Winter is traditionally a rough ride for the NHS, and 2016 has already been a challenging year. Junior doctors went on strike for the first time in a generation over changes to their working terms and conditions, and as the government continues to try to close a £22 billion gap in NHS finances, doctors have warned that catastrophe looms unless cuts are halted and more staff are trained.
As this year's chill sets in, BuzzFeed News asked NHS doctors: "What are you most worried about this winter?" Here's what they said...
Dr Dagan Lonsdale, intensive care registrar, London
Winter is a time when the bed capacity of a hospital is most severely tested. We now run near to capacity for much of the year, and so winter can be especially challenging, particularly with struggling community care services.
We do not increase our medical staffing in line with the increase in demand, so my biggest concern is managing with the increased workload over the period.
Dr Jessica Hanlon, junior doctor, London
For more than a month, we face a situation where every day, we walk into work and hear a new level of despair from our bed managers: "We've got 45 people waiting for beds."
I have been told by senior nurses that I absolutely must find more people to discharge, that my responsibility "goes beyond the 33 on this ward" and I have to "think about those people stranded downstairs in A&E". I tried to explain that this is impossible – I can barely look after the ones assigned to me properly with the staff shortages we face. As happens daily in hospitals, tension and anger spills into the room, and I try not to let it affect me. I try to explain my ethical viewpoint.
It should be black-and-white: We won't discharge someone who's not ready to go. Certainly, if harm comes to them, blame will fall on us, their medical team.
"We're usually unable to meet the high standards of care we were taught."
But I'm seeing this more and more: senior doctors and nurses feeling so pushed by this constant pressure that they discharge more, faster – often unsafely, I believe. And time and again we see them returning to hospital. As I'm thinking about this I can think of numerous examples of people coming in more and more (and in some cases life-threateningly) unwell.
So I'm worried about the inevitable increasing demand of winter, up against staff shortages and horrendously low morale. We, the healthcare workers, are forced to spread ourselves thin and suffer the consequences, including angry patients who are dissatisfied with our service. And I'm worried of feeling ashamed that I can't offer better because it's physically impossible. We're usually unable to meet the high standards of care we were taught, and that takes a toll.
All of this is marking the downward spiral of the NHS. Each problem potentiates the other: declining social care provision, longer waiting lists for clinic appointments and worse public health provision, less support for the most vulnerable. It's a profoundly foolish false economy and it's true regression of a developed country. To say I'm deeply saddened doesn't really cover it.
Philip Lee, consultant in acute and elderly medicine, London
The system is already under enormous pressure. Most hospitals work at near 100% or more occupancy and if things get busier, it's hard to see how acute services will cope. We've actually not been out of winter mode for several years now, because more beds are needed throughout the whole summer too.
"If a bad flu season hits ... we'd really be in a bad place."
One of the big problems is difficulty discharging patients who are already in hospital and medically fit but waiting for a care home or packages of care in their own home.
Cuts to social care and community care via councils means these waits are looking likely to get worse, and the fact that funding for those is separate from the NHS means we have little control over this.
Morale is also pretty dire amongst junior doctors after the dispute with their contract over the last year. I think many felt badly let down, not just by the government, but by the doctors union, the British Medical Association, too. The goodwill that usually plasters over the cracks in the system won't be around for much longer.
Mental health also really worries me. Patients are waiting for psychiatric beds for many hours in A&E, or even days in a general medical ward. They are not getting the treatment they need and are getting overstimulated in the wrong environment. It's been getting worse over the last 3-4 years and it compounds our problems.
If a bad flu season hits, with the level of critical care occupancy we have now, some difficult decisions will need to be made. We'd really be in a bad place.
Dr Nadia Masood, anaesthetic registrar, London
It's not just the NHS in the winter that worries me. The NHS is in its worst state ever: chronically understaffed and in the midst of a massive financial crisis due to chronic underfunding.
Patients are already feeling the effects of this all year round, with waiting times the longest ever this decade, causing irreparable damage to some patients' health, or worse, causing fatalities. I am worried that patients will suffer even more unless our government urgently addresses the need to fund and staff our NHS properly.
Our government has denied [that] the NHS is struggling for too long, and only recently are we finally seeing some acknowledgment from NHS Providers and NHS England that the NHS is underfunded.
Despite this, they still seem insistent on continuing with their catastrophic plans to spend less per person on the NHS, despite a massive funding deficit, and to stretch an understaffed workforce even thinner in the pursuit of a "seven-day NHS", and to downgrade or close services as part of their controversial Sustainability and Transformation Plans [STPs].
"Our government has denied the NHS is struggling for too long."
Services have already been cut because of understaffing, yet we are learning that further downgrades and closures are planned.
Rota gaps are growing, with too few nurses and doctors to look after our growing population.
Junior doctors took unprecedented industrial action this year, supported by NHS staff and the public, to protest against contract changes that followed these plans. It was ignored by our government, and the new changes being imposed on the NHS workforce will see these dangerous plans introduced.
What am I worried about? I'm worried that our NHS is almost completely broken, and our government's plans are clearly not going to fix it; even worse, they will be the final blow to the NHS that each and every one of us relies upon.
