struggle to cope with demand on the back of Covid burnout, while patients face delays and difficulties in accessing the care they need.

From GPs, who are seeing more patients than ever – with fewer doctors, ambulance crews battling to get to patients in time, hard-pressed hospital nurses and doctors, and care workers struggling to make ends meet, the system is facing crisis, with many staff describing workers at "breaking point".

It all comes on the back of huge rises in the cost of living, with the price of food, energy and the access to a warm home only making the problems worse.

The system is backed up from one end to the other – with community care packages and care home placements key to freeing up vital space on hospital wards – and in turn A&E units, then ambulance crews.

Figures released last week show that across the country more than 14,000 hospital beds across the country were taken up by patients who no longer needed to be there.

That is the second highest figure ever recorded and 12 per cent higher than the same period last year, when it was 12,498.

At Shrewsbury & Telford Hospital NHS Trust at one stage this month 150 of its 700 inpatient beds were taken by patients who were fit to be discharged – but they lack care packages to go home, or a care home place.

The lack of bed space has a knock-on impact on elective surgery, with beds needed for patients undergoing surgery, and on Accident and Emergency departments which cannot move people into other areas of the hospital for treatment.

The situation results in people being treated in other areas of the hospital – on corridors or newly created ward space, or having to wait in the A&E department itself.

In December only 44.7 per cent of A&E patients in Shropshire were admitted, transferred or discharged within the Government target of four hours. In fact 962 patients at the hospitals waited more than 12 hours in the same month.

In turn fresh patients from ambulance crews can then not be admitted, leading to lengthy waits in hospital car parks, with some paramedics spending entire shifts at a hospital and not answering a single emergency call.

In the West Midlands some patients have waited for more than 30 hours in ambulances outside A&E departments.

All this means fewer crews are available to respond to fresh emergencies, leaving patients waiting for longer than they ever have for help to arrive.

West Midlands Ambulance Service saw its crews losing 2,000 hours a day waiting to hand over patients in December, while the situation has had a stark impact on its response times.

Response times for Category Two calls – strokes, heart attacks, and other serious illnesses, were an hour and 30 minutes in December – five times longer than the government target of 18 minutes.

The level of decline is laid bare when compared to the December 2021 response time – 14 minutes and 46 seconds.

While the statistics make for sobering reading, the individual experience of patients, relatives, doctors, is harder than it has ever been.

The Shropshire Star has spoken to a number of those throughout the health system to get their take on the reality of the NHS in 2023 – some who wish to remain anonymous, and others who don't – all are unanimous that it is a system in crisis, and in need of help before it is too late.

A GP's view

A GP has told of “overwhelming” levels of work with the feeling that the service has been abandoned by the Government.

Dr Jess Harvey, a GP at Much Wenlock and Cressage Medical Practice, said doctors are facing unsustainable levels of demand, as they try to keep up with requests for appointments.

She has called for the NHS to be removed from politics and run by a cross-party select committee with real experience of the system, in a bid to ensure it meets the demands of the population.

She said: “It’s overwhelming. Not just the volume but the complexity, and I think that is just a reflection not just of the ageing population but increasing medical science, which means there is more we can do for people. It feels a bit like we are fighting against the tide, and it is a tide of demand and negative publicity and uncertainty with the future and that makes it quite difficult.

“You hear everything that is said and the news and no-one is offering any help, and it feels like we are being left out to dry. It is just quite hard mentally at the moment.”

Dr Harvey said that there was frustration as general practice looks to politicians for help and a plan to improve the situation.

She said: “I think there is a lack of leadership at the top. Where is the Health Minister in saying ‘here is something to help you?' Then it is difficult because you hear the leader of the opposition slating you and you just think 'who is here to help us?' You think 'where is the health minister when it is all falling apart?'”

She said without investment to increase the number of GPs there needs to be a recognition that the service is currently over-capacity.

“General practice has got to the point where we are seeing too many people and it is not safe. No one wants to find themselves in that position. I am sure patients don't want that either, but what patients struggle with is us saying ‘you can’t have an appointment today’.

"There is a struggle between the expectations of patients and what is achievable and that is what needs to be addressed.”

