‘Like a horrific board game’: 33 hours inside an NHS in crisis

Crammed wards, burned-out GPs, patients waiting hours for ambulances – the health service is at breaking point

Inside the dimly lit command centre at King’s College hospital, staff arriving for the first beds meeting of the day are greeted with a warning: the hospital is already under strain. “So, we are under pressure this morning,” the head of nursing, Naomi Hosking, informs colleagues stood around her in a semi-circle. No one registers surprise. “We’ve got a lot of patients in ED [emergency department] with little space to see new patients, so we need to get some early movement.”

It’s 8.32am and ED – maximum capacity 60 – is packed, with 61 patients inside. The oldest is 98; the youngest 30 days old. Later, that pressure will intensify: the number of ED patients – in beds, on trolleys or in chairs – will more than double to 137.

The crisis is not unusual, nor unique to King’s. In every corner of the UK, demand for urgent care is rocketing, and emergency departments are swamped.

Live data fed from eight computers to four TV screens on the walls of the command centre reveals more bad news. There are no “definite discharges”. It means there isn’t a single patient in the 724-bed hospital that is definitely able to leave that day. There is no room at the inn.

About 33 months after the World Health Organization declared Covid to be a pandemic, the Guardian spent 33 hours inside the NHS, examining the state of the health service.

Covid is no longer the dominating, deadly factor it once was. But the NHS now faces an even greater challenge, with a record backlog and a relentless surge in sick people needing urgent care – on top of a myriad other factors, including a huge workforce crisis.

In the command centre, no one is less surprised by the statistics relayed in the meeting than the director of operations, Lesley Powls. “We’ve got Covid, flu, seasonal viruses, the impact of the cost of living crisis,” says the former nurse, who spent 707 days managing the trust’s Covid response.

More people are in a worse state of health than at any time in the last 33 months, Powls adds. “What we’re seeing now is a patient population that is much, much sicker than they were pre-Covid.”

The result is a drastic increase in serious health conditions, and enormous demand for care. “We’re seeing an increase in patients who are having strokes, an increase in people who are having heart attacks, an increase in people who just can’t cope with their physical illnesses any more.”

But it’s not just physical conditions. “The other big hike we’re seeing is people who are presenting with mental health as their primary reason for their presentation,” says Powls.

With mental health services being left to fail, some patients struggling to access care are only getting help when they reach crisis point. “They are coming into ED because there’s nowhere else for them to go,” says Powls.

Finding enough beds for everyone is an impossible task. “It’s like a really horrific board game,” says Powls. “And you can never quite get past one place on the board.

“We’re in an absolute kind of cycle at the moment where we just cannot release enough beds in a day to pull patients through the emergency department in a timely manner.”

Powls is blunt about her fears for the NHS. “I’m really worried,” she says. “I don’t think we’ve got the robustness to manage a winter with potentially something else laid on top of it, ie another Covid surge, or flu, or respiratory illnesses in children.”

A few miles away, the London ambulance service (LAS) emergency operations centre is also a hive of activity.

London ambulance service call coordinators at the LAS HQ in Waterloo, central London.
London ambulance service call coordinators at the LAS HQ in Waterloo, central London. Photograph: David Levene/The Guardian

Call handlers in dark-green uniforms speak to people who are anywhere between anxious and petrified about a health emergency that has befallen them, a loved one or a neighbour. All want something that no one can guarantee any more: an ambulance, and quickly.

“Emergency ambulance,” says call handler Antoinette Tucker, picking up a call. A care worker has arrived at her client’s home to find him lying on the floor. “Is the patient breathing?”

The care worker is worried because the 83-year-old she looks after has fallen next to the door, stopping her from getting in to see how he is. She can only see his leg. “Is he awake?” The care worker isn’t sure.

She gives her mobile number to Tucker, then tells the man: “Help is coming, don’t worry.”

However, it is unclear when exactly that help will arrive. “We’ll be there as soon as possible,” Tucker tells the care worker. But, she cautions, the current response time for category-two calls like this is up to one hour and 40 minutes – far more than the NHS’s 18-minute target for such calls.

Last month, the NHS had the highest number of ambulance callouts for serious illness in its history for any November on record. “Everyone wants help right away,” says Tucker. “But it’s not realistic to get it right away.”

