The NHS is a top election issue – both Labour and the Conservatives promise they would pump in billions to save it. But what do the people on its frontline – the workers who know it best and care for it most – think it needs?

Paramedic: ‘Binge drinkers should get a bill of £60 to £80 when they are discharged from hospital’

I have been a paramedic for the NHS for 13 years. We are under a lot of pressure; an ambulance crew in my service is often sent out on 10-14 calls a day. Some calls can take an hour, to an hour and a half – and we work 12-hour shifts. The majority of the time we have to work overtime, anything from 20 minutes to several hours.

We rarely get breaks; you may try to snatch lunch, get a coffee and a rest in the 14 minutes between passing a patient on to the hospital and leaving. Some of my colleagues are on new rotas – working nights getting hardly any rest, and then being put on early shifts. In my opinion, two sets of people are being killed here – ambulance personnel, slowly and surely before we retire; and patients dying because we are on unnecessary call-outs when they need us.

Paramedics and ambulance personnel are leaving their jobs in droves. Private ambulances are now attending emergency calls.

NHS 111 is partly to blame – especially the privately owned parts. All they care about is not being sued so they send ambulances out for everything. If someone has had a cough for three days, so has chest pains from that, they will call us out. Some even tell patients they might be having a heart attack! It’s disgusting.

Facebook Twitter Pinterest Paramedics attend to a woman after a night out – would charging for callouts help tackle the problem of binge drinking? Photograph: Matt Cardy/Getty Images

Sometimes a doctor will call asking for a patient to be taken to hospital even if they could go in a taxi. Other professionals call ambulances because they fear litigation, or feel out of their depth with simple first-aid issues. Private companies and supermarkets do it, too; if someone vomits, they will call an ambulance rather than a first-aider.

The problem is that call handlers are not clinicians. We are sent out if someone cuts their finger. My colleagues have been called out to someone who was scared by a horror film. If every paramedic had to do a few days a month in a call room, they could use their clinical judgment to say: “You don’t need an ambulance.”

Binge drinking is another problem. Young people think it is a badge of honour to be sent to hospital in an ambulance. When they are discharged they should get a bill of £60 to £80. I am not talking about alcoholics – you wouldn’t penalise people for addictions – but a doctor could easily make the distinction.

We need to teach people common sense, and how to look after their bodies.

Stuart Gray

GP: ‘There should be pressure on drug companies to lower their prices’

Today, I had 51 patients, including telephone appointments. I started at 9am and finished at 9pm. On my last “on-call” day – seeing urgent patients – I had 76 appointments.



I started at this practice five years ago and today there are 15% more patients. Patients find it hard to get an appointment so understandably save up their problems – they may have four things to discuss in a 10-minute slot. In that time you have to call them in, get them settled, discuss all the issues, examine them if appropriate, talk about further tests or management options. Plus there may be other issues you have to pick up on that they don’t mention, which may be more important than the symptoms troubling them. You don’t want to make a mistake, because that’s someone’s life you are dealing with.

GPs have to do more, partly because secondary healthcare is under pressure, but partly there is just much more we can do. More tests and treatments, clinics at the local hospital may want us to continue to monitor patients we have referred to them or do follow-up tests.

We have an ageing population, and when people live longer they often have several medical conditions; the conditions or treatments can interact, making care more complex. It also means house calls have probably doubled in our practice in the past five years. Even if the patient lives 10 minutes away, it is a 20-minute round trip, plus time for filling out notes etc.

Facebook Twitter Pinterest GP Sithu Maung: ‘If people want the NHS to stay the same, they have to pay more tax.’ Photograph: Christopher Ison

Of course there are rewards to being a GP: you get to know your patients, their families, friends and emotional ties. They let you into their homes. But it’s hard to recruit GPs now because of the pressure – our practice recently spent around £5,000 on advertising a position and only got two applicants.

Politicians need to be honest about resources and stop doing down GPs. The NHS needs more money just to do the same things we always have: people live longer with more chronic health problems. That’s without politicians promising things such as GPs being available from 8am to 8pm. It’s a misconception of need; the elderly and young need us most frequently, and they don’t want to come in at 8pm.