Dr Harvey said the only way to ensure the NHS is truly run for the benefit of the population is to remove it from political interference.

She said: “I think it should be de-politicised and run by a select committee, and decisions should be taken by clinicians, not managers.

“I have nothing against managers but I have problems with politicians and civil servants imposing proposals from on high that make no sense. The NHS should not be used as a political football, it should be for the best of the population and if politicians wanted the best for everyone they would stop using it for their own gain and use it for the benefit of the population, and the only way to do that is join together on a select committee that has pooled experience.”

An ambulance call handler's view

An ambulance call-handler has spoken of heart-breaking pressures they face as the service is overwhelmed with demand.

The past 18-months have seen a continuing increase in the number difficulties facing West Midlands Ambulance Service – with increased numbers of calls, and ambulances unable to respond due to crews being frequently tied up waiting at hospitals.

In December the service was losing 2,000 hours a day across the region as its crews waited to hand patients over to A&E departments.

The situation is so stark that response times have seen a huge rise in the past 12 months.

The wait for crews to get to urgent conditions such as heart attacks and strokes – Category 2 calls – are the longest on record, with patients waiting one hour and 31 minutes for help in December – more than five times longer than the 18-minute target.

In December 2021, the average Category 2 response in the region was well inside the target at 14 minutes and 46 seconds.

An experienced call-handler with the trust said they were simply struggling to cope with demand – with the service unable to do any more than at can.

They even questioned whether more paramedics would make a difference, or if it would mean that more end up waiting at hospitals, and also hit out at people who abuse the service, further impacting its ability to respond.

She said: "The time-wasters make it so bad, but at the moment it is not down to them, it is the massive delays at the hospitals. The ambulances are just tied up. We have seen paramedics literally spending their whole shift in the back of an ambulance, then another crew has to come and take over from them."

She added: "It is absolutely heat breaking because all you do all day is apologise.

"Five years ago it was a nice steady job, You had your bad days and your busy days, but knowing like it is now, the service is abused a lot more than it was.

"No matter how many call-takers they take on, no matter how many paramedics they take on they just cannot keep up with demand.

"People will regularly say they don't want an ambulance they just want checking over by a paramedic. There are just a lot of calls where people do not need an ambulance."

She also spoke of the mental strain on workers of having to tell patients it could be several hours before an ambulance can get to them.

She said: "The worst is when it is like Category 2 call, someone having severe chest pains, difficulty breathing, you are telling them even now it could be several hours. That is a serious problem and even now the instructions are due to the demand at the moment, your ambulance could be several hours.

"Then you just have to hope they will say I will make my own way there – but you cannot suggest that.

"Sometimes we say it could take several hours and they will ask would it be quicker to take them myself, and it's is like then 'yes, that would be much quicker'."

She added: "It is just soul destroying and I think the worst is when someone elderly is on the floor – two days they can be on a floor. It is just crazy, something needs to be introduced to sort out picking up the elderly."

A paramedic's view

Paramedics are at the very forefront of the problems faced by the NHS – spending hours waiting with patients in ambulances outside hospitals, and seeing critical response times balloon.

A Shropshire Paramedic, who has been with the service for nearly 20 years, has spoken of his 'guilt' and 'frustration' with the struggles worse than at any point during his career.

The situation has seen patients dying because ambulances have been unable to attend incidents in time – something that was previously unthinkable, but has now become a reality.

The paramedic said the job – which he still calls the best in the world – has changed hugely in the past five years, with delays now at unprecedented levels.

He has spoken of the frustration at some shifts where the only job is to drive to a hospital to relieve another crew that has been waiting with a patient to be admitted.

Some occasions entire shifts can then be spent waiting in the ambulance outside a hospital.

He revealed how at the A&E at Princess Royal Hospital in Telford, they have actually rearranged the parking bays to fit more ambulances in, as a response to the frequent queues.

He said: "20 years ago you would have had periods in any shift where there wasn't any work. Five years ago that was not the case, you would always be out doing six to eight jobs, responding in a shift. Now you can have a day when you have not gone to a patient's home or the scene of an accident, you just go to the hospital, pick up a patient and you are there all day."

