NHS Providers says the health service has, over the last month, become as stretched as it was at the height of the pandemic in January, and the situation is likely to get worse before it gets better.

In a letter to the prime minister, chancellor, health secretary, and chief executive of NHS England, the organisation which speaks for every NHS hospital, mental health, community and ambulance service in England sets out a combination of pressures which many trust leaders say now, collectively, match the strain the NHS was under at the start of the year.

These include:

• work to recover care backlogs across hospital, mental health and community services
• record levels of demand for urgent and emergency care
• growing admissions for COVID-19 alongside increasing mental health and long COVID pressures
• continuing additional infection control measures restricting capacity
• a large number of staff self-isolating and increasing numbers suffering from stress and mental health issues
• high levels of summer leave, including time-off that was postponed earlier in the pandemic.

The letter warns these pressures will probably intensify in the coming months as the service contends with continuing COVID-19 infections; the challenges of extending the vaccination programme, organising boosters and the expanded flu campaign; and dealing with what is expected to be one of the most difficult winters the NHS has ever faced.

All this, for a workforce that is already 'tired and overstretched'.

The letter calls on the government to make 'the right decisions' over the next month as it finalises NHS funding for the second half of the financial year.

Because of COVID-19 the NHS budget was only set for the first six months of the financial year and the government now needs to set the NHS budget for October 2021 to March 2022. The letter sets out what trust leaders need from the government to meet the pressures they face:

• continuation of discharge funding that has helped to prevent delays for patients and freed up capacity to admit people who need treatment
• top up financial support for planned operations to maintain, and speed up, progress on tackling the care backlog
• emergency capital funding to expand emergency departments, crisis mental health services and community and ambulance capacity in time for winter
• full funding of the government's recently announced 3% pay award, ensuring trusts do not have to eat into other budgets, risking patient care
• help trusts speed up recovery by funding the use of all available capacity, including the independent sector, as happened earlier in the pandemic
• recognise that the immediate pressures will restrict trusts' ability to make the near record efficiency savings needed to balance budgets pre-pandemic
• no repeat of the distracting and unhelpful uncertainty from the start of the year when trusts were only informed of their budgets 13 days before the financial year started.

The chief executive of NHS Providers, Chris Hopson, said:

"The NHS has delivered in an extraordinary way over the last 18 months, often at the drop of a hat.

"Many NHS chief executives believe the next phase of our fight against COVID-19 is likely to be the hardest yet given the scale and breadth of pressures they face.

"They are clear that, now more than ever, the NHS must get the funding it needs to win that fight.

"Trust leaders have strongly welcomed the financial support they've received over the last 18 months. It's been crucial to coping with COVID-19.

"But the government is currently stressing the need to repair the public finances and some are arguing that NHS funding can 'return to normal'.

Trust leaders want the government to be clear with the public about the scale of the challenges the NHS faces over the next nine months.

"Trust leaders want the government to be clear with the public about the scale of the challenges the NHS faces over the next nine months.

"A massive care backlog to get through, a much more complex second phase vaccination campaign, likely further waves of COVID-19 and the prospect of one of the worst winters on record.

"Trusts and frontline staff are committed to maintaining the quality of care that patients rightly expect through these challenges.

"But that can only happen if the government provides the right funding for the rest of the year.

"Trust leaders are seriously worried that the current signals from government indicate this won't happen."