The prospect of waiting at least six weeks for a biopsy was too much for Neil Perkin. In February, the 56-year-old was told that he had suspected prostate cancer which needed to be confirmed by examining a sample of his tissue. “After the initial appointment with the consultant, there were no letters, texts or anything,” Perkin said. Instead, he decided to pay for it himself: £5,000 – a substantial sum for the part-time ferry operator. The results from a private hospital in Guildford confirmed the cancer. “I’d lost faith in the NHS by this point and I went private,” he said. “The cancer was spreading and my surgeon made it clear that if I’d waited for the NHS for my prognosis, [the] chances of cancer recurrence would be far worse.” In May he paid another £22,500 for the prostate to be removed at a private hospital in London, with financial help from his family. “I feel let down. It turned out from the pathology that this was urgent and a delay would have made a huge difference to my outcome, my prognosis and quality of life. They got there in the nick of time.” Portsmouth Hospitals University Trust said it was sorry to have been unable to meet Perkin’s expectations and strived to provide quality and timely care. “But we recognise that across the NHS there is an increased demand on services and this can impact patient waiting times.” With demand rising faster than the health services’ ability to meet it, the cracks in the system have been widening. Last week junior doctors announced they would stage a four-day strike in August, adding to the huge numbers of cancelled operations after months of industrial action that began with nurses last November and saw radiographers and consultants strike last week. So far, 819,000 operations, procedures and appointments in England have been postponed, adding to the 7.5 million people waiting to start routine hospital treatment. Each union has said low pay is leeching health workers away from the NHS, often to work in Australia or Canada or the private sector, leaving those remaining to deal with what the British Medical Association called “catastrophic” levels of pressure. It is a grim situation on the 75th anniversary of the foundation of the NHS, according to Pat Cullen, the Royal College of Nursing’s general secretary and chief executive. “We cannot take for granted that the NHS will be here in another 75 years – we need to fight for it. And it isn’t just the long-term future. With winter coming I’m deeply worried about how our health service can withstand the next few months.” Even NHS staff who are not involved in the strikes are frustrated at not being able to deliver the kind of care they want to. “Our emergency care system is making people sick, rather than helping them get better,” said Dr Adrian Boyle, president of the Royal College of Emergency Medicine. He sees the effects of the long waits first-hand, working in the emergency department of a major teaching hospital. “The effects of these long waits are mostly felt by the older patients. In 2022, the average length of stay for somebody over 80 was over 15 hours in an emergency department. The problems will not be felt evenly. They will be worst for the people least able to deal with them. “If you take an old person and keep them in the emergency department for a long time, they’ll fall over, they’ll get delirious, they’ll get more confused. It’s not dignified, and it’s very, very frustrating and actually heartbreaking to see.” The revolt by NHS staff heralds an autumn of discontent and a winter of pain for the government, with Rishi Sunak’s five pledges not yet delivered, including a promise to cut NHS waiting lists. If the prime minister hopes that he can blame unions if the target is missed, that may not wash with the public. Although the strikes are controversial within the medical professions and uncomfortable for those on the picket lines, even patients with acute conditions who need urgent treatment do not blame the strikers for the delays. “The consultants, the nurses, everyone else on the ground – they’re absolutely trying their best – it’s not about the strikes, it’s about the huge pressure on the health services,” said Chris (who only wanted her first name used). She cares for her 28-year-old daughter in Buckinghamshire who has intestinal failure which means she can only be fed with a Hickman line – a tube going directly into her intestines. “We’re waiting for a new Hickman line because hers broke back in mid-June. Immediately the doctors in A&E said this was a massive infection risk and it needs to be changed ASAP.” Yet even with the risk of sepsis, the earliest date for an operation was mid-August because of a lack of general anaesthetic slots. Two months of waiting and watching for any signs of illness are taking their toll. “It’s just a huge constant worry on top of all the other concerns,” Chris said. “We know we might have to drop everything. It’s having an impact on her life span.” Going private is not an option for patients with complex needs, but data from the Private Healthcare Information Network (PHIN) shows that more and more people are spending their savings on medical treatment for hip and knee replacements, hernias and cataracts – in 2022, 820,000 people were treated as in-patients in the UK, 8% higher than in 2019, but still dwarfed by the NHS backlog. Not every patient has a good experience – a woman suffering with a rare form of bowel cancer, who had private surgery during the lockdowns, said that after she suffered a recognised complication, her private provider was not