He added: "It is not the hospitals' fault we are delayed. They do not have enough staff and they cannot release patients into social care beds."

The paramedic explained the frustration of knowing that patients need help – and being unable to respond.

He pointed to West Midlands Ambulance Service's (WMAS) own admission that patients have died because of the inability to get to them on time – in December WMAS lost 2,000 hours a day across the region as its crews waited with patients to be admitted to hospitals.

Average response times for Category Two calls – strokes, heart attacks, and other serious illnesses, were an hour and 30 minutes in December – five times longer than the government target of 18 minutes.

The sheer level of decline is illustrated when compared to the December 2021 response time – 14 minutes and 46 seconds.

He said: "If there is someone in the community in what is classed as a Category One response – the most serious life threatening calls such as cardiac arrests, that goes out on the radio and you will hear ridiculous times attached to the nearest crew. It is rare but occasionally there is no crew available and then you are sat there knowing there is someone in Category One, the highest acuity, and you cannot get to them.

"It comes back to that frustration that someone is suffering, and people have died because we were delayed at hospitals.

"In West Midlands Ambulance Service it is the highest risk rate and that was not lightly by the board."

Despite the lengthening response time there is a level of public understanding and appreciation, although the paramedic describes how they cannot help but feel guilt at the situation.

He said: "I like to think that all of us that work on the front line on ambulances are providing the best we can, and I get quite a few thank you letters so I do feel appreciated. If anything we are getting more thank you letters because the public know the NHS is bad and they appreciate it.

"But we are walking into patients' homes and the first words out of your mouth are 'sorry it has taken us so long' and that is something we should never be saying."

He added: "Every member of the public is really understanding but that does not change the frustration, and to an extent guilt, even though it is not me that has caused it.

"There is no doubt it is as bad as it has been at any point in my career."

A number of projects are being brought in to help – with dedicated handover areas at county hospitals to release ambulances, money invested in increasing the number of social care places, and improvements to county hospitals.

The paramedic said: "There are things happening but at this moment in time have I seen a direct benefit? No, I have not, but I do get the hunch there are green shoots around the corner. It will improve with the weather anyway. The winter pressures are always there. What it will be like next winter I honestly don't know. It depends on how those projects work."

He added: "Morale is low, and morale is low because we are not doing out jobs. When we are doing our jobs it is the best job in the world. I thoroughly recommend it to anyone, I love my job but it's just we are faced with these frustrations."

A hospital nurse's view

A nurse has warned staff are at "breaking point" as they struggle to cope with wards and corridors that are more like a "battleground" than a hospital.

The county's emergency hospitals – Princess Royal Hospital in Telford, and Royal Shrewsbury Hospital, were struggling to cope pre-pandemic, but recent months have seen a dramatic rise in the number of patients needing care.

Patients are facing long waits in A&E – 962 waited more than 12 hours to be seen during December, while at one stage this month (JANUARY) 150 of the hospitals' 700 in-patient beds were occupied by patients who were fit to be discharged – of which 45 have been in hospital for more than three weeks.

A nurse at the hospitals has revealed the level of strain on staff trying to help patients, and the "desperate" need for help to tackle the problems.

She said: "People that have worked there for the past 20 years will say it is the worst they have ever seen it, and for patients it is horrible as well – we are talking about a situation where some patients have been waiting for two or three days on a corridor for a bed.

"For nursing staff it is constantly overwhelming and staff are getting poorly as well, and lots of staff are leaving.

"It is not a fun time. There is a lot of stress, a lot of pressure and the patients just keep coming – they need to be there because they are poorly, but it is relentless."

She added: "I love my job and I love looking after people, I love the challenges it gives me but everyone is at breaking point."

The nurse told how the sheer number of patients was having a huge impact on hospitals which were already struggling to cope.

She said: "There has always been pressure on A&E and waits for beds and ambulances but now, in the last six months, they have gone up dramatically."

She added: "Every bed is taken. They are opening new areas of the hospital desperately trying to get staff to look after those beds, and you still have a queue outside and ambulances waiting outside. It is a horrific situation and it has been building for many years."

As nurses across the country take strike action she said the government needed to step in to start improving the situation.

