Concern about the impact of seasonal pressures over winter on your trust and system(s)

  • More than nine in 10 trust leaders (95%) across all trust types said they were extremely (72%) or moderately (23%) concerned about the impact of seasonal pressures over winter on their trust and local area. 4% said they were slightly concerned. Last year, 89% of trust leaders were extremely concerned and 11% were moderately concerned.
  • Trust leaders provided various reasons for their concern about the impact of seasonal pressures over winter. The most common response was industrial action, with many saying that this will exacerbate existing winter pressures. Other workforce issues were also causing concern, including low staff morale, burnout, staff sickness, and vacancies. Many respondents also mentioned financial pressures, including a lack of winter funding, and the impact of respiratory illnesses. Equally, trust leaders emphasised the significant pressure they have already been facing over summer, alongside concerns about extremely high bed occupancy.


The financial pressures mean that we are not investing in additional capacity to support winter pressures which is very concerning given the flu / Covid pressures we are likely to be facing.

   Acute trust, South East

I suspect this year will be another challenging year with demand outstripping resources and hospital handover delays increasing and impacting on ambulance services ability to respond to 999 calls in the community.

   Ambulance trust

What is/are your Integrated Care System(s) (ICSs) doing to ensure your trust and its partners are collectively in the best position to sustain high quality services for patients this winter?

  • The most common action reported by trust leaders was planning. Many respondents said that their ICS is undertaking collective winter planning, with some saying that planning is taking place earlier and at place levels. Joint working was another action mentioned by a large number of respondents; trusts said that their ICS is involved in collaborative working with partners, and there are strong relationships across the system.
  • Another way that ICSs are ensuring their trusts and partners are collectively in the best position to sustain high quality services for patients this winter is by obtaining additional capacity. This is through opening additional beds and expanding virtual wards.

We will work closely with colleagues in other trusts and the ICS to ensure safe cover across the patch as always.

   Mental Health / Learning Disability trust, London

ICS-wide winter plan in place, working with partners including local authorities to secure additional capacity out of hospital.

   Acute trust, South West

There is winter planning in place, but I think this is not as effective as it could be due to distractions of industrial action, financial control focus, changes in commissioning and its implications and ICB reorganisation. There's too much going on in systems with finite resource.

   Acute Specialist trust, London

Likelihood of ending 2023/24 in a better financial position

  • Across all trust types, 76% of trust leaders said it was very unlikely (48%) or unlikely (28%) that their trust will end 23/24 in a better financial position than it ended 22/23.

The pressures on NHS finances are unsustainable.

   Acute trust, South East

Savings targets completely unrealistic. No joined up thinking between pressures to meet 65 week wait target and the ask to cut costs so significantly.

   Acute trust, South East

What is your biggest concern in relation to your trust's finances over the next 12 months?

  • Industrial action: Trusts are concerned about the impact of industrial action. Strikes have carried additional direct costs - due to temporary staffing costs – and indirect costs given the loss of elective income. Workforce shortages have compounded the pressure on trusts to live within national agency spend limits.
  • Inflation: NHS England recently flagged the impact of spiralling prescribing costs, with inflation feeding into higher medicines prices. However, trust leaders have flagged unfunded inflationary pressures are also exceeding the assumptions baked into both Integrated Care Board (ICB) allocations and trusts' financial plans.
  • Under delivery of Cost Improvement Plans (CIPs): The under delivery of stretching CIPs is challenging trusts' and systems' capacity to meet their financial plans. Some of this is explained by industrial action. For example, there is increasing concern that leadership and management headroom is constrained by the need to focus on managing strikes safely, limiting their capacity to deliver waste reduction plans (WRPs) and to prepare for winter. The potential under delivery of CIPs is also explained by how stretching the targets were in the first place; trusts flagged concerns that system-wide efficiency savings targets were not realistic at the start of the financial year.
  • Use of non-recurrent funds to reach balance: Providers have less balance sheet flexibility than they had at the end of 2022/23. Trust leaders have highlighted they are concerned that they will have to top-up their year-end position through non-recurrent means, therefore the financial ask in 2024/25 will be even more challenging.
  • Emergency demand pressures: Trusts are significantly concerned about their capacity to fund additional escalation beds over winter, beyond the numbers agreed in initial 2023/24 financial plans. Trust leaders have also flagged the challenge of reducing average length of stay given current levels of patient acuity.

The impact of industrial action is a major factor, not just on income but also in terms of bandwidth of operational managers to identify and deliver CIP targets.

   Acute Specialist trust, London

Very challenging system target to break even which has been impacted by industrial action. The scale of financial savings required are threatening the quality of services and the relationships across providers.

   Mental health/learning disability trust, London

The break even plan was hugely aspirational and based on achieving a reduction in acute bed numbers with removal of [Medically Fit For Discharge] FFD. None of this has happened.

   Acute trust, Midlands.

We simply cannot deliver all of our core services within our income.

   Combined Mental Health / Learning Disability and Community trust, Midlands

This is the most challenging financial year the trust has ever experienced and I am really concerned about our ability to deliver our plan.

   Acute trust, South West

  • All trust leaders (100%) strongly agreed (82%) or agreed (18%) that continued industrial action over 23/24 will compromise the NHS's ability to deliver national recovery targets for elective and urgent and emergency care.
  • Nearly all trust leaders (99%) strongly agreed (75%) or agreed (24%) that continued industrial action over 23/24 will compromise the NHS's ability to recover care backlogs including in community and mental health services.
  • Eight in 10 trust leaders (80%) strongly agreed (31%) or agreed (49%) that winter 23/24 will be tougher than 22/23.
  • Two thirds of trust leaders (66%) strongly agreed (28%) or agreed (38%) that winter 22/23 was the most challenging they have seen in their NHS career.
  • Nearly six in 10 trust leaders (58%) strongly agreed (3%) or agreed (55%) that there is consensus across their ICS(s) about where the greatest risks to service provision lie this winter. 14% disagreed and 2% strongly disagreed, whereas 22% neither agreed nor disagreed.