interested in following up. “Would I pay for private cancer care again? No,” she said. “But in those desperate initial days and weeks I would have sold my soul to the devil for treatment.” How did we end up in a situation where patients are so desperate and scared that they will spend their life savings on treatment, or travel overseas to find care more quickly? A decade of underfunding followed by the pandemic has left the NHS and social care “in a really, really challenging position”, according to Sir Julian Hartley, chief executive of NHS Providers, with not enough investment to meet the growth in demand from an ageing population. Last year Health Foundation research showed the UK spent about a fifth less on healthcare than the 14 richest European nations. “I’ve been a chief executive in the NHS for 20 years, and I can’t remember a time where the challenges of the operational, financial and performance pressures have been more intense,” he said. After the pandemic, NHS workers had to cope with a “very, very difficult winter”, the backlog and the cost of living crisis. “We need to find a resolution to the industrial action because that is a real problem right now for the morale and team spirit that you rely on in any hospital,” he said. “That sense of teamwork is fundamental to all NHS organisations and that is fraying because of the challenges of industrial action. “Staff are getting frustrated because all their time and effort is taken up with dealing with the impact of the strikes, like rebooking patients and finding cover. That takes a toll so they’re not able to focus on other priorities.” Matthew Taylor, chief executive of the NHS Confederation, said trust leaders believe they could have met government targets so that nobody waited more than 18 months for treatment but the strikes had “put a spoke in both wheels”, he said. “We need a recovery plan, with some pretty intensive investment, because without that investment and support in the short term, it’s going to be very, very hard to hit the targets we’ve got.” Richard Murray, chief executive of the King’s Fund, said: “If the strikes end, we’ll hopefully get back on track. But remember, [the strikes] are of fairly limited scale. GPs are not on strike but people still struggle to see one. There’s no golden bullet here. God forbid we reach winter with industrial action still in play. “And we need to take the long-term decisions that mean we’re not stuck in this Groundhog Day of waiting for every winter to come along.” Although Sunak’s pledge to cut waiting lists may be weighing heavily on him, ministers and NHS leaders have made some progress. In June, the NHS published the first Long Term Workforce Plan, aimed at filling more than 100,000 vacancies for doctors, nurses and other healthworkers – a plan that has been broadly welcomed by health leaders. Steve Barclay, the health secretary, has trumpeted a £14.1bn investment in health over the next two years. He wants to improve the digital NHS, and use AI to help diagnose illnesses more quickly, and has dropped some targets to help NHS trusts. There are new, integrated care boards who are supposed to be able to link acute hospital care with social care more easily. And last week Helen Whateley, the care minister, announced £600m over the next two years to pay for more carers, while NHS England has announced it is funding 800 new ambulances and 5,000 hospital beds. The NHS England board met last week to discuss further plans for winter, including incentives for trusts that overachieve. Yet the Royal College of Emergency Medicine believes this will not be enough. “We’re really worried about the iceberg that is coming up ahead of us of this next winter,” Boyle said. “We know that what went on between November and January last year was completely unacceptable. And we’re not confident that there are there are sufficient mitigations to avoid us having a similar problem this winter.” Taylor said there was no real vision for “the bigger structural changes in the medium term to have a health service that is resilient. To do that, we need a health policy, not just an NHS policy. The NHS only determines about 15-20% of our health outcomes, so we need a joined-up approach across government.” That includes a national obesity strategy with “better regulation of food” and encouraging people to keep fit, he said. “We should be saying smoking will no longer be legal by 2035, as they’re doing in New Zealand, and raise the age at which you’re allowed to smoke each year.” Shifting resources to primary prevention and social care were vital, he said, and there would be a “diagnostic revolution” that would mean that in three to five years people could have a blood test to identify most major diseases. “We need to level with the public,” added Taylor. “They need to have agency over their own health so that they have their vaccinations, they take those diagnostic tests and they follow them up.” Views from the front lines The radiographer Jennifer Thompson, trainee consultant therapeutic radiographer for breast cancer at a Midlands hospital and a member of the Society of Radiographers We can’t carry on like this. It’s not just breast cancer either, it’s like this for prostate cancer as well. This is the first time we’ve properly [gone on strike] in forever. This time it’s about more than just pay; it’s the fact that there’s less people coming into the profession. Over the years, we’ve had less oncologists coming in to handle more complex cases. When I did my training, it was covered by a bursary, but that’s not the case