As the sun comes up on Monday 19 July, the day England’s Covid-19 restrictions ended, my crewmate and I find ourselves assessing a patient with a new cough to see if he needs to be taken to hospital for further care. We check his observations, listen to his chest, assess the effect that walking has on his breathing and consider the safety net of family care he has around him. After three weekend night shifts, it has become clear to me that calls to Covid patients, both confirmed and suspected, are firmly back in the emergency ambulance repertoire. The break was nice while it lasted. I’ve struggled to get excited about “freedom day”. With infections rocketing, and hospital admissions and death rates rising steadily, I’ve found myself feeling trepidation, fatigue and disbelief that we are here once again. In healthcare, that phrase “getting back to normal” has become a double-edged sword. The pressures of the last 18 months, supposedly unprecedented, have become the new normal. Ambulance services are already besieged with the fallout of the last year and a half. As well as the fluctuating impacts of Covid itself, we’ve dealt with the increase in mental health problems during lockdown, the destructive effects of various addictions, the new phenomenon of long Covid and even domestic tensions boiling over (I’ve often found myself performing impromptu family mediation sessions, reminding myself to take my own advice when I get home). We’ve also felt the effects of a restive population emerging from lockdown with a bang. Children have been exchanging various infections as if they are catching up on lost time, while adults have been celebrating their freedoms a little too hard and in the heat of the summer, drinking, assaults and accidents have sadly increased. Then there’s the issue of primary care. One consequence of the pandemic that has received little coverage is the difficulty patients have experienced in accessing their GPs. This is something I hear from patients every day, as ambulance crews find themselves dealing with higher rates of low-acuity calls. Responding to the NHS long-term plan’s commitment to accessible, decentralised healthcare, this is a development the ambulance services have in fact embraced: you only need to visit the websites of England’s 11 regional ambulance services to see how they’ve rebranded themselves as providers of urgent and emergency care. But there is an inevitable impact on the response to the most serious emergencies. That planheralded the development of video consultation, and the pandemic has both encouraged the use and demonstrated the value of such innovations. Likewise, telephone clinical assessment is now well established in call centres, GP surgeries and ambulance control rooms. However, the complications of remote assessment and a triage system that is necessarily cautious mean that many patients, even after a series of phone conversations, are deemed to require a face-to-face consultation – inevitably, a visit from an ambulance crew. It’s generally assumed that people with Covid-19 become an issue for the NHS only when they require hospital admission, and it’s true that many can be left at home to care for themselves. However, many of these patients still need to be assessed in person, meaning ambulance crews often visit multiple Covid households each shift. Hospital avoidance may count as a win for the health service but it’s draining, time-consuming work for us out on the road. What concerns me most about the current situation is the number of vulnerable patients I meet who are still unvaccinated. Each individual is entitled to make their own choice but over recent weeks, it’s been instructive and concerning to hear people’s reasons for declining the vaccine – and the sources of the advice they’re following in opposition to the published research. Their apprehension suggests such patients aren’t declining because of a lack of concern about Covid; rather, they distrust the vaccines. Government data shows regional variations in vaccination figures and disparity of more than 30% in uptake between different ethnic groups. Clearly further work needs to be undertaken to determine why some of the most at-risk patients have been least inclined to protect themselves from the worst effects of the virus. I suspect that for some patients, the decision to decline the vaccine felt academic when it was made, because transmission was low and social contact was limited. But in the coming weeks, as the country opens up and the virus moves about unfettered, the consequences of that decision are going to become very real. It’s inevitable that my colleagues and I will be seeing more critically unwell patients, and this will have effects on healthcare provision beyond Covid-19. This is the point I’ve tried to convey in my conversations with patients over the last few weeks. People retain the right to choose, but the context of that choice is about to change – and it’s OK to reconsider. Jake Jones is a paramedic and the author of Can You Hear Me? An NHS Paramedic’s Encounters with Life and Death.