She pointed to a difficulty in discharging medically fit patients, and a lack of nurses and doctors – with low pay seeing her colleagues feeling undervalued and leaving to seek less stressful work.

She said: "Before Christmas we had three or four wards of people fit to go home who need packages of care or nursing home places and those people upstairs stop people coming through the front door.

"It is very frustrating because the hospital is not the best place for a lot of people, while people are sitting in beds waiting to go to places to be looked after they are getting worse. They are not moving around, they are not eating as well, and the requirement is all on us to look after them, which is having a massive impact on their quality of life.

"It means they go home, get weaker, then have to come back and it is a vicious circle at the moment and it is heartbreaking."

She added: "You go into this career because you want to help people and when you see people progressively get worse because they are not where they should be and there's not a place for them, it is really upsetting.

"Social care needs a massive injection. I am not saying people there are not doing a good job, because they are doing the best job they can, but there is no investment in quality community care, and on top of that you need more doctors and more nurses."

With reference to the current industrial action she said that without steps to improve pay the profession will struggle to attract new staff, and more nurses would leave – increasing the pressure on those that remain.

She said: "We are trying to safeguard the future of nursing. There was a 40,000 deficit when I started training and on top of that you have a lot of nurses who are now coming up to retirement because they did a massive recruitment drive at the start of the 1980s – and they knew that was coming.

"A lot of people have been leaving because the pandemic really was hell for people, and if we don't increase the salary to pay what nurses are worth we are never going to recruit people into the profession."

She urged the public to support more help for the NHS, saying: "I heard a relative talking to a patient about how they had spent three days waiting on a corridor for a bed and they were amazed.

"Another relative said 'this is every hospital, it is not a poorly managed hospital' and something needs to be done. We need something done desperately because it is not going to get any better."

She added: "The situation is horrendous, it is like a battleground.

"You just feel like the system is broken. It is like 'it is going to break, it is going to break, and now it has broken'. And to walk in in recent weeks and see the number of people we have in the wards, it is really scary and it is really heartbreaking.

"Everyone has a breaking point so to literally work under the same pressure every shift, you have got a lot of staff leaving to try and work somewhere else where it is less high-pressured."

An emergency doctor's view

Dr Amy Attwater, 36, is a senior middle-grade emergency medicine doctor. Brought up in Pattingham, she has worked at various hospitals across England for nearly 12 years. Way before the pandemic, in 2015, she spoke to the Star about the pressures on the NHS under the pseudonym The Secret Doctor. Today she lifts her cover to explain how the crisis has deepened:

Eight years I pleaded for the future of the NHS as the Secret Doctor. Have things improved? No, just the opposite. Has the Government listened and tried to give the NHS a lifeline? No. The Health Secretary Steve Barclay says it is a "challenge". No it is a very real crisis.

In every hospital the situation is much, much worse now. The Government can’t use a sticking plaster to cure an NHS that is on life support. It may have contributed £500 million now to social care but why wasn’t this predicament planned for months, or even years, ago?

Looking back at my life as a junior doctor back in 2015, l told of being punched in the face by a patient who was fed up of waiting, to not finding a moment in a long shift to go to the toilet let alone having something to eat and drink, and exhausted and crying on the drive home after witnessing so many harrowing events.

In 2015 we felt overwhelmed. But now the number of patients coming into A&E has rocketed and we are seeing the highest numbers we ever have. Many emergency departments are trying to see three times the number of patients that the buildings are designed for; it’s a logistical and safety nightmare. This, combined with an increasing elderly population with many complex and challenging health conditions, means we are stretched far beyond our resources.

The current situation is untenable. Why isn’t the government doing more? Why has the number of beds been reduced by 13,000 in the last 12 years? Why are my colleagues having to deal with situations such as examining testicles in a cupboard, finding their patient has died in a store cupboard or even driving dying patients to hospital themselves?

Well, that is just the tip of the iceberg now. Just walk a day in our shoes and you will see...

When I get to work, it is chaos, like a war zone. The noise is unbelievable and there are patients everywhere they can be squeezed, in cupboards and blocking fire exits. It scares me that if there was a fire, we might not be able to get everyone out alive, as the department is like an obstacle course.

