Is our NHS on its last legs?
As an advanced nurse practitioner, working on the front line in primary care, I am witnessing an unprecedented increase in the pressures faced by NHS services. Patients are struggling to get appointments, and oftentimes, when they are finally in a consultation with me, they have a list a mile long, of all the ailments they have not been able to report for the last hundred years. I have other patients who are being appointed to request treatment for conditions that can only be managed by specialists, under secondary care but they are unable to get a review for the next decade.
I have worked in the NHS for 24 years, spending the first two in Endoscopy, and the rest of the time in one role or another, in primary care. There have always been struggles with the NHS as a service, and this is old news for most of us. There have always been financial pressures, staffing problems, winter pressures and waiting times. But recently, I have been hearing some horror stories, and indeed, reading the discharge letters that confirm the realities of the care provision in local hospitals.
A patient I saw yesterday explained that her mother has been in the hospital for the last two weeks, on a bed in the corridor! I might not have believed this, had I not heard the identical story from a close friend whose elderly aunty was being moved from corridor to corridor! At one time, she was positioned just near to the A&E exit, where each time the doors opened, she received the full throttle of the winter air. This is unimaginable. Ambulances are backed up in double figures, outside, stabilizing patients in the vehicles, because there is no room in the A&E departments.
One patient, a nurse herself, explained that her mother, who is the victim of a stroke, and cannot move her left side, was being left in bed, sometimes on a bed pan, with her meals, left in front of her. The lack of basic nursing care is having to be replaced by around the clock nursing from relatives.
This is a terrifying situation. As a nurse, I can list a plethora of red flags just from the example above. If the patient has been left on a bed pan, not only has her dignity been stripped away, but she is very likely going to sustain a pressure sore, and if her food is left to go cold, because she cannot reach it or feed herself, the pressure sore she develops will have no choice of healing if malnutrition is added to the problem. If she is not being supported to hold a fork or utensil you can bet she isn’t being supported to hold a drink. This increases her risk further of poor skin integrity, due to dehydration, and this is before we consider dehydration and risk of urinary infection or acute kidney injury.
In 2025 you can almost guarantee you will become more unwell in the hospital than you would at home. But sometimes as professionals, we have no choice but to make that dreaded decision to send our patients to A&E, or ring 999, or admit them to a ward. However, there is more chance of the Prime Minister replacing that poor lady’s bed pan than getting a patient directly onto a ward now.
The other day I had to direct two of my patients to A&E and it was with a heavy heart that I made both decisions. However, clinically I had no choice. The first patient requires an incision and drainage of an infected boil, and this simply cannot be done in primary care, and the other hadn’t passed urine for 18 hours! That might be how long his wait will be once he gets to the department.
The pressures in secondary care are having a direct impact on the decision making within primary care where I work. I initiated treatment with antibiotics for the first patient with the infected boil because I anticipated that she may not be seen and treated for goodness knows how many more hours. So, I justified the prescribing decision with this in mind. At least she would be able to start her treatment while waiting. She might have completed the 7-day course before they call her name.
There are patients who are being discharged from hospital who appear on my on-call list, requesting home visits because they are as ill if not worse than when they are admitted. The process of getting admitted, when the patient is elderly can involve cancellation of care packages. This is a carefully designed arrangement of carers, appointed to visit the patient on an agreed rota, to provide day-to-day or time-based care. When a patient is admitted into secondary care, these are either cancelled or suspended. When the patient is discharged, these need to be revised as part of safe discharge to ensure that the patient’s needs will be met once they return home.
Imagine an oscillating door. Then picture a patient. That is the experience of many of my patients and the speed of admission, discharge and readmission. Because the hospitals are under huge pressure for beds, patients are often discharged before a safe package of care has been implemented. Furthermore, the patient is often not fully recovered. This is around the time I can expect a call, with a concerned relative requesting a home visit for concerns about ongoing symptoms. I then learn that this has been exacerbated by absence of support to meet the patients’ basic needs.
I want to stress that the front-line staff in secondary care deserve medals. Instead of giving knighthoods to those who are famous for being able to put a flying circle into a net, they would be more deserving for staff working on wards and in the emergency departments. I would also shout out to every carer, every nurse, every volunteer and every relative, who dedicates their time to helping the frail and the unwell. Banging pans every teatime is the only appreciation they have really been given and what use is that? I’d rather replace those pans with the heads of those who sit in Parliament.
