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How big is the crisis facing the NHS? To many, this is the same debate we’ve been having for a long time. Critics can point to years, if not decades, of headlines suggesting that the NHS has “weeks to survive.” But it feels as though many things have come to a head—some due to politics, some due to the NHS itself and its leadership, and some the inevitable consequence of a pandemic, perhaps obfuscating what was always coming.

Take emergency care and growing queues: those concerned knew that these would become an issue, since social care wasn’t being supported. Unless we tackle the problems in social care, queues for emergency care will keep growing. Yet, as a system, we’ve chosen to focus on internal processes, pathways, and initiatives such as early discharge. The people involved knew that these were small wins, although not many said it publicly.

Major changes are needed, not marginal gains (or “low hanging fruit,” as the NHS calls them). They’re always there, always attractive, and always good for a CV or an award submission. But they’re not much use at a population level. Take “quicker discharge summaries” in the morning: a noble intention that does help, but one with inordinate focus on it. When you look at a process mapping you try to tackle the biggest challenge. In this case we didn’t.

The growth of waiting lists for treatment isn’t new, and part of the build-up predates the pandemic. But there’s no doubt that the pandemic pushed this growth into overdrive. Cut the data any way you want, but without consultants doing the procedures the waiting lists won’t get shorter—and the pension issue is the crux of the problem. The difference between the pension issue and problems with the emergency pathway is that the government has nailed its flag to sorting out doctors’ pensions, and elections aren’t that far away, so we can expect some major shifts in this area shortly.

Which brings me to workforce. Yes, years of below inflation pay rises or pay freezes haven’t helped. But let’s also factor in how we as a system treat our staff. Firstly: GPs. Sections of the media, aided by some politicians, have decided as a policy move to label GPs as work shy, lazy, a cause of troubles in life. And, as a system, we failed to push back enough. We decided that not standing by the single most important part of the workforce was a good move. Many colleagues have simply had enough, leaving the whole of the GP workforce in flux.

Secondly: new entrants to the NHS, whether they’re medical students or those starting at any other stage. Our approach is stuck in the past, with a faint whiff of “Aren’t you so lucky to work in the NHS?”—a strategy that relies on guilt tripping, gaslighting, and infantilising. Factor in a modern generation who don’t tolerate such nonsense, along with other opportunities in life, and we have a workforce crisis. Throw in public discussions around racism in the workforce and the rhetoric of a country not liking immigrants (yet still reaching out to other countries to fill the healthcare gap), and it’s a mass of conflicts, pain, and rota gaps. A faltering approach to workforce over the past decade has only compounded this.

Finally: deprivation. It’s not uncommon to hear this equated with ethnicity and given the tag of “wokery,” sidestepping the fact that deprivation is far wider than a person’s ethnicity. Yet it’s linked to poorer health outcomes, and there’s a huge focus in the NHS to close these gaps. The NHS is now being asked to step into areas such as poverty, fuel bills, and living costs—none of which it was built to do. The result? An overstretched system now stretching itself further. No amount of zeal to do “the right thing” will help with the mortgage or keep the lights on.

So, here we are: social care crumbling, finance issues for consultants, a lack of workforce strategy, and a society where inequality is still widening. Can the NHS escape the impact? I don’t think so. Yet with the right determination and focus some things can be turned around, even if we’re probably looking at a decade of recovery. If we don’t, with the resources we have we’ll be forced to prioritise emergency, maternity, and cancer care, with all else taking a back seat. It doesn’t add up any other way.

It’s vital that health service leaders start talking openly about the NHS’s problems, rather than choosing to stay quiet or talking behind closed doors because it’s “politically unpalatable” or there’s “a bigger picture.” Without this, there may be no canvas left to paint a picture on.