I catch him before he slips out of the NHS ahead of Christmas. After 46 years in the health service, no better time for an exit interview with a leading NHS trust chief executive, who has seen the best and worst of it. Nick Hulme is in brutal truth mode. He has one foot out of the door of his East Suffolk and North Essex NHS foundation trust, just as the resident doctors strike for the 15th time, amid a rampant flu crisis. But he’s off, his time is up.

“I can’t remember a time when the NHS was at such risk,” he says. Labour has put in more money and staff, productivity and activity has risen a bit, waiting times down a bit, yet waiting lists stay stubbornly high. “That’s dangerous ammunition for Nigel Farage and the Conservatives,” says Hulme, “a narrative for people who want to kill the NHS.”

Private practice is soaring, but it fell steeply when Labour last cut waiting to historic lows. That could happen again. He says that at the “top of Bupa’s risk register is the danger that NHS waits fall”. He scorns politicians promoting “choice”, when that would require spare capacity, and at the moment the system is running red hot. He’d be tougher on consultants keeping their lists long to fuel demand for their private practice, but the BMA and Royal Colleges, with their professional silos, are hard to confront. “Look how they oppose physician associates, used widely across Europe,” he says.

He laments how in the pandemic everyone did everything, out of silos, acting up and acting down collaboratively: he thought it was a new dawn, but afterwards they went straight back to their restrictive practices. Once a shop steward for the now defunct National and Local Government Officers’ Association (Nalgo) trade union, he knows about demarcations. He started out as an 18-year-old porter, rising to a brief (unhappy) time inside Boris Johnson’s No 10.

Our conversation covers familiar NHS territory of forever dilemmas and paradoxes. He is full of enthusiasm and frustration, strong conviction and infinite exasperation, struggling to make the system work despite rotating politicians with spinning targets, austerity and reorganisations. Hulme is exceptional, yet typical of many of the best public servants, confronted like them with the effects of poverty and inequality beyond his doors. His trust has a delightful cottage hospital in affluent Aldeburgh, worth a fortune if he dared sell it, boasting a dementia-friendly “peaceful sensory garden” kept by its many volunteers, who collected £320,000 for a new X-ray machine. But his patch includes the poorest places, too: Jaywick and Clacton. “What couldn’t we do for Jaywick with those scanners. They have fewer GPs, too,” he says. A Clacton family just told him they wouldn’t go for smears or screening, as it took three bus rides with small children.

These facts about warped NHS spending priorities are hard but not impossible to change, he thinks. Poor places get less, the older patients dominate resources, maternity and children are neglected, shifting funds to prevention looks near unattainable when the public always demand more treatment. He says 70% of patients in his beds are over 65, with 75% suffering the diseases of poverty – smoking, obesity, diabetes, missed early diagnoses “and poverty itself”. The NHS spends expensively on the effects of poverty that could be more cheaply prevented. He would run a social priority list, treating “the Clacton postman’s knee, off work for a year, run out of sick pay, before getting the retiree back on the golf course”.

The day we talked at Colchester hospital, he was bristling over an infuriating Care Quality Commission inspection after an interview checking if his trust is “well-led”. “But whatever their judgment, I’ll be gone!” The last inspection found Colchester “requires improvement”. That grates. He agreed reluctantly to add to his trust a hospital Jeremy Hunt called “the worst in England” and did well to lift it out of “special measures”. Marked down over documentation, he asked the inspector, who had no background in acute hospitals: “But did you encounter any poor care? ‘No’, he said.”

Nothing is easy. His gleaming new £90m orthopaedic centre has mostly private-style single rooms, en suite. “But that costs 30% more in nursing than bigger wards.” He is disappointed that fast-flowing throughput hasn’t raised productivity more: some surgeons do four operations when they used to do three, others still only do three but could do five, under scrutiny from the new Epic electronic data system. “Why do some wards turn around an empty bed in 20 minutes, others take three and a half hours?” It relieves stress in a ward to keep beds empty, but people wait in corridors. “NHS work was easier when I began, and more fun,” he says. “Most patients weren’t very sick, staying in for two weeks after a hernia.” Pressure to raise productivity means chasing every unforgiving minute: electronic labels halve the time to take a blood test. “But what do they do with that extra time? Chat or do more tests?” he says.

The orthopaedic centre is still not full: that requires the integrated care board – a local control system undergoing yet another interminable restructure – to close units in district generals to send patients here for better specialist treatment. Will that happen? He sighs, recalling a time he closed a dangerous A&E in a small hospital: it took 42 public protest meetings led by a local MP, and many doctors admitted in private the unit was unsafe, but not in public. He jokes that he would be a new Beeching (the man who shut more than 2,000 railway stations) closing district general units, to send patients to further off specialist centres. But others plead convincingly too for the decentralised familiar local.

He has survived many a 10-year plan, forgotten in a year or two, but enthuses about Wes Streeting’s 250 neighbourhood health centres. However, remembering similar clinic plans in Ara Darzi’s 2008 report, experience makes him wary: “Will hospitals swallow up all the money again?” A rumbling under Aneurin Bevan’s founding principle worries him most. “Unless the NHS improves fast, people will fall for charlatans offering snake oil alternatives. This is the best system, but not producing the best results.” He departs with hopes and fears – and sharp words for privileged resident doctors. “Not many have such a guaranteed very good job and pension for life, starting at £38,000, £109,000 once fully trained.” He thinks they forget their privileged state, out of touch with what others earn in the NHS.