I don’t know what the future is for the NHS, but I am witnessing dangerous situations in real time. A patient last week had to attend A&E due to a crisis in their long-term condition (this required immediate medical attention only provided in a hospital setting). That patient waited 12 hours, and then a further 5 hours in a corridor with a drip (unattended). She was then offered not a bed, but a chair on the ward, because there was a waiting time for beds. The only reason she had waited the 5 hours in the corridor was because there was a waiting time for the chairs on the ward.
Soon there is going to be a waiting time for waiting time for waiting time. So many medical presentations are time sensitive, such suspected DVT, suspected stroke or suspected sepsis. While this crisis is mounting all over the UK, the government continues to put health promotion adverts up, about seeing your doctor if you’ve had blood in your stool, or if you’ve had a cough for three weeks or more. This is all true and necessary but what do the patients do if they cannot get an appointment for 2 months?
Even though I have highlighted some negative examples of patient care, I don’t want this to distract from my passion about the service I am part of. If only I could dress the reality up and deliver you a story of reduced waiting times, empty emergency departments and nurses who remembered what a toilet was. I can tell you that when I see my patients, in those golden 15 minutes, I dedicate my undivided attention to each individual. In that small window of time, I see an opportunity to witness what it is to be that person. I focus on holding space to listen to their story.
When a patient feels heard, when they feel like you are giving them space to express their worries, in their words, this is where the therapeutic relationship starts. Lets face it, we can’t give the patient the solution of faster wait time for secondary care, a shorter wait in A&E or a buy one get one free on beds. But what we can do, in primary care, in support of our colleagues in the hospitals, is to engage with the patients, to address their fears and frustrations and be present for them.
As a doctor I work with once said to me, there is not always a pill for every ill. `There are so many other ways that patients can be treated. The pharmaceutical industry is a very powerful force, when it comes to the decision making in a medical consultation, not least because of patient expectations but also from what we are taught as clinicians. The Medicines and Healthcare products Regulatory Agency are supposed to ensure that medications are rigorously tested and safe to use, and their benefit to patient care is evidence based. However, increasingly, conditions are becoming over medicalized. Menopause for example, is a natural phase in a woman’s life and there are so many natural products, supplements and lifestyle changes that can vastly improve the experience women have with symptoms.
There is emerging evidence, from studies conducted at Oxford university, revealing the benefits of honey, in comparison to antibiotics for the treatment of respiratory infections. We already know that honey has antibacterial properties, but this new information indicates there are even more benefits. However, disseminating this kind of knowledge into the minds of those whose belief has been that antibiotics are the only remedy for their ailments is an entirely different task.
This month will see a steep increase in the number of patients presenting with upper and lower respiratory tract symptoms, and I make every effort to take a thorough history and assessment for every patient. If I have no suspicion that their symptoms have a bacterial cause, it is then my job to convince them of this. Of all the challenges in my job, this is one of the greatest. I may be speaking to a 70-year-old whose core belief for decades is that every cough requires a treatment. He or she may have been given antibiotics every time they have had a chest infection, and furthermore, they may have experienced a faster recovery. You can see I am on the back foot already, trying to convince them they don’t need a prescription.
But, this is central to my role as an independent prescriber. Education and health promotion are essential to my role. But take yourselves a couple of paragraphs back, where I highlight the importance of that therapeutic connection. If, at the start of my consultation, I have given the patient the attention and respect they deserve, and I have shown empathy and respect, they are more likely to mirror that respect back. Not always of course, but more times than not, I manage to avoid the use of antibiotics.
Now I can’t claim that I will revolutionize the NHS with my small contribution. But if we start somewhere, then we are starting. If I can start to empower patients, to show them and educate them, what if I can reduce one admission that day? If I can hold space for one person’s experience, what if they decide to take the prescribed course of treatment that they were otherwise going to avoid? It works both ways. Sometimes patients decline to take medication, because of side effects, or lack of knowledge. This could lead to deterioration and admission, unless I exercise my skills of health promotion and education.
Sadly, the NHS is currently operating in a very reactive fashion, fighting fires, with no time to be proactive. Preventative medicine is the ideal scenario, and the Government are merely paying lip service to this now. But I am hopeful, and I must be. Otherwise, what would be the point? I wouldn’t enjoy my job, and I do. I love it. I want to move away from an emergency department full of patients who are only there because there were no GP appointments. I want to facilitate a service in primary care where the patients are seen on time, when they need it and with the right person.
I also want to be part of a service that empowers and teaches patients so that they rely less on medication, operations, and reactive care. We are living longer and in years to come there will be a large percentage of patients with complex needs. If we can challenge current beliefs, educate our patients, facilitate ownership of health to the individual, we make space for those patients who really do need our support.