any more, and you can clearly see it year after year with less people coming in. You have people who are short-staffed, getting burnt out, and then leaving. We’ve had to close one of our machines because we don’t have staff to operate it. We know more people are going to get cancer, and we don’t have the staff to treat them. Who is going to treat them in the future? [The government] has got to come to the table and listen to us. We’re the ones dealing with this day in day out, we just want to be listened to. It feels like we’ve been treated with contempt. The consultant Prof Bhairavi Sapre, consultant psychiatrist in north-west England and a member of the BMA I specialise as a perinatal psychiatrist, working with mothers and babies. We’ve seen growing demand for services since I was a trainee. Post-pandemic it feels like a relentless battle to manage numbers of referrals with a resource that isn’t expanding at the same rate. I started as a consultant in inpatients in 2011. If someone needed a bed for psychiatric emergency, we managed to get them a bed, probably mostly local to their home. Now, it’s not uncommon for us to be managing patients, multiple patients, in A&E for days at a time. We’re meant to have seven consultants, but we only have five. We’ve put the job advert out over and over again, but there’s not even a single applicant, and that’s been going on for two years. I felt physically quite nauseous at going on strike. I never thought in my career I’d ever go on strike. Even saying it out loud, I can’t believe what’s happening. Genuinely, it’s not about people like myself, we’ll be OK. I want to make sure these posts that are unfilled can be filled in the future, because if we don’t there won’t be an NHS. The dissenter Dr David Randall, a kidney specialist in London, speaking on BBC Radio 4’s Today programme on 20 July I decided not to strike, because ultimately I don’t feel patients should suffer as a result of a dispute between doctors and the government. I walked around my dialysis unit seeing my patients last week, and I was struck by just how many are waiting for things – clinic appointments, operations, investigations – and that’s having a real impact [on their lives]. I didn’t feel in good conscience that I could join a strike that would contribute to that. But I recognise the good intentions of all of those who are striking. I don’t think [I have come under pressure from colleagues to strike]. I think there’s mutual respect. I feel concerned about where we’re going to end up in this dispute. We’ve had seven days of industrial action this month, including the consultants and the juniors. There’s a further seven days scheduled in August. If that becomes the pattern, seven days a month, that’s a quarter of clinical time lost. I don’t see how that’s compatible with providing good or even safe care. So I think it’s absolutely imperative that the BMA and the government come together. I would challenge the government to produce an offer that doctors can accept. And I would challenge the BMA to accept an offer that the government can afford to give. The junior doctor Dr Arjan Singh, a junior doctor at an acute hospital in London, and chair of the BMA’s North Thames junior doctors’ committee Our department, and all departments in my hospital, are short-staffed: we don’t have enough doctors. The reason is very obvious: doctors are leaving to go to other countries because of the pay. And because we don’t have enough doctors, we’re having to do the job of two doctors. So you’re seeing more patients. You have to see them quicker, faster and you have to make decisions quicker and faster as well. And this leads to people getting burnt out, it leads to people making mistakes. Mistakes in hospitals are not like mistakes you make anywhere else. People die when mistakes are made in hospitals. And my hospital is no different to any other hospital. We need to retain more staff. They need to feel valued, and pay is a metric of value. It is not sustainable, or sensible, to continually cut the wages of doctors and expect them to stay. As doctors we don’t operate in a national market – we are operating in a global one. None of us want to go on strike. All we want is a credible offer. But we wrote to the government last August and they didn’t respond. They didn’t respond in October, or January, or March. So we have no choice. The GP A 69-year-old retired GP from the West Midlands who wants to remain anonymous I fell and sustained a complicated fracture to my wrist. I was put in a temporary front slab of plaster in A&E and told I would require pin and plate within two weeks maximum otherwise bone regrowth would be in a distorted position. It was a complicated fracture, and according to Nice guidelines, it should have been surgically corrected and fixed within 72 hours, but that doesn’t happen now. In fact I was on day 18 when it was fixed. My surgery was postponed twice due to more urgent cases filling the operating list, and I’ve been in a lot of pain. The staff were absolutely wonderful and I appreciate there’s pressure – they cancelled elective cases to get the acute cases done. The problem is that some acute cases are more urgent than others – mine was less urgent. For some fractures, if they’re not surgically corrected within 24 to 48 hours, you’re going to have somebody, probably an elderly person, who is never going to get out of that bed. The care I’ve had has been wonderful and I don’t blame anybody for what’s happened. This is just an example of the pressures that acute fracture services are under.