By ITV Wales Journalist Ryan Bounagui
The sense that the Welsh NHS has been operating under immense pressure stretches far beyond the coronavirus pandemic.
Even in pre-pandemic times, in what must now feel like a different world for many of those working in the NHS, it was clear the health service was struggling to cope.
Damning reports questioning the sustainability of the NHS, people living with painful conditions complaining of long waiting lists to be seen and dire warnings from senior health figures: the NHS was feeling the heat long before coronavirus existed.
As far back as 2014, the British Medical Association (BMA) Cymru Wales was warning that the health service faced “imminent meltdown”.
Then, in 2020, the coronavirus crisis erupted and changed everything.
Hospitals were stretched to capacity, GPs were forced to completely change how they operate and interact with their patients and the entire health service came under an almost unthinkable amount of pressure.
But, on top of the obvious coronavirus challenges, what is it that is driving this immense pressure on the NHS? Where are the fault lines in a health service every one of us relies on at some stage in our lives?
And, most importantly of all, what is the answer to fixing all of this and reducing the strain?
ITV Cymru Wales has spoken to a range of senior health figures to get their insights into the NHS, where they think its pressure points are and what they believe needs to be done.
Staffing and recruitment
It's often said that the Welsh NHS would be nothing without its people.
Those last few words could be said of virtually any organisation in the world but they feel especially pertinent when discussing the health service.
From the consultants and emergency department nurses to the cardiologists, neurologists, paramedics, surgeons, GPs and paediatricians; the NHS relies on a wide range of people with an even wider range of skills and abilities.
Although, speaking to senior medics it appears that staffing issues are having a huge detrimental impact on the functioning of the health service.
"Well I think at the moment we've got several challenges," says Dr Olwen Williams, speaking in her capacity as vice president of the Royal College of Physicians in Wales.
"Not only the winter pressures which are normal at this time of year but added on top of that the pressures of the backlog from the work that hasn’t been done over the covid pandemic.
"But I think probably more phenomenally our challenge is around the workforce and I cannot stress how much the workforce has actually contributed over the last 18 months to ensuring that safe care has been provided.
"What we've realised is that the number of individuals that we've got within the workforce is not adequate for providing services on an ongoing basis.
That issue around staffing numbers, Dr Williams believes, had existed before coronavirus struck.
"I think we went into the pandemic knowing that we needed more doctors, more nurses, more care assistants, both in the acute and community sites and at the moment what we're actually finding is that we definitely need [more staff]."
Dr Williams' view is shared by the man who helps oversee the largest health board in Wales, Betsi Cadwaladr University Health Board, Dr Nick Lyons.
Interestingly, Dr Lyons believes funding - the issue that so often dominates the seemingly endless political rowing over the Welsh NHS - is not the problem. It’s staffing.
"Money isn't the issue here," Dr Lyons says.
"I think the main problems for us are staff and training more staff. The problem isn't the staff, the problem is we need more.
"It's the inability to recruit that is our real challenge."
"For me, it’ll be staff, training more staff, getting them to the frontline and working in different and more innovative ways.”
Dr Williams offers a practical suggestion as to how she thinks some of those staffing issues can be alleviated.
"We certainly need to double the number of medical student places we've got, which amounts to about 70 places per year for the next five years," she explained.
"We know that there are challenges around recruitment and also around retention and I think that’s something the Welsh Government have to really think about."
"They have to really think about having a very robust NHS workforce plan going forward. Not just in the NHS itself but also in health and social care."
Staffing involves funding - a topic that has and will undoubtedly continue to be a constant source of political debate in Wales.
The pandemic prompted a significant increase in health spending by the Welsh Government, with health revenue funding - spending on the day-to-day running of NHS services, central support and public health activities - increasing from £7.9 billion in 2019-20 to £9.6 billion in the latest financial year, according to Audit Wales figures.
But is more money the answer to healing the NHS and pushing down the pressure gauge?
It partly is, according to one senior clinician.
Dr David Bailey, speaking in his capacity as chair of the British Medical Association in Wales, believes that with some more investment, the NHS system could perform much more smoothly.
"I think we do need to invest more," he said.
"I think, critically, we have to look at getting the numbers of staff right. We need to look at getting the estate - the hospitals, the practices - large enough that we can actually provide decent services for people.
"But we know that we invest less than other countries in the health service. Whilst it's not a huge amount it's certainly a significant amount, it's well over a percentage point of gross national product (GNP).
"We could do a lot more with that. We could provide more hospitals, we could provide more clinical staff."
The state of social care
The social care sector may be an entirely separate healthcare arena from the NHS but what goes on there has a huge impact on the health service.
Just like the NHS, the coronavirus pandemic has had a devastating impact on the social care sector and those who provide and receive care.
Social care providers have spoken of severe problems with staffing and filling roles. In September a care home on Anglesey was forced to knowingly bring in staff who had coronavirus, as it had no one else to provide care for its residents.
