Ahead of what trust leaders expect to be an incredibly challenging winter, the results of this year's survey reflect the cumulation of pressures facing the NHS which have been building up for a decade or more, exacerbated by the pandemic and the lack of resolution for all staff groups undertaking industrial action. These 'fault-lines' include workforce challenges, and staff shortages, a lack of sufficient capital investment and wider financial pressures as well as a need to address health inequalities and place social care on a sustainable footing. 

In the midst of these challenges, these results also serve to highlight the commitment of trust leaders and their staff to patients and to quality improvement, highlighting a number of achievements and innovations that trusts and their partners in local systems have led successfully over the past year.