If you compare the NHS with any private healthcare system in the world, it trumps them all. But expectations still need to be managed.

Take medication: drugs costing £30,000 or less are approved by Nice if they allow you an extra year of life. And for cancer that goes up to £60,000. But the average wage in England is less than £30,000, so you can’t do that for ever. The pressure shouldn’t be on the NHS to spend more, but on the drug companies to lower their prices.

We should drop the amount we will pay. Drug companies claim their prices are high because of research costs, but spend more than half of their budgets on advertising. They also fund pressure groups. The BMJ recently reported that the drug company Novartis had tried to “scupper” trials of a cheaper drug – quoting an opthalmologist who said the company’s representative would be challenging the trials through the charity RNIB.

We should be honest: if people want the NHS to stay the same, they have to pay more tax and possibly work longer. But an ageing population means the demands on the NHS will soon be untenable. It’s good that people are living longer, but we don’t know how we will pay for it.

Sithu Maung, Brighton

Consultant oncologist: ‘We need to invest funding in early diagnosis and prevention’

Facebook Twitter Pinterest Obesity must be tackled in the fight against cancer. Photograph: Anthony Devlin/PA

At the Royal Marsden we see patients with the most challenging cases, so I have not noticed an increase in the volume of people we are seeing. But my colleagues at other hospitals tell me things are getting busier and busier, and that the pressure they are under is too much.

To save the NHS we need to invest funding in early diagnosis and prevention, because a lot of the problems we are facing are lifestyle-related. Obesity is a running theme through many cancer areas and we need to tackle that as hard as we try to tackle cancer.

The smoking ban shows how effective public health interventions can be. You could do the same with junk food – make advertising for fast-food outlets less prominent, make healthy foods more visible.

Make advertising for fast-food outlets less prominent, make healthy foods more visible

Drugs to treat cancer are expensive, and it’s hard to see how the NHS can afford them, but I understand why the prices are so high. Pharmaceutical companies have to try different versions, and then claw back the costs for all this research. At the moment there is a slightly weird two-tier system, where the price the NHS will pay for cancer drugs is higher than for any other medication. Even so, some drugs I can no longer use as a first line of treatment.

But if we can give a patient an extra six months of life, you can’t place an economic value on that. It may allow them to see their grandchild born, or their daughter marry or to say goodbye to their family in the way they wish. Sometimes, you get people saying an extra two months of life is not enough to make the cost of a drug worth it, but anyone would want that treatment if it was for themselves or their family members.

If the NHS is not at breaking point now, it soon will be. The reasons are a combination of not enough funding, an ageing population and lifestyle issues. I see patients in their 70s and 80s now who are fit for treatment. It’s also because the NHS is an old infrastructure, and our needs are different now – the technological and drug advances have been dramatic, too, and that all needs investment.

Naureen Starling, London

Community mental health nurse: ‘We need psychological services so people understand their own warning signs’

Facebook Twitter Pinterest A nurse helps an elderly patient to play solitaire – but are hospitals designed with the care of older people in mind? Photograph: Peter Titmuss/Alamy/Alamy

We see patients over 65, or younger if they have early-onset dementia. Patients are referred by their GPs, and we assess them and either send them to a crisis team or see them ourselves. Then we look at what medication they need and their housing, what day centres they could go to and do a carer’s assessment.

In the field of older adults, compared with working-age adults, there are fewer support workers and there is less time to see patients. We give patients therapy – CBT for instance – and try to encourage them to go into the community if that’s what they need.

It’s a frightening time for people, so I try to offer emotional support. The carers may actually need more help – either some respite or to go on a “caring and coping” course. But respite care is lacking at the moment. And the day centres have been closed.

Cuts in auxiliary services are really hitting our patients – they need stimulation and their carers need a break

There used to be six day centres in the city but now there are only two. I think the cuts in auxiliary services are really hitting our patients – they need stimulation and their carers need a break. We are filling the gaps of social care, too. There is a waiting list for home care, so we hold on to people. We were an integrated service – with social and healthcare teams working together – but because of funding issues, that broke down.

For older adults accessing services can be harder. Drug and alcohol services are supposed to be for all ages but it’s hard to get the over-65s seen, especially if they have dementia. The use of drugs and alcohol has increased in older people, and I think in the past there has not been the need for the same services.