I know the media always say there is a ‘winter crisis’ but this is like nothing we have ever experienced before, even during Covid.

We knew it was going to be extremely difficult this year when patient numbers didn’t reduce in summer as they usually would. This crisis has been quite clearly developing and extremely obvious for a long time – why hasn’t it been better planned for? Why has social care not had the cash injection it clearly needs to prevent the bed blocking and subsequent difficulties in emergency care? The fact is you cannot admit more patients when you can’t free up the beds to put them in.

When l became a doctor l swore to always protect the dignity and choices of my patient. But where is the dignity when in the waiting room a patient is being examined with only sheets held around them due to lack of space?

Every patient who dies, who we might have been able to save had they been seen sooner, leaves us feeling traumatised and goes against every ethical principle we stand for. Witnessing these events goes against our individual values and moral beliefs and leaves us with distressing psychological side effects.

I feel furious for the patient who has been sexually assaulted and had to wait for hours for medical clearance until they can go to the Sexual Assault Referral Clinic (SARC) to be forensically examined. In that time vital evidence may be lost.

Another patient has been waiting on the ambulance outside for six hours. They have sepsis secondary to urinary tract infection and have extremely low blood pressure despite our medical interventions. They need special blood pressure support in intensive care but we are unable to unload the patient to the emergency department, which leaves us feeling desperate.

For the NHS to continue we need real change, not false promises. It won’t be quick, and it won’t be easy, but we need more funding in social care and better pay for carers and nurses to encourage more recruitment as there are currently around 48,000 nursing vacancies in the UK. We are running on skeleton staff all the time. If we could discharge all our medically-fit patients to social care, it would help to ease the situation hugely. Where is the long-term sustainable plan for the NHS and its staff?

People blame GPs but the fact is, they see more patients than ever before. I know many who are working 16-hour days and barely get to see their children. They are drowning, much like we hospital doctors are.

Never have so many doctors felt so dispirited, gone on sick leave or left the profession altogether. Some have even taken their own lives. It is tragic when they are driven to this because they feel they cannot provide the level of care they want for their patients. Doctors are the most likely workforce of all professions to commit suicide, estimated at about four a week.

I personally knew one brilliant and compassionate medical doctor who was so overwhelmed he took his own life, leaving behind a young family. Words cannot describe what a tragedy that is. And around 50 per cent of doctors are now thought to suffer with mental health issues caused by overwork and trauma. Imagine seeing someone die and immediately having to move onto the next patient without even a short break.

Never have so many nurses and doctors cried in their cars when they finished their shift. They are dedicated to caring for their patients and keeping them safe but know that they face an uphill battle every day.

Many of our colleagues have already left and more will go. For many of us, the NHS and its values run through our blood, and it is hard to give up… but we have a breaking point.

I hope people realise how desperate the situation is and support us for demanding a safer NHS.

We are fighting for the right standard of care that our patients need and deserve. Saving lives should be at the top of everyone’s agenda.

We need action, and we need it now.

A consultant's view

A consultant says the NHS must get investment – both in people and facilities – if it is to improve for patients and workers.

Mark Cheetham, a Shrewsbury-based consultant in general and colorectal surgery, has spoken of the current difficulties facing the NHS – and ideas on how to improve it.

Mr Cheetham, 54, who is also the National Clinical Lead for General Surgery at Getting It Right First Time (GIRFT), has outlined a number of issues to address, such as the need to invest in social care to relieve pressure on hospitals and GPs, to improve pay and conditions for NHS staff, and for people to think about maintaining their own health to reduce the demand on the health service.

The consultant, who has been a doctor for 30 years, spoke about the impact of the last decade – and how it has manifested in his own area of medicine.

He said: "I remember when I first started as a consultant it was pretty hard work and we spent a lot of time improving cancer care and getting elective targets down, and by about eight to ten years ago we had kind of cracked it.

"My waiting list, I had about 12 to 14 people on it and they all had a date – if you saw me in clinic I would operate on them within about six weeks of seeing them. Currently I have got 50 people and the longer waits are over a year."

Mr Cheetham said the issue of community care places was causing a huge strain for hospitals – both in caring for people who don't need to be there, and the delays it causes to bringing in fresh patients.