* * *

Fears of a tripledemic

Three doctors silhouetted against a window looking at a patient in a hospital bed with equipment surrounding them.
Doctors from King’s College hospital checking patients on their rounds. Photograph: Graeme Robertson/The Guardian

When Covid first hit, hospitals and ambulances scrambled to stop patients and staff infecting each other. But amid the unfolding disaster, doing so proved almost impossible. “We were flying blind,” says Dr Carmel Curtis, the lead doctor for infection control at King’s. “Covid came along and completely blew out of the water all that we had thought about infection control.” At one point, King’s was testing 2,500 people for Covid every day.

Despite the best efforts of NHS staff, with the absence of any Covid treatments or vaccines, or knowledge of how best to care for those afflicted, the disease proved fatal for many. “A lot of patients died,” says Dr Jimstan Periselneris, a consultant respiratory physician.

Now, though, medical staff have worked out how to better manage Covid, without the need for invasive options such as ventilators and breathing tubes. Treatments have emerged, and Covid jabs protect millions from becoming seriously ill or dying.

The Covid death rate at King’s – 27.2% during the first wave – plunged to 5.5% in the third. “We’re in a completely different place now,” says Periselneris.

However, the coronavirus has not gone away. Since the height of the pandemic, deaths have plummeted, but about 400 people a week in the UK are still dying with Covid. Covid-19 infections in the UK recently jumped above 1 million again.

Farah Kirk, 62, an administration assistant from Orpington, managed to avoid Covid for 33 months and was fully vaccinated. But last month she became infected and ended up battling to stay alive.

“When they said I had to come here and go on a ventilator, I was horrified,” says Kirk. “I’ve been very fearful of it [Covid], because I’m asthmatic.

“And I knew if I got it, the consequences could be really severe for me – and they were. But, touch wood, I’ve come through it,” she says. She is recovering on a respiratory ward.

King’s is now caring for 134 Covid patients, compared with 776 during the peak of the second wave in January 2021. Most of the current patients with coronavirus are being treated for something else.

However, they must still be isolated from patients who do not have the virus, piling pressure on staff to find more space for them.

Getting the Covid vaccine “saved my life”, Kirk says. She’ll miss her dream trip to a Brussels Christmas market this month, but being alive and – hopefully – returning home to her husband and son in time for Christmas is all that matters.

Covid patients coming off ventilators can take months to return to normality, however. “I don’t think it’s a five-minute recovery,” says Kirk.

Medics are already seeing bursts of other viruses such as flu and RSV. Although most cases will be mild, a “tripledemic” of flu, RSV and Covid could sicken large numbers of Britons.

Flu is circulating more widely among the population, with hospital cases in England up nearly 50% in the last week. But Periselneris says he is more concerned about having enough staff to treat those infected. “Today, we only had four nurses on, when we should have had more,” he says. “I think that is a concern everywhere.”

Another worry, he says, is the risk of a knock-on effect on elective care if respiratory wards were to become so overstretched that more space was needed elsewhere in the hospital. “I think we’ll survive this [respiratory season], but we may … have impact on planned care,” he says.

“If we spill out on to surgical wards … it means they can’t do the operations they normally would.” That would pose a fresh headache. “We all know there’s a massive waiting list for various things at the moment.”

* * *

The waiting game

Kings College hospital
An appendicitis operation at King’s College hospital.
An appendicitis operation at King’s College hospital. Photograph: Graeme Robertson/The Guardian

Waiting lists for NHS hospital treatment are now at an all-time high in England, with 7.2 million people waiting to start hospital treatment at the end of October – the highest figure since records began in August 2007. Wait times for planned care were poor before the pandemic, but Covid accelerated the crisis.

“Waiting lists obviously absolutely skyrocketed,” says Dr Anneliese Rigby, the clinical director for theatres and anaesthetics. Unlike most hospitals, King’s kept three theatres open for operations, which meant some surgery could continue, but patients still faced longer waits for elective care.

The NHS is making inroads into the backlog. Very long waits of two years in England have nearly vanished, while the numbers waiting 18 months for treatment have dropped by about 60% in the last year, the Guardian found.


By February 2021, the number of King’s patients waiting a year for care hit 6,813. After theatre staff shifted to working six or seven days a week, that has since been cut to 693.

“Everyone is putting in 110%,” says Rigby. Two-year waits have been also been eradicated among the 1.2 million population King’s serves.