We don’t have a 24/7 crisis team either – it is only 7am to 7pm – not out-of-hours. And they can only take a certain amount of referrals a week – so they might be full by Monday afternoon; that’s hardly a rapid response.

Memory services, which diagnose dementia and memory problems, also have a waiting list – patients may have to wait 26 weeks to be seen, and then after that they have to have an assessment – so it could be 30 weeks before they start medication.

We also need more money for psychological services, then people can understand their own warning signs and get in touch before they hit a crisis. We need more nurses. Four people retired in the city and their positions have been filled by agency workers. Name withheld, Yorkshire

Consultant nurse: ‘Everyone should have a sound foundation in geriatrics. The majority of our patients are elderly’

Facebook Twitter Pinterest Are highly trained nurses with degrees ‘more likely to look after a patient’s psychological needs’? Photograph: Dimitris Legakis/Dimitris Legakis/Athena Pictures

My job is to improve the experience of older people in hospital. Most older people are well, and contributing to society. But of those who are ill, most will have at least three conditions – for instance heart failure, dementia and diabetes. We knew we would be treating more older people for a long time, but we haven’t planned for it.

Older people need lots of different teams – and they may have mobility difficulties, or cognitive impairments, and social issues such as loneliness (which is as bad for your health as smoking). Older people also don’t recover as quickly. The problem is that the NHS – and especially hospitals – were designed for younger people with one acute medical problem. For instance, I am in a shiny new hospital building, but there is no day room where I can get older people sitting round a table socialising and eating. They end up getting de-conditioned, losing muscle tone and fitness and take longer to recover.

We have cut back on intermediate care beds – where you can recover. Without these, older patients can decondition further. That blocks up the front door and they may need more care when they come out. Family carers can step in, but they tend to be older and have their own problems. Patients may need social care packages, but these have been cut badly. And home carers might only be given 15 minutes to help someone – but if the patient has cognitive impairment, that’s just not enough.

It does make you angry, because if children were treated like this, people would be screaming and shouting. Nurses leave because they can’t live with not being able to care for people properly.

You can’t find the extra people you need because the NHS cut back on the number of student nurses it was training

My hospital has said we must not go below one nurse for seven patients, which is great. But nurses still get ill, while some patients need one-to-one care. You sometimes just can’t find the extra people you need because the NHS cut back on the number of student nurses it was training. So we are going overseas to recruit staff now.

To improve things everyone should have a sound foundation in geriatrics – because the majority of our patients are elderly. And we need to move quickly to an integrated model with the patient in the middle. Health and social care need to work together.

Older patients should be taken home to be assessed by an occupational therapist or physiotherapist – that shouldn’t be done in a hospital. And we need expert geriatricians in A&E. Someone who can see the whole picture, give a timely diagnosis, a comprehensive assessment and a plan for the next five days. We also need more frailty units.

Cutting back on high-quality, trained staff is false economy. This idea that nurses don’t need degrees is nonsense. Nurses with a degree are more likely to complete their tasks and look after a patient’s psychological needs. And if you have more registered nurses on the ward, we know the outcomes are better for patients. They are less likely to fall over, get infections, get pressure sores – so they will stay in hospital for less time.

Vicki Leah, University College Hospital, London

Clinical psychologist: ‘We need to provide antenatal care and manage anxiety

after birth – this would save money



down the line’

The young people we see are so vulnerable, and at a stage in their life when a tailor-made timely intervention can make a massive difference: leave them for 18 months and the impact on them socially and educationally will be huge. They may have problems with relationships, drug and alcohol offences, or not being able to hold down a stable job.



We are not a crisis team – we don’t typically see children who have attempted suicide, but as our waiting list goes up, more children and young people we will need those crisis and inpatient beds.

We see children suffering from anxiety, low moods, or difficult behaviour – such as anger and aggression. We offer therapies for children and parents, working alongside teachers, social workers, school nurses. Thanks to social-care cuts, cuts in voluntary sector services and preventative care, the number of cases being referred to us has doubled. Our capacity is now much less than the demand, so our waiting lists will grow.

