It's complicated.

In England social care (care homes) are funded by local authorities, not the NHS, and are overwhelmingly provided by private providers. We've had decades of under-funding of local authorities, and the Conservative government has made it very difficult for LAs to raise funds via taxation.

So, during a time where we have an ageing population we do not have nearly enough beds for these people to be cared for.

When people go into hospital, either as a planned (elective) admission or as an emergency, and they get treatment, and they're ready to leave hospital they have to have somewhere to go to. Lots of people will go back to their own home, but some people will be unable to do this because it's not safe to do so. These people need a care or nursing home. Because there aren't any available beds, and because there aren't any available suitable home care packages, these people stay in hospital on the wards.

Those beds are now not available to be used.

So, now you have a problem of flow of patients through hospitals. You can't discharge patients from the ward, which means that ward can't now accept patients from elsewhere (surgery, ED) in the hospital. This means that elective care reduces, and emergency care slows down. People wait in Ed for very long times. And because ED is full people can't get in to ED, so ambos queue outside ED for hours. This means many ambos are queued outside ED waiting to transfer a patient, and not available to travel to people. So now people in life-threatening emergency or with severe injury are waiting far too long for an ambo.

Fixing care homes and nursing homes would do a lot to fix patient flow, but it's not going to happen because we have a government that hates the NHS and hates LAs and hates taxation.

On top of all of this we have an incoherent approach to staffing. The English NHS is full of staff who've come to England to work. We need these people - they improve the quality of care and they increase the amount of care we can deliver. We should be making it easier for people to come here, but we don't, we put up a load of weird bureaucratic blocks. (Because we have a government that hates immigration.)

We need to train very many more staff (there is something like 100,000 staff shortage, at least 10,000 doctors and 50,000 nurses) but we've made it more expensive to train to become a nurse, or a doctor; we've cut pay for all staff (for junior doctors to achieve pay restoration they'd need something like a 25%-30% pay increase).

We need to retain the staff we already have, but there are a range of things that make working for an English NHS trust pretty terrible. It's not just pay, but poor pay doesn't help. There's a weird thing around pensions that means many doctors can either retire early or face a massive increase in their taxes. Lots of staff have trouble getting paid on time when they start work at a new organisation. People have to pay for car parking, and they're fined if they overstay even if that overstay was caused by saving the life of a very ill patient. (These can be over-turned but why should it happen at all?). Rest areas are generally awful and expensive. Hot food is generally not available 24 hours a day. Rotas are chaotic. Doctors can apply for leave a year in advance and then have that denied with very short notice. Some NHS trusts have toxic work cultures and problems with racism, sexism, and bullying. And these are just the things I can remember, the real list is very much longer.

About demand: there has been an increase in demand for healthcare. GPs are seeing more people than they were before pandemic, but there's a perception that it's quite hard to see a GP. (I don't have much trouble, but I have cancer and my GP is pretty good, but I recognise other people have difficulty with weird access restrictions). This trickles through to ED - a few people turn up to ED needlessly. Before pandemic we had clear evidence that it wasn't really enough to make much difference to the overall ED demand. The picture is less clear during pandemic - certainly people going to GP not ED if they need GP is a good thing because they get better care, but it's hard to know if it's making the ED problem much worse.