The hushed lamplit bedroom is stuffy and smells of sickness.
An 84-year-old woman whimpers occasionally, clutching her abdomen. She sounds like a wounded animal. Otherwise, she is silent.
Occasionally, she vomits into a bowl held by her daughter who looks worn out and lost. You sense immediately this family has all been trapped in this tortuous stasis for some time.
The lady has kidney failure and is now at the end of her life. She has an end of life care administrative form, but inexplicably none of the drugs it says she is supposed to have to relieve pain and respiratory secretions - which can feel like drowning.
Her two daughters have no contact details for a palliative care team or district nurses, have been given no advice, and have struggled to get time with their GP.
A wounded animal wouldn’t be allowed to suffer like this.
In distress, the family has rung 999. The paramedics arrive, not to handle an emergency, but to spend two hours on the phone in this lost limbo of a room, to an out-of-hours GP, in turn mediator to the palliative team, to help this family set up support to help their mum die peacefully.
While they’re doing this, a couple of Category 1 calls - the most serious emergency calls which should be answered within seven minutes - chatter raspingly on their radios. They’re not necessarily the closest team on hand, but aren’t free to answer them either way.
“This family has been let down,” explained paramedic Simon Day, when the crew finally left at 10pm. He looks exhausted in the headlights of their truck. “We have been here two hours, all we have done is arrange an appointment.”
As the government fails to get a grip on Britain’s NHS crisis, stalling the publication of plans to recruit doctors, GPs and nurses to fill some 112,000 vacancies in England, it is our emergency services who are “filling in the cracks”.
The Mirror witnessed this during an 11-hour shift with West Midlands Ambulance Service last month. On the Tuesday after bank holiday, traditionally a day busy with urgent call-outs, none attended was what even the crew would term a true emergency.
Each one resulted directly or indirectly from lapses in primary care or wider social or mental health support.
The alarming winter crisis with headline A&E waits and ambulance queues has receded, but we found paramedics still feeling unable to do their job, claiming a four-hour queue is “common”, and that it is “rare” to meet target attendance times.
One described attending a 103-year-old two weeks previously who had been on the floor after a fall for 17 hours.
“It breaks your heart,” she said. “We go in waving a white flag.”
The need to “mop up” primary care failures is one key driver of delays.
Simon explained: “Every ambulance crew delayed at hospital, dealing with someone who can’t get a GP appointment, or mental health and social care, cannot respond to the life-threatening calls people believe we are there for.
“It’s something ambulance staff see day in, day out. The bottom line for me is if we haven’t got the ability to respond to emergency calls, we’re not an emergency service.
“Until there’s a radical cohesive response from government across all healthcare, the public will be at ever increasing risk of harm.”
He explained desperate non-emergency patients will now call 111 or even 999, and either because of overly simplistic triaging, or their own frustration, use trigger words which prompt an ambulance call-out.
He added: “People are calling 111 to get a GP appointment, and they are getting an ambulance instead.”
His colleague Jo Lewis described attending an immobile gentleman who couldn’t get his surgery to pick up the phone. He was “poorly, but didn’t need hospital.”
“We tried calling, we’d be on hold for 18 minutes and then get thrown off. In the end I walked to the surgery to get him an appointment - I was livid,” said Jo.
The Tories’ workforce strategy setting out NHS recruitment plans was due to be published last year but has been delayed over and over.
The 15-year plan is set to double medical school and nursing training places. An outlay of £1billion has been promised, but this week it was reported it has still not been signed off.
Community care is hardest hit by shortages, with district and community nurses down by almost half since 2009.
The Royal College of General Practitioners has said 6,000 extra GPs are needed. The numbers of fully-trained GPs are down, while the population rises, although the government points to trainee numbers being up. Large large numbers are proposing to quit.
Rishi Sunak has already proposed GP receptionists shoulder responsibility for re-directing some suitable patients to pharmacists, who will in turn be given authority to prescribe more in some cases.
A letter to the prime minister from 40 health organisations this week has called for his plan to be published without delay.
And in response to the knock-on pressures this tsunami of gaps in the system causes, mental health-related sick days taken by ambulance staff have increased by a third since 2020.
Simon admitted: “I am frustrated. Colleagues are suffering burn-out. We chose to be paramedics, not nurses, mental health practitioners or even GPs - we are being used to fill in the cracks.”
It doesn’t help that the number of assaults on emergency workers is also increasing.
