DO you know what a medical emergency looks like? Let’s hope so. “People should consider whether their condition is an emergency, such as a stroke, heart attack or major trauma, before going to A&E,” says health secretary Humza Yousaf. He has been reminding people all spring and summer not to attend hard-pressed A&E departments unless there is genuinely an emergency.

But how do you tell? Say it’s Saturday and you have a wound that you fear is infected – should you rock up to casualty then? What if you have an elderly relative who’s fainted – is that an “emergency” or should you give her a cup of tea and take her to the GP in the morning? What if you have sudden painful stomach ache and can’t understand why? What if it’s 10pm, you have an unwell teenager in acute mental crisis, they’re on a year-long waiting list for counselling and NHS24 can’t help – does that meet the threshold for an A&E visit?

This is the difficulty with asking us only to attend in an emergency. We might decide to stay away when we shouldn’t.

Fortunately, we have GPs and NHS24 to help us assess our symptoms and they will be very busy this winter doing exactly that.

But they too are under pressure and can be difficult to get hold of quickly. The lingering worry is that some people who should really attend casualty departments, will not do so. Some may mistakenly see themselves as a burden on the NHS; others may be put off by eight-hour waits on plastic seats, but by staying away, they risk getting more sick.

Even if they do attend, there is no guarantee of timely treatment. In a tragic development earlier this week, two patients died while waiting for treatment at Queen Elizabeth University Hospital A&E in Glasgow. It’s understood they had cardiac arrests while waiting to be assessed.

NHS staff and patients are looking at the winter ahead with dread in their hearts.

No wonder the Royal College of Nursing (RCN) Scotland, worried about staff shortages, opens a strike ballot today for the first time in its history.

The current state of the health service is unprecedented. This week, it emerged that in August, A&E waiting times were the worst on record. August, for pity’s sake: the height of summer.

In Australia where it has been winter, flu – suppressed for two years by anti-Covid restrictions – is back with a vengeance. This raises the prospect of increased winter flu infections in the northern hemisphere, probably on top of a Covid resurgence: how, one wonders, will we cope?

Humza Yousaf has promised 1000 more staff this winter recruited from overseas, including 750 more nurses, midwives and allied health professionals, but he admitted it would be “an extremely challenging season”.

How did we get here? A persistent theme of Mr Yousaf’s statement was to associate the pressures on the health service with “recovery” from Covid, but this is only half the story. Yes, staff absences caused by Covid have contributed to pressures on remaining staff; yes, huge backlogs of procedures are creating additional pressures (backlogs that staff are making inroads into); yes, as a result of all this, staff are burned out and having to take time off for stress. (How inadequate our lockdown applause seems now against this torrid picture of relentless effort.)

But medical and nursing leaders point to long-standing problems that predate Covid-19 by years. The pandemic has compounded the stress, they say, not created it.

Top of the list is the recruitment and retention of staff. Currently, there are 6,000 nursing and midwifery vacancies in Scotland but there were already over 4,000 in 2019.

Nurses feel wretched that they can’t give patients the quality of care they need, but this understaffing also adds to the pressure on hospitals. Take community-based nurses. They help keep elderly and infirm patients out of hospital. Insufficient community nurses mean patients are more likely to be admitted to wards.

Brexit has made recruitment of health and social care staff more difficult, without doubt, but we are still not training enough nurses to meet need. Attracting people remains a challenge: an upswing in interest last year, hasn’t been sustained. Nurses who graduated this year in Scotland all have jobs and this year’s training courses have begun, but 700 funded places remain unfilled. Clearing will continue until December in a bid to fill them.

We can recruit from abroad, as the health secretary is doing, but this raises ethical questions if nurses are coming from countries with hard-pressed health services of their own.

Meanwhile, a BMA Scotland survey of junior doctors (those who are neither GPs nor consultants) has found that nearly half are considering quitting the job in the next two years, feeling pressured and undervalued.

Scottish ministers repeatedly allude to the “record numbers” of staff – the health secretary did so twice delivering his winter plan – but for those at the sharp end, that’s not the point: the real question is whether there are enough staff to meet need and to make working conditions tolerable. The answer is a resounding “no”.

The integration of health and social care is the big reform that was meant to reduce pressure on hospitals from an ageing population, by caring for people for longer at home.

But the pace of integration has been too slow and social care faces staffing shortages of its own.

Which brings us back to recruitment and retention. Fair, competitive wages and sustainable working conditions are needed to attract and keep staff.

That is what underlies the historic strike ballot for members of the RCN Scotland. Their rejection of an under-inflation five per cent pay offer, is not just about the cost-of-living; it’s driven by fear that, without a decent pay rise, more colleagues will leave this vital profession and it will get even harder to attract new nurses.

This is punishingly tough for the Scottish Government. Budgets are tighter than ever, inflation will continue to eat into pay awards and there’s no simple fix for a scarcity of workers.

But there’s no escaping it: had the NHS and social care been in a better state to start with, Covid would not have brought things to this sorry pass before winter has even begun.

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