In response to an unpredictable external environment and forthcoming winter months, trust leaders expressed significant concerns about seasonal pressures, COVID-19, workforce burnout and staff shortages. Trust leaders also noted how their trusts and local areas are preparing for this year's seasonal pressures, particularly with winter planning and collaborative working as a system. The survey results emphasise the significant pressures trusts are under and some of the concerns ahead of winter, and highlight some of the achievements and innovations trusts and their partners in local systems have led so successfully over the past year.