The mammoth obstacle for hospitals trying to reduce the backlog is not a lack of will, or a lack of space, but a lack of staff. NHS vacancies in England have risen to a new record high with more than 133,000 full-time equivalent (FTE) posts unfilled, according to data reviewed by the Guardian.

“We’re chronically short-staffed, like all of the NHS is,” says Rigby. In particular, she adds, there is a national shortage of operating department practitioners and anaesthetic nurses.

Inevitably, the shortage and sheer size of the backlog means longer waits for patients – and also means they are sicker when they get to the front of the queue. That can make operations riskier.

“What we’re seeing is far more complex surgery is required, so the operations take longer,” says Rigby. Longer operating times also squeezes the time left to operate on other patients.

“It’s a relentless task,” says Dr Shraddha Gulati, a consultant gastroenterologist who is part of a team that has significantly reduced the endoscopy waiting list at King’s.

Flexible working practices are key, she says, knowing that Covid will never fully disappear. “It is now 33 months after the pandemic was declared and it’s ongoing, right?”

* * *

‘Everybody needs more time’

GP Steve Mowle seen reflected in a mirror
GP Steve Mowle: ‘Eleven hours for me is a short day.’ Photograph: Graeme Robertson/The Guardian

With record waiting times for treatment in hospitals, GPs are spending more time caring for patients who are stuck in the NHS backlog. One such GP is Dr Steve Mowle, who is dedicated to doing his best for every patient at the Hetherington group practice in Brixton, south London. But like the rest of his profession, he is overworked and can’t do everything in anything like a normal working day.

“I literally don’t stop from eight o’clock in the morning until seven o’clock in the evening,” he says. “Eleven hours for me is a short day.

“The main stress in general practice is time. Everybody needs more time,” he says as he considers how the pressure on GPs has grown during his 25 years as a family doctor.

Mowle, 55, used to have a proper lunch break. These days, lunch is a ready-meal cooked in the microwave of the surgery’s kitchen – and eaten while answering emails.

Despite such a punishing schedule, he still loves his job. He now works “five-eighths” of a working week: Mondays, Wednesdays and Fridays, “but that’s still 35 to 40 hours a week”. The pressures of the job are too intense for him to work “full-time”.

Revealingly, all eight GPs at his practice work less than full-time for the same reason. Working full-time is now “impossible” for family doctors, says Mowle.

“Sadly, I think many GPs are retiring early because they cannot keep up with the pace and they’re frightened that they might miss something serious [during a consultation]. Every GP’s nightmare is that with every patient we see … the most minor cough or cold could turn into something fatal.

“GPs think, ‘It’s getting too difficult, getting too hard, I’m going to retire and quit while I’m winning.’ It’s a huge shame if GPs are retiring early because they can’t cope, and a tragedy for the country.”

Mowle lists some of the changes that have increased GPs’ workloads: more paperwork; patients’ increased expectations of what medicine can do for them, and multi-morbidity – the heightened complexity of illness that an ageing population has brought.

The Guardian has also been told by multiple family doctors that hospitals are pushing them to take over from them more and more investigation and management of patients’ conditions. Even patients with serious disorders such as anorexia nervosa are being bounced back to GPs.

Such heavy responsibilities become a serious problem when the number of family doctors has gone down, not up.

It is inevitable that patients’ access to GPs has become more difficult, Mowle says. Millions are struggling to get appointments, and as a result, some patients will not have serious medical conditions diagnosed until it is too late, a recent analysis of official data suggested.

Mowle is frustrated that the government’s response to that problem in England has involved “bashing” the profession by forcing every surgery to publish details of how quickly they see patients and how many they see face-to-face and remotely. These are crude league tables which do not factor in the number of GPs at each surgery, he says.

Caring for patients while they wait for hospital treatment has become a key aspect of the job. “Recently I had a patient who has a severe lung condition and has been really struggling, and it’s not even deep winter yet. His appointment was cancelled and rearranged for four months’ time.

“Winter will have come and gone by then. That’s heartbreaking for him and heartbreaking for us as well because we want patients who have serious conditions to have the best possible care.

“Delays for patients in being seen undoubtedly doesn’t just have a psychological impact on them, it can have a physical toll. Their condition can worsen, and in some cases may even be untreatable by the time they’re seen,” says Mowle. “It’s a real concern this winter.”

Carole Stagg, 62, is in to see Mowle about a persistent cough. She highlights another consequence of the NHS’s increasing inability to give patients timely care: people paying for private medical help.