The social care sector's ability to cope with growing demand and provide care to those who need it, will to a considerable degree determine how much heavy lifting the NHS is required to do.
If hospitals cannot discharge medically fit patients due to the absence of a suitable social care solution then capacity is reduced. This has a knock-on effect on other patients arriving in need of treatment beds.
The Welsh NHS Confederation, the body that represents all the organisations that make up the NHS in Wales, argues that health and social care have to be more joined up in order to lower the pressure on the health service.
"We know that the unprecedented demand on the NHS needs us to work very closely with social care colleagues," says Nesta Lloyd-Jones, the assistant director of the Welsh NHS Confederation.
"But also with the voluntary sector, to keep people well at home but also for those who are in hospital that they’re able to go back to the place that they want to go back to.
"As NHS leaders we are talking about NHS and social care, they [the social care sector] are a key part, a vital part, of the health and care system.
"We are looking at things such as how we can support staff recruitment in the social care sector and also calling for increased funding for social care and also better wages for social care staff.”
A decade of challenges facing the NHS
The relationship between health and social care is one of mutual dependency, Dr Williams believes.
"We have to look at health and social care as one system, not as two separate systems," she says.
"Without one, the other won't survive.
"I think, when we look at our population needs in Wales we know we have an ageing population, we know in ten years time we'll have the biggest number of 80-year-olds ever and we have to think about that and how we actually provide care.
"Not just in our hospitals but also in our communities. Looking around investment in virtual wards, in intermediate care and also having clinicians that are happy to work in the communities with our primary care colleagues to ensure that people have care closer to home."
It’s well known how devastating the coronavirus pandemic has been for the Welsh NHS.
The virus may have been with us now for some time, although, despite the successful development of vaccines that have helped break the link between hospitalisations and deaths from Covid-19, it continues to have a substantial impact on the day-to-day running of the health service.
Many people infected with Covid-19 continue to require extensive hospital treatment, NHS staff themselves can be forced off work due to catching the virus or being forced to isolate and hospital capacity is markedly reduced to allow for social distancing and infection prevention control measures.
And that is before taking into account the huge backlog of patients and planned treatments, delayed to enable the NHS to fully focus on fighting coronavirus, that the Welsh Government has indicated could take five years to work through.
Money alone will not be enough to alleviate that pressure, Dr Williams believes.
She said: "You can throw a lot of money at the backlog, I'm not sure if that is going to make a huge difference to actually making it any shorter. And when we hear the health minister say that it could be five years before it's cleared, I tend to agree.”
The belief that it is time - not money - that will help alleviate the wide range of pressures brought on by coronavirus is also reflected by Dr Lyons.
"Our emergency departments were designed for a pre-covid world," he says.
"Now we have to keep, obviously, our patients who we are concerned might have Covid away from those who don't for everybody's safety.
"We all know about social distancing... Waiting rooms were never designed to accommodate that sort of pressure.
"I think it’s going to be several years before the system stabilises.
"I think there are a lot of unknowns in this. It's difficult to know how long, because we don't know what the future holds, but I think it will be some time."
The Welsh Government said it was confident the NHS would find its way through its many challenges.
Eluned Morgan, the minister for health and social services, said it was her firm belief things would improve.
"I don't think the NHS is broken," she said.
"I think it’s under pressure like it's never seen before. Not since the days when Aneurin Bevan established it, but I'm absolutely confident that we're going to get through this.
"We've already put significant additional funding in, to help the ambulance service for example, £25m additional funding in there.
"We've got the army helping us out, to try and get to people quicker."
On the issue of social care, she said: "It's not going to be a quick fix but we're having huge recruitment campaigns, we've put a huge amount of additional funding into the system.
"There's lots of things coming together here that we're trying to fix to get us through the winter and then, of course, we're going to have to look at a longer term fix because we have an ageing population and that's going to be something that's not going to go away.
Despite all the challenges and the ongoing pressures facing the Welsh NHS, there remains a notable sense of commitment from some of its most experienced people.
For those who have spent their working lives in the health service, there is a steadfast belief that things can and will get better with some improvements in places.
Dr Bailey explains: "I've lived my entire professional career as indeed have all doctors, pretty much... We've all lived through this. The BMA, all of the health unions, are utterly committed to a free at the point of service NHS.
"But we do have to start to think a little bit about what we can do to try to make those wheels run more smoothly."
Dr Williams shares that sense of commitment and is optimistic that the NHS can make a full recovery.
"Is the NHS in an existential crisis?
"No, one of the things we have got, certainly in Wales, are some excellent people who've got vision, who've got drive, who will want to take the NHS forward, who will want to innovate and change and put it in a place we haven’t seen for many years."
You can watch Wales This Week: Inside the NHS on ITV Cymru Wales on Monday 22 November at 8pm. The programme will also be available online shortly after its transmission.