Specialist domestic violence services have been cut so we can’t refer young people who have witnessed violence in their homes. Previously we may have referred young people who are at risk of offending to other services, but those have gone, too. On top of this, the threshold for social care has increased – so when practical problems need to be addressed before a young person feels safe enough to tackle their emotional health issues, our referrals may not be accepted.

The NHS is working on goodwill. My colleagues take files home to work on Saturdays, on top of working through lunch, going in early and leaving late. Our staffing levels have been cut in a restructure.

Facebook Twitter Pinterest Heading for the exit: having a high turnover of staff is not cost-effective. Photograph: Suedhang/Getty Images

We have fewer staff but more managers, and they have little knowledge of the service. For instance, we have a high number of missed appointments. A manager suggested booking in two patients at the same time. But people with emotional health difficulties need to trust that we will be there for appointments before they will talk about their anxieties. Wouldn’t it be better to tell patients the appointments cost the NHS £250, so they think twice if they can’t make it?

People want quick savings without thinking of the long-term effects. For instance, consultant posts have been cut in our service so there is no possibility of career progression. That means three other staff have left. I always thought I would work in the NHS for life, but now that may not be possible.

Other staff are on long-term sickness leave because of stress. Having a high turnover of staff is not cost-effective. We should be investing in preventative work. There is currently no remit for psychologists to go into schools or supervise midwives. We offer nothing in terms of antenatal care, managing anxiety and post-traumatic stress after birth, or even what a healthy relationship with your baby looks like. All this would save money further down the line.

Child and adult mental health services should work together – most adults are parents, and some children will access services post-16. Adult services never call us – so if the parents are going through a crisis it is not fed back.

Rachel Andrew, principal clinical psychologist, children and young people’s mental health, East Lancashire

Sexual health/ HIV consultant: ‘The five-year political cycle is not a good way to run the NHS. Health needs a 20-year cycle’

When I started in the NHS I thought it was inconceivable that I would ever leave, but I certainly don’t feel like that any more. I am frustrated with the inefficiency, the lack of organisation and the inability to involve me in decisions.



We are being hit by a double whammy: shrinking budgets and organisational instability. The disruptions feel constant. In 2013, the Health and Social Care Act came into force and it led to 18 months of stasis.

The old system was chopped up overnight. Theoretically, it made sense – moving commissioning and public health from PCTs [primary care trusts] to the local authorities – but people weren’t ready and the skills weren’t there initially. Local authorities put lots of sexual health services out to tender and that was destabilising. For instance, there might be a range of organisations providing services in a local area: an STI clinic in a large hospital, community-based contraception services, general practice and charities such as Brook or the Terrence Higgins Trust. To the local authorities, offering one contract to deliver all the services can seem like a way of encouraging services to work together and drive efficiencies, but it can also be disruptive and lead to everything being driven downwards to the lowest common denominator, which is cost.

Facebook Twitter Pinterest Sexual health services need to worked better together to make economies of scale. Photograph: Alamy

The five-year political cycle is not a good way to run the NHS. Health needs a 20-year cycle. We need long-term strategic vision to deal with the challenge of an ageing population, increasing costs and limited funds. For instance, there are large savings to be made in the long term by increasing HIV testing. It would get people on treatment earlier and reduce transmission to others, but because the testing budget is separate from the treatment budget, the testing budget won’t see the savings – so there is little incentive to drive change.

I also work for a charity and, in that service, if someone told me to save 10% I would know how to do it. In the NHS, I don’t get to manage my budget and it is hard to get a clear idea about how much my service spends and how much it brings in. Decisions about contracts are made much higher up – but savings have to be made at the clinical coalface. No one understands the service as well as those who deliver it – what the needs are and what possibilities for service development and cost savings exist. It would be sensible to involve us in the discussions.

Staff are holding the NHS up, but we are not being well supported. If all the sexual health services in one geographical area worked better together and were more sensibly commissioned, we could coordinate opening hours and access and make economies of scale. Simple things can be delivered simply and cheaply, by nurses or healthcare assistants, in the community or online, and specialist services can be better targeted to those with more complex needs. We need more stability and less meddling. Maybe it’s time to take the NHS out of the politicians’ hands.

Name withheld