“There’s an obvious decline in the NHS service as a whole,” she says. “There’s more difficulty for patients to get just a basic appointment, even in more acute situations.

“A lot of my friends have, in their frustration at waiting, and obvious concern about their future healthcare, have been caught up in finding alternative ways of getting their health issues dealt with. They’ve gone private.

“It’s been a real last resort. It’s not something they would elect to do ordinarily. It’s not something they applaud themselves for doing. They feel, actually, a bit of a traitor in some respects.

“My son recently has had something quite alarming going on and had weeks of delay even getting to see a GP before he could even be referred to a specialist.

“Because of this issue that he’s had, he’s thinking about the possibility of [taking out] some kind of insurance plan for him and his family because he’s worried that in the future they might have some health issues that they can’t get dealt with … in a reasonable timeframe.”

Mowle says: “We need more doctors, we need more nurses, we need more allied health professionals. There needs to be more give in the system. Otherwise it simply can’t go on.”

* * *

Pharmacies take the strain

Pharmacist Renna Barai.
Pharmacist Reena Barai says some patients have turned up so ill she has driven them to A&E herself. Photograph: Graeme Robertson/The Guardian

With pressure on primary care rising, pharmacists too are seeing more patients. Once a sleepy pharmacy, SG Barai in Sutton, south London, is now a bustling healthcare centre. “I’ve never seen so many people walk through the door,” says Reena Barai, who has increased her team from three staff to nine in order to cope.

Her team has vaccinated more than 10,000 people against Covid and, like many pharmacies that stepped up during the pandemic, proved a lifeline for patients. At the start of the pandemic, patients here were panic-buying paracetamol and hand sanitisers. Now, they are walking in seeking urgent care.

“We’re getting people coming in to us when they’re struggling to get appointments with their GP; we’re getting people coming to us because they’re frightened to go to the hospital,” says Barai. “And actually, they’re very seriously ill, but they just want some advice.

“I almost felt like we became a sort of mini-A&E in our pharmacy. Sometimes it’s minor illness, sometimes it can be even more serious things – they’ve got chest pain, they’ve got an ulcer or a wound that they’re worried about.”

In some cases, patients have been so ill when presenting, she has driven them in her own car to the local A&E.

Most shockingly of all, perhaps, Barai says she has recently seen a surge in people arriving at her pharmacy who are seriously mentally unwell. Most of the time, it is because they were unable to access care elsewhere. Some are suicidal.

Barai and other pharmacists also told the Guardian about colossal problems with shortages of medicines – an issue they believe has not received sufficient attention from the government.

Patients facing difficulties accessing treatments often have to go to multiple pharmacies to get a prescription or return to their GP to be prescribed an alternative drug.

Some of the medicines affected include pain relief drugs, antipsychotic drugs used by bipolar disorder and schizophrenia patients, inhalers and even insulin.

Despite their enhanced role, funding squeezes mean some pharmacies are being forced into shorter opening hours. Some have even had to shut permanently because of a lack of financial support. “We’ve never been busier, but we can’t afford to keep going,” says Barai.

* * *


Richard Frempong, a medical performance matron, talking about the day’s targets and concerns at the morning meeting at King’s College hospital.
Richard Frempong, a medical performance matron, talking about the day’s targets and concerns at the morning meeting at King’s College hospital. Photograph: Graeme Robertson/The Guardian

Back inside the command centre at King’s, the key concern at the 12.30pm beds meeting is ED, which now has 106 patients inside. Other departments are also noticeably busier. “We need to move at some significant pace,” says Powls, urging colleagues to act ahead of what is shaping up to be a volatile afternoon. “We know we’re going to be rammed.”

Among those tasked with finding more beds is Richard Frempong, who is the first to admit he’s lucky to be in the room. Whacked with Covid during the first wave, he found himself in intensive care – and on the brink of death.

At one point, tearful colleagues telephoned his wife of 23 years, Comfort, to tell her he would not survive the night. Miraculously, though, Frempong’s colleagues saved his life.

“When I came into hospital, I just packed a few toiletries, thinking I would be out in a few days,” the father of five and grandfather of two recalls. “Then my breathing worsened. I was intubated on ITU, and I woke up seven weeks later, thinking, ‘Where am I?’”

He was left with permanently scarred lungs, and still suffers from breathlessness 33 months later. But his infectious sense of humour remains intact. Determined to make the most of his second chance at life, he runs 5km every weekend, and – reluctantly, he jokes – he’s also improved his diet.