He has spoken of the need to improve pay for care community workers, to attract more staff for a vital point in the flow through the health service.

He said: "Seeing all the patients being stuck in a corridor, patients who want to be discharged because there are no community care place for them, it is really demoralising because there so much we can actually do now."

He added: "I think there is some fairly straight forward stuff we can do to improve things. If we paid people who care for people in their own homes more you would be able to recruit more and that would unlock space.

"For me, that is the main thing, that patient is disadvantaged because that patient will recover better at home with the support than they will in hospital.

"There are two people involved in this too – there is the person waiting to go home, and there is the person waiting in pain at home for a bed in hospital for a hip replacement – and it is costing more money than if we paid the carers properly."

Mr Cheetham said that investment in the NHS is key to improvement – in staff as a priority, as well as in buildings, and equipment.

Asked whether more money is needed he said: "I don't think we do fund it enough. There is a big funding gap. Yes funding has gone up in recent years but you have to take out the Covid funding, that money is different.

"We have not invested in buildings or kit. A lot of kit is broken and worn out. Even if we got a lot of money there is decade of underfunding you have got to catch up on.

"But fundamentally it is about pay and conditions. Health care is a human industry and you need humans to do the work. I think the government needs to get around the table and compromise and sort it out."

A social care professional's view

The continuing crisis currently sweeping over the NHS has had been felt in all sectors of the health and care industry.

NHS leaders across England have said that staffing gaps and a lack of capacity in social care are putting the care and safety of patients in the NHS at risk.

The pay situation has been one of the key problems, with one in five care worker estimated to be in poverty and the average hourly pay of £9.50 currently £1 less that novice healthcare assistants in the NHS, while warehouse jobs with Amazon are available at £11.45 per hour and Aldi store jobs at more than £13.

Martin Jones, is CEO for specialised home care organisation Home Instead UK & International, which provides care for people in their own home, enabling them to be released from their hospital bed.

He said that taking the issues facing the NHS and social care sectors and finding effective solutions had eluded governments and policy makers for decades and that it was time to find a proper solution.

He said: "The situation is particularly acute at the moment with pressure on the NHS being described as 'intolerable and unsustainable', by the British Medical Association.

“With this in mind, we strongly believe the Government should be taking a more holistic approach to tackling this ongoing crisis.

"They need everyone around the table on this, including for-profit providers who have the potential to play a crucial role."

Mr Jones also agreed with the sentiment expressed around having more beds available for patients at home.

He said: “Everyone recognises that beds at home, and earlier discharge into the community, works better for patients and is a more cost-effective solution.

"If you consider the spiralling costs of patients being unnecessarily stuck in hospitals, and of ambulances being forced to queue because of the growing lack of hospital bed capacity, it’s obvious that improving community care provision is crucial.

“Homecare is an under-recognised partner in the healthcare ecosystem and private providers play an important role in offering choice and being able to respond to local needs with more agility.

“On top of this, better trained care professionals can become a critical support network to the NHS to free up capacity for those who truly need it."

Another care provider from the West Midlands, who asked to remain anonymous, said money was one of the issues, as well as there not being sufficient providers to take in people for care after being discharged from hospital.

He said: "The NHS and social care are two completely different bodies and one of the problems with a crisis in the NHS is when people are bed blocking and there isn't sufficient providers out in the field to be able to accommodate people who need the help.

"The issue is really centred around the fact that local authorities aren't paying enough money for people to actually enter the market. I think they need to probably think about moving some of the resources into the social care system, as the minimum wage is rising to £10.42 and it's not sustainable for the local authority to be paying £15 to £16."

A care worker, who asked not to be named, said the conditions she and her colleagues worked under were very difficult and said she felt a change of government was key to improving the situation.

She said: "You find that you are always tired and overworked and consistently doing the same thing over and over again and you feel like you're being left alone to do everything.

"The only way I think things will change is with a new government as the current one don't seem to understand that we need more money for what we do."

Solutions

NHS Consultant Mark Cheetham, who we heard from above, has a number of suggestions to improve and revive the health service:

• Invest in social care

There are large number of patients stuck in hospital who cannot be discharged because they are awaiting a care package at home. There are also people who are just about managing at home – these people are at risk of decline in their functioning which can result in them being admitted to hospital.