Dr Mohsin Khan, junior doctor and trainee psychiatrist, London
As winter approaches, short staffing is what worries me most. So many hospitals have rota gaps, not enough doctors or nurses, when we all expect the number of patients to skyrocket as winter approaches.
"Patients get a poorer experience."
Winter funding will help in some areas, but often won't be enough to recruit the required number of staff. It’s not just hospital doctors either – we need more GPs as well. My local surgery is looking at closing its doors to newcomers because there are already too few doctors for their patients. Not enough staff makes it harder to get a GP appointment, and harder to be seen quickly in A&E or on the wards.
Sadly, patients then get a poorer experience. Short staffing will increase the pressure on hospitals and emergency services just as the public need them most this winter.
Dr Roshana Mehdian, surgeon and trauma and orthopaedics registrar, London
At the moment my main fear is not winter, but the bigger picture.
The government has sought to undertake a radical shake up of the NHS in the shape of Sustainability and Transformation Plans. These plans have been formed and are due to be implemented without public scrutiny. It has even come to light NHS England has told all trusts to keep their plans private.
This is extremely concerning. There have been reports STPs are likely to result in the closure or downgrade of 1 in 3 hospital A&Es. Trusts themselves are said to be very angry about the lack of time, funding, and public scrutiny of the plans, but their hands are reportedly being tied; another top-down reconfiguration.
Sustainability plans may be positive, but if so why not make them public? They should be shared with the public and debated openly. That's not happening. Instead the plans are being implemented in an underhand manner, with a concerted effort to keep them secret.
Huge swaths of our hospitals could close or be downgraded, beds be further limited, and services made unavailable to local populations without appropriate scrutiny – that really frightens me.
Dr Osman Khalid, GP trainee, London
Every winter is a pressure in the NHS – this year will be no exception. Now I am most worried that the NHS will finally run out of its most precious resource and the one thing that has been keeping it together for so long: its staff and their goodwill.
This year the government mishandled its way through the junior doctors contract ordeal, resulting in the first doctors strike in a generation. We're left with half of junior doctors emigrating or ending their careers after their foundation training. Those who remain must lick their wounds as they recover from being called “misled” and “militant”, and being accused of “playing politics”.
"A demoralised workforce will eventually say that enough is enough."
As the government blunders its way through Brexit, the Department of Health has announced its plan to reduce reliance on European doctors. In my department 1 in 3 doctors are from the EU. One European doctor in my department has resigned and I see no sign of a replacement.
As we haemorrhage staff, those already ubiquitous rota gaps are becoming more commonplace. Locums once filled many of these shifts, but the government has chosen to cap their pay and end this practice in order to cut costs.
I’ve had colleagues who have been forced to take on last-minute 24-hour shifts because of rota gaps and not get paid for the extra hours. They felt obliged to stay and cover the shift purely out of responsibility for patients.
I fear a thinning, demoralised workforce will eventually say that enough is enough. No more extra hours for free. No more going the extra mile.
The knock-on effect could be catastrophic. Waiting times in A&E, already reaching record levels, could increase further. Beds could become scarcer as there are fewer doctors to discharge patients. Waiting times for elective surgery would soar.
As we see the political winds turn and the relationship between government and frontline NHS workers turn frosty, one thing becomes clear: Significant changes are needed if the NHS is to weather the storms this winter.
Stella Vig, consultant surgeon, Croydon
Ever since I qualified in 1991, the winter has been a challenge for the NHS. This year feels different as the NHS has struggled against pressures all year round and now goes into a deep freeze.
Financial pressures are high, the bed base reduced, and workforce reduced as well as demoralised. There is no escalation money to open beds or extra resource as there has been in previous years. If finances are not kept very tight, trusts will stay in special financial measures and that is a huge driver for senior managers.
"The NHS now goes into a deep freeze."
Clinicians and managers will have to be held to account to ensure that patient safety is not compromised during these very challenging times.
Dr Jeeves Wijesuriya, GP trainee, London
We are facing an enormous challenge with healthcare in this country, because we have failed to adequately plan for the long term. The changing demographics of our population and the challenges we face with recruitment and retention of doctors have left us without an adequate workforce to meet demand.
The NHS is globally acknowledged to be one of the most efficient healthcare systems in the world, but it continues to be underfunded as a proportion of GDP compared to similar nations with similar systems.
As we approach a challenging winter, we must acknowledge that unless we address the needs of our workforce, inadequacies of funding and provision of social care, these problems are only set to worsen.
Dr Mike McLaughlin, A&E doctor, Hartlepool
We thought we had heard the last of NHS winter crises, but not only could they be back, they could be worse than ever. Jeremy Hunt has no plans to tackle this, and that’s frightening. A damning indictment of a government that has lost control.
Not only is the NHS facing a bed crisis, it's facing a staffing crisis. Experienced nurses are leaving, especially in emergency medicine. Fewer doctors are choosing A&E as a career.
As a result of Sustainability and Transformation Plans this government will oversee shutting down more hospital wards, closing more A&Es, and reducing staff numbers, putting further pressure on an already perilously strained system.
I fear for the very future of the NHS as we know it. The current government has no plan, no money, and no commitment to the NHS.