As a performance matron for medicine, his task of freeing up beds for patients by discharging others as soon as they are medically fit to leave is made trickier by the crisis in social care.

“A lot of community services have come to a standstill,” he says. “We have patients ready to go to care homes, but they haven’t got the spaces for them.”

A drastic shortage of district nurses also makes it harder to arrange community care for patients ready to return to home. “That is slowing us down,” says Frempong. “I joked about it – we need to get the army to open the ExCeL.”

How serious could things get? “We’re already struggling,” he says. “It’s obviously going to be tough this winter, but we always give our best, and do what we can.”

* * *

‘It’d be nice to get out’

Chris Richmond
Chris Richmond was admitted 141 days ago after suddenly collapsing. Photograph: Graeme Robertson/The Guardian

Three floors above the King’s command centre, in adult intensive care, one bed Frempong would like to free up is occupied by a computer programmer, Chris Richmond. He was admitted 141 days ago after suddenly collapsing. Later diagnosed with motor neurone disease, he has been stable enough to return home to Bromley, in south-east London, for some time. However, delays in confirming community care arrangements for him prevent his departure. “We want to discharge him,” says charge nurse Stefan Maciejuwski.

Delayed discharges are equally frustrating for patients. Richmond, 69, was not aware of how difficult it could be to arrange care for people leaving hospital. “All this is new to me,” the married father of three says. “I’ve been in this room for three months. It’d be nice to get out.”

More than nine out of 10 people in hospital beds in some parts of England are stuck there despite being fit to leave, figures show. Levels are particularly high in the north-west of England, where, at some trusts, 95% of patients in beds no longer need to be there.

Richmond, and most patients around him, do not have Covid. Previously, for long periods of the last 33 months, intensive care staff spent most or all of their time treating critically ill Covid patients.

Today, though, there are fewer than 200 Covid patients on ventilators nationwide. “It’s extremely unusual now to come in with Covid as the sole cause of the ICU admission,” says Dr Tom Best, the clinical director for intensive care.

Tom Best, a critical care consultant at King’s.
Tom Best, a critical care consultant at King’s. Photograph: Graeme Robertson/The Guardian

“It’s a combination of community immunity through the vaccination programme, previous exposure to Covid, and it’s an impact of mutation into forms that are perhaps less deadly,” says Best. “And there’s an element of us improving our ability to deal with it. But I would say the majority of it has to be related to immunity.”

Still, intensive care unit occupancy rates remain high – in some cases close to or over capacity – across the country. Hordes of other types of patients have returned, and, as in the case of Richmond, the social care crisis makes it tough to free up beds. “Today, for example, we’re staffed for 90 beds, and we kicked the day off with 88 patients,” explains Best. “So, functionally, that’s close to 100%.”

* * *

Anger and abuse

Ambulance workers help a patient at King’s College hospital.
Ambulance workers help a patient at King’s College hospital. Photograph: Graeme Robertson/The Guardian

The lack of beds means patients must wait longer than ever to be admitted to hospital. Siobhan Taylor is frequently in and out of hospital with a serious breathing condition, but has never waited so long to be admitted. Speaking to the Guardian from her bed in a respiratory ward, this time, she says, she waited 16 hours to be admitted.

“The waiting room was rammed,” says Taylor. “I’ve never seen it like that. Trolleys were just piling up in the hallway.”

But she has nothing but praise for staff doing their best in fraught conditions. “You know they are working hard, and I think they are amazing,” she says. “The NHS needs to be given a bit of a break.”

Patient Siobhan Taylor.
Siobhan Taylor: ‘Trolleys were piling up in the hallway.’ Photograph: Graeme Robertson/The Guardian

Not all those experiencing long waits for care are as understanding. Between January and June, there were, on average, 391 cases of violence and aggression against King’s staff a month; between July and November, that grew to 467.

Research shows patients’ unhappiness at the delays is rising. As it does, many different types of NHS staff are bearing the brunt of increased frustration, anger, and verbal and sometimes physical abuse, including A&E staff, paramedics and GP staff.

“Patients will often get quite heated when they speak to a receptionist, saying that the receptionist doesn’t understand them [or] doesn’t understand their needs,” says Mowle.

“Things often get quite personal. They’ve been trying for weeks to get through. And they will vent their anger, which is understandable.”