This week it was reported paramedics are being told to take a police escort to more than 1,200 addresses in response to the abuse they have faced, although common assault or battery of an on-duty emergency worker is a crime.
The Mirror met Simon, 56, and Jo, 49, at the Shrewsbury hub.
The first call was to a mental health facility. Jo estimated in her experience near half of calls she answers are mental health related nowadays.
England’s 10 NHS regional ambulance services saw mental health related 999 calls rise by nearly a quarter between 2018-19 and 2021-22.
Yet, Simon claimed: “We do half a day’s mental health training a year if we are lucky.”
Recently, Jo recalled a distressing call to a man with long-term mental health issues threatening suicide. They could not leave for four hours as no mental health team had staff available to support.
The lady we pick up now isn’t an emergency, the crew decipher. They decide she may have had a reaction to medication and the facility doesn’t appear to be able to access other transport.
At Royal Shrewsbury Hospital we join five ambulances queuing.
A queue, but it’s nevertheless a welcome reduction. In February, Simon recalls how he spent a 10-hour shift waiting with a patient, and then re-joined her on his next day’s shift, still waiting. She was in pain with abdominal problems.
Queues this extreme caused dangerous delays, as ambulances were stuck waiting, unable to answer urgent calls. Figures for last year suggest the number of patients who died before paramedics reached them hit an average of 120 a day, although causes would have varied.
Certainly call-out wait times in England grew in December - to 93 minutes on average for a Category 2 call, when the target is within 18 minutes.
Two days before our visit, Jo still waited over four hours with a patient, and explained this is still common. This time, it’s 25 minutes as the lady has a nurse accompanying her. Our next call comes in. An overdose. Inside a darkened B&B room a man is curled in bed and his partner is slurring. They have been waiting over an hour despite the call being defined as a Cat 2.
But there’s no true emergency here either. Both men are conscious and not in any immediate danger. They appear to have taken Diazepam recreationally, but aren’t at serious risk.
The paramedics spend an hour puzzling the context. It transpires the men are homeless, and there’s an addiction and mental health background potentially.
During this time two Cat 1 calls come in.
“I’m sure they need lots of support, but we are not it,” said Simon. He is full of compassion, but this call has taken up a lot of time - the paperwork takes even longer - and after making sure the men are safe, there is little more he can do.
Next, we are called to an 87-year-old woman who has chest pains. She’s in a GP practice.
Again, this is registered Cat 2, but she waits 40 minutes for us to arrive.
Simon points out if an ambulance is taking longer than a taxi would, something is going wrong.
We find her in the nurse practitioner’s room sitting in her coat looking apologetic and confused.
“I haven’t even got my phone with me,” she frets. “I need to call my daughter and let her know what’s happening.”
Simon soothingly explained chest pains are a genuine reason to call 999.
But the disturbing fact emerges this lady has been suffering the pain for two weeks and in that time has been trying to get a GP appointment, unsuccessfully. Today, she has finally managed to see a nurse practitioner
Simon and Jo look astounded, but focus on the task in hand.
“We may have been called out anyway,” Simon admitted, later. “Or the GP may have referred her to an outpatient appointment. But a nurse is not going to make the call.”
The lady is safely deposited at hospital.
By evening, we finally get to answer a Cat 1 call, even diverting from a Cat 2 call which is a motorcycle accident.
This call has been deemed more serious because the notes suggest the man is unconscious. Only when we arrive, he’s not. He’s homeless and drunk, curled in a ball.
It is a desperately sad case, the gentleman is clearly suffering from a range of social problems, but the motorcyclist’s needs were probably more urgent.
The paramedics spend a lot of time with him, again understanding the context, checking there is no emergency need. In the end, he simply walks away.
Towards the end of the shift we join the lady who needs end of life care.
In her oppressive bedroom, Simon repeatedly makes calls to the out of hours GP.
“She has an admin form for an end of life package but no package, no drugs, no advice, no contact details. No one has spoken to the family…” He repeats these facts patiently for two hours by her bedside.
It is the paramedics who explain to this confused family that their mother and grandmother is truly facing the end of her life.
Simon and Jo feel at least they have helped, that is fulfilling - but is this what they trained for?
The family is so grateful for the appointment Simon arranges for early the next morning to discuss palliative care. If only they’d had that before...
“That would have saved us calling an ambulance,” they say.