Providing care in a care home or within a person’s home environment is demanding and is not adequately paid. These staff should be paid at the same rates as people doing comparable NHS jobs. Health Secretary Steve Barclay’s idea to discharge patients from hospitals into care is on the right track but without improving pay, conditions and training for carers, there is not enough workforce to enable this.

• Pay and conditions

All staff groups in health and social care have suffered over a decade of below-inflation pay increases, meaning an effective cut in take-home pay. There is a global shortage of clinical trained staff with 147, 000 vacancies in the NHS alone. Without a reasonable pay settlement there will be ongoing industrial action and further resignations.

• Fix the pension tax fiasco

Since 2008 there have been several changes to the NHS pension scheme and the arrangement around taxation of pensions. The end result is that many NHS staff end up paying more into their pensions and get a smaller pension than previously.

The bizarre arrangements around pension taxes means they are able to put much less money into their pensions than 10 years ago without incurring a hefty tax bill.

For some consultants and GPs this has meant that they have been forced to reduce their hours or retire earlier to avoid a large tax bill.

• Invest in care out of hospitals

Currently in the UK when we talk about healthcare we often mean hospitals – yet most healthcare happens in other environments. We need to recognise this and invest in pharmacies, GP practice, therapists and district nurses to provide care close to home when appropriate.

In Europe and many other Western countries significant amounts of tests and treatments are carried out in clinics which are separated from large hospitals. This means a better experience of care and much reduced risk of cancellation.

The creation of community diagnostic centres and surgical hubs will go a long way to improving this, but these will need an increase in staffing numbers in order to function.

• Planned and emergency care

The Covid-19 pandemic has demonstrated the benefit of separating planned surgery, allowing it to continue safely while reducing the risks of infection and cancellation. We need to learn from the experience and where possible provide separate facilities for planned treatments away from emergency sites either in ring-fenced areas of a hospital or an separate sites.

• Fewer and bigger hospitals

Currently there are many small hospitals in the UK that are trying to do everything. The model of District General Hospitals is out of date – it is simply not possible to deliver modern healthcare everywhere due to the need to staff all these specialities around the clock. There is also evidence that hospitals with larger caseloads have better outcomes. The experience of setting up stroke units, heart attacks centres and the trauma network in England has shown that that in many cases it is better to travel further to a fully equipped and staffed hospital which can provide cutting edge care.

• Better training

We need to focus on training staff across health and care so that they can provide the best possible service. This will including increasing the numbers of nurses and pharmacists who can prescribe, training other staff groups to do some of the tasks currently done by doctors and upskilling staff working in social care.

Currently doctors are becoming too specialised and we should move back to a model whereby doctors have a range of skills and knowledge to look after patients with several conditions without always involving multiple other specialists.

• Reduce waste

Some of the processes in healthcare are strange and hugely wasteful resulting delays for patients and increased costs. Widespread streamlining of care processes will improve access to tests and treatments while cutting costs. A good example of this would be to give GPs more direct access to tests currently only available to hospital consultants.

• Investment in IT and co-ordination

IT systems in the NHS are shamefully poor in many organisations compared to other areas of modern society. There is a legacy of failed huge projects in health care IT which have promised much and delivered very little. As a result the systems are out of date, fragmented slow and cannot communicate well between different organisations. Many processes in the NHS are done manually with pen and paper, wasting huge amounts of time for the staff, much of this can and should be automated. Although there is much hype in the press about artificial intelligence and other high tech solutions, I think most people who work in the NHS would settle for a PC that boots up quickly and integrated software based around the needs of a patient.

• Health above healthcare

The NHS has reportedly been spared much of the cuts to public service spending over the last 12 years (although the investment in the NHS has been largely below inflation). However only about 20 per cent of the health of a population is due to healthcare. The other 80 per cent of the health of the nation comes from the wider determinants of health, like education, clean air and water, warm dry homes, good public transport links, exercise and a good diet. There has been insufficient attention and investment to these wider determinants of health over the last decade and this has caused more health inequality and further pressure on the health service. We need society and government to ensure that this changes.