Patients’ frustration weighs heavy on the shoulders of NHS staff. Many on the frontline are burned out, the Guardian found. Still reeling from the horrors of the height of the pandemic, many are suffering prolonged stress – with no sign of pressures easing.

* * *

Blue lights spread thin

Laura Brown and Jennifer Nelson take a break after carrying a patient to King’s hospital in south London.
Laura Brown and Jennifer Nelson take a break after carrying a patient to King’s hospital in south London. Photograph: David Levene/The Guardian

In the arrival bay outside King’s ED, seven ambulances are parked up, with their engines turned off. None of the ambulances can leave to attend to other 999 calls, because there is no room inside ED to admit their patients.

About one in seven ambulance patients in England now wait more than an hour to be handed over to A&E teams at hospitals, with nearly one in three waiting at least 30 minutes.

“We don’t keep them in the back of the ambulance,” says Dr Emer Sutherland, the clinical director for emergency medicine. “But sometimes we have to hold the crews with them because we have no trolley to offload them.

“We’re busier than we’ve ever been,” she adds. Many of those arriving at ED are frail, older people, and not all can be helped, she adds. “We’re worried because we’re not able to give the care to all of the patients that come through that we want to.”

Some of those arriving have undiagnosed cancers; others have performed DIY dentistry because they could not see a dentist.

Waits for ambulances are the longest they have ever been, and demand for them never ceases. “Generally you don’t stop for the whole day,” says Laura Brown, a paramedic with the LAS.

“You might get 15 minutes to put some food down you. But generally you don’t stop because as soon as you green up, literally there’s a job ready for you. Because there’s always someone somewhere who needs you – someone being born or someone being stabbed or someone with chest pain.”

Emer Sutherland, King’s clinical director for emergency medicine.
Emer Sutherland, clinical director for emergency medicine at King’s, says patients sometimes have to be held with ambulance crews because there is no trolley to offload them. Photograph: Graeme Robertson/The Guardian

“Greening up” – letting the ambulance control room know she is available to respond to another 999 call – dominates her 12-hour shifts. Once one job is over, and the necessary paperwork completed, she pushes a green button on a small computer screen. She is usually on her way again within seconds to another patient in need of urgent, sometimes life-or-death, medical attention.

Brown, 40, joined the LAS only in May after a previous career as a designer. “I know it sounds like a Hallmark card but to be able to give a little bit of yourself to every patient you attend, to be able to say to them, ‘I’m going to help you,’ is a privilege,” she says.

Her partner in the ambulance is Jennifer Nelson, 24. Nelson joined as a trainee paramedic in 2017 and has been fully qualified for 18 months. “Our jobs are great. You get to be a clinician and you get to change and save people’s lives,” she says.

But quite often crews like this and others nearby are already busy and unable to help, even if it is a life-threatening emergency, so patients have to wait, and wait, and wait.

“You might be sat on a job and your radio will be going off and your dispatch is like, ‘we’re holding this job’. There’s someone not breathing round the corner or someone who’s been assaulted. It’s so disheartening [that you can’t attend] because you want to help everyone,” says Nelson.

The first call of their noon-to-midnight shift illustrates the limits of the LAS’s capacity. A 77-year-old man has fallen outside his flat in Brixton. “Patient on the floor,” is all their computer screen says.

The control room got the call at 12.05pm. It’s a category-three call, so the LAS should have attended within half an hour. However, a shortage of crews means no one could respond until Brown and Nelson were assigned the job at 1.26pm.

Blue light and siren on, and after weaving in and out of the lunchtime traffic, they arrive at 1.38pm, an hour and a half after the initial 999 call. When they get there, equipment slung over their shoulders, they find that neighbours, worried that no ambulance had shown up, had in the meantime taken the patient to hospital themselves.

The second call sees the paramedics travel 5.3 miles, again because there is no nearer crew. The patient is 62-year-old Malcolm Harvey, who uses a wheelchair and is housebound as a result of having had both legs amputated because he has a serious circulation problem.

Laura Brown (left) and Jennifer Nelson help Malcolm Harvey after responding to an emergency callout in Catford, south London.
Laura Brown (left) and Jennifer Nelson help Malcolm Harvey after responding to an emergency callout in Catford, south London. Photograph: David Levene/The Guardian
Brown and Nelson help take  Harvey to hospital after a fall.

