If there's one thing that keeps NHS trust leaders awake at night, it's the thought of another gruelling winter.
Last winter was the toughest that many in the NHS can remember and most trust leaders expect that this one will be even more testing.
This is the most difficult and demanding time that people like me who have worked in the NHS for years have known. The scale of the challenge for trusts today is extraordinary.
Already having to tighten their belts to find unprecedented – some would say unrealistic – efficiency savings while inflation eats into tight budgets, there's little in reserve for the extra resources needed for winter which piles on the pressure not just in hospitals but also on community services and primary care including GPs and pharmacies.
On top of trusts' many financial obstacles, they have been deeply disappointed by the government's failure to cover the £1bn-plus cost of months of strikes.Chief Executive
But money worries continue to mount, with more than three in four trust leaders saying they are set to be in a worse financial position than last year. Funding pressures are fuelling concerns about trusts' ability to ramp up services for the winter surge, as well as patient safety and the quality of care.
With a record-high 7.77m appointments and treatments on the waiting list, experts have estimated that number could climb to 8m by next summer.
Yet despite the deep concerns expressed by trust leaders in our annual State of the provider sector survey there is also clear evidence of an unrelenting determination and sustained focus on improving the quality of patient care. Patients' care and safety are rightly front and centre in everything that trusts do.
I know from my time as a chief executive in the NHS that sheer hard work and determination by trusts and their staff has driven down the longest waits for treatment as they work flat out to see patients as quickly as they can.
But it can feel like an uphill struggle. More than 125,000 vacancies across the NHS in England means that persistent pressure from severe staff shortages continues to take its toll. Over one in four NHS staff absences are due to anxiety, stress and depression.
On top of trusts' many financial obstacles, they have been deeply disappointed by the government's failure to cover the £1bn-plus cost of months of strikes – including the direct costs of hiring temporary cover for striking staff and the indirect costs of rescheduled appointments and procedures. Industrial action was another factor weakening trusts' ability to tackle care backlogs including in community and mental health services.
There are worries too about the relentless rise in demand for mental health and learning disability services post-pandemic amid concerns over the long-term fallout from the cost of living crisis, and being able to give people the care they need in adequate facilities. As one trust told us, there are mental health services "working out of 1830s buildings".
We must be optimistic for the future but realistic about what these most testing times for the NHS are storing up.Chief Executive
We can't carry on like this. What NHS leaders really want to see this winter is for talks to succeed between doctors' unions and the government, which would bring months of disruptive strike action to an end. These do seem to be going in the right direction.
But if talks between the government and doctors' unions don't settle unresolved disputes, then the threat of more strikes on top of staff burnout, relentlessly rising demand for care and a severe squeeze on healthcare budgets could scupper efforts to make more inroads to those long waiting lists and put paid to the prime minister's pledge.
We must be optimistic for the future but realistic about what these most testing times for the NHS are storing up for already low staff morale and the quality of care we can give patients.
The NHS isn't only in the grip of winter but a climate where the going just keeps getting tougher.
This opinion piece was first published by The Times, alongside an article on the findings from the State of the provider sector survey.