He says he dialled 999 because the ulcers on his back were leaving him “screaming with the pain”. They talk to him about his love of cats.

But the crew’s examination shows up other concerns too, including a thumb that has turned dark and sore and hands that are crusty and discoloured, again as a result of his peripheral vascular disease. “My hands are worrying me, because I’ve got no legs. The hospital have said they might have to amputate my left hand,” says Harvey, anxiously.

The paramedics take him to King’s and hand him over to A&E staff, with no delay, their job done.

Today’s visit is the 28th time since July 2021 that the LAS has gone out to Harvey in his ground-floor flat and helped him with his daunting array of problems. The ageing and growing population, and complex cases such as Harvey’s, are factors in why callouts attended by ambulances in England have doubled from 7m to 14m over the last 10 years.

The information on the crew’s screen for the next call – “66-year-old female, passing out and not passing urine” – is again scant.

“We’re the ambulance service, sweetheart. Can you open your eyes? Can you squeeze my hand?” Nelson says gently to Clarice Freckleton, who is unconscious on a hospital-issue bed in her daughter’s living room. She can do neither. Her daughter Selina called 999 when repeated efforts to rouse her mother failed.

A London Ambulance Service crew respond to a 999 call in south London
Clarice Freckleton being attended to by a London ambulance service worker.
Clarice Freckleton being attended to by a London ambulance service worker. Photograph: David Levene/The Guardian

Freckleton clearly needs to be in hospital. But the paramedics feel it would be too risky for them to lift her from her bed on to a carry-chair and then into the lift down to the ground floor and into the ambulance.

However, one quick call to LAS control and within 10 minutes four firefighters arrive to help out. At King’s, she goes straight into the care of a medical team in the resuscitation unit, bypassing A&E.

Today’s shift does not involve any handover delays. However, Nelson recently spent seven hours in one hospital A&E waiting for her patient – a frail, elderly man – to get a bed. She read half a book to pass the time but could not respond to other 999 calls.

Like so many NHS staff, both women worry about the risk inherent in patients having to wait for the urgent care they need.

“Delays for people who need urgent care are almost by definition not good. The worst-case scenario is someone dies at home,” says Nelson.

Data published by the Association of Ambulance Chief Executives shows delayed handovers in October exposed 41,000 patients to potential harm, including 5,000 at risk of “severe harm”.

* * *

‘Some days it works – just’

Paramedic Gerry Healey consoles Marisa, 85 whose husband Ronnie is very ill at home, as part of a 999 callout.
Paramedic Gerry Healey consoles Marisa, 85 whose husband Ronnie is very ill at home, as part of a 999 callout. Photograph: David Levene/The Guardian

As another frantic day in the NHS nears its end, weary ward managers and department heads gather again in King’s command centre. The beds situation is not looking any better. In fact, it’s looking worse. First on the agenda is ED, where this morning senior staff were alerted to the fact there were 61 patients in a department equipped to deal with 60. Tonight, that number has swelled dramatically. “We are pretty chocker,” says one of the beds managers. “We’ve got 137 patients in the department at the moment … Really not looking great.”

Hosking requests updates from other wards; there is little space anywhere in the hospital. “Hopefully, we might find some surprise beds?” she ventures, peering around at colleagues. Everyone laughs. Some then awkwardly stare at the floor. The room falls silent for a moment. They all know the likelihood of “surprise beds” miraculously emerging that evening is zero.

Doctors at King’s take a brief rest.
Doctors at King’s take a brief rest. Photograph: Graeme Robertson/The Guardian

“We’re gonna have a tough old morning tomorrow, aren’t we, based on what we’ve got tonight?” sighs Powls. “So we will do it all again in the morning.” “Have a hearty breakfast,” quips Hosking.

After the meeting ends, and staff zip back to their desks to pick up ringing phones, Powls is honest about her disappointment. “We haven’t managed to clear enough beds to manage the emergency patients coming in today,” she tells the Guardian.

“It’s a horrible juggling act, to do this day in, day out,” she says. “It is really, really tough. Some days, it works – just. And some days it doesn’t work at all. And today is one of those days.”

  • Additional reporting by video producers Adam Sich and Maeve Shearlaw

  • In the UK and Ireland, Samaritans can be contacted on 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org. You can contact the mental health charity Mind by calling 0300 123 3393 or visiting mind.org.uk


Andrew Gregory and Denis Campbell

The GuardianTramp

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