Trust leaders are predicting a winter like none they have ever seen before, according to new findings from NHS Providers.

And the long-range forecast is just as worrying, according to the membership body for every NHS hospital, mental health, community and ambulance service in England.

The great majority (85%) of the 183 leaders from 121 trusts who responded to the annual State of the provider sector survey are more worried about this winter than any previous one in their NHS careers. Many (86%) are concerned that their trusts will not have the capacity to meet demand for services over the next 12 months.

The survey found leaders across the NHS are using their usual ingenuity and innovation to find a way through the challenges ahead, but that they face an uphill struggle. One chief executive said that "high-quality services…will not be sustained over winter" while a chair described high vacancy rates, the threat of strikes, the cost of living crisis, COVID-19 resurfacing and winter pressures as "a perfect storm". Another NHS leader said the health service was facing an 'onslaught' this winter.

The findings come as trust leaders take part in Exercise Arctic Willow to stress test the NHS as it braces itself for the double impact of major operational pressures over winter and strike action.

They show that severe staff shortages top the list of the biggest challenges facing health and care services, with social care capacity not keeping up with demand and tight budgets also major causes of concern.

The survey found that:

• The great majority of leaders (85%) are more concerned about this winter than any previous winter during their NHS career;
• Many (86%) are worried about having the capacity to meet demand for services over the next 12 months; 
• Almost four in five (77%) are worried about having the right numbers, quality and mix of staff to deliver high quality healthcare now;
• The overwhelming majority (93%) are concerned about 'burnout' across their workforce, with 80% concerned about morale; 
• More than four in five (84%) say it is unlikely that their trust will end the financial year in a better financial position than it ended 2021/22;
• Nearly all (94%) are worried that not enough investment is being made in social care.

The survey also highlights concerns about the likely pace of backlog recovery with just under half (48%) of leaders saying their trust is on course to meet end of year elective recovery and cancer targets.

Saffron Cordery, interim chief executive, NHS Providers, said:

"Winter always piles extra pressure on the NHS and our survey paints a worrying picture for patients, staff and trusts.

"Leaders across the NHS are telling us about demoralised staff and a rise in resignations and retirements. Below-inflation pay awards, increases in the cost of living and wider dissatisfaction mean the health service is on the cusp of a highly challenging winter with a number of healthcare workers now contemplating industrial action alongside nurses.

"Social care is a huge concern. Thousands of people are in hospital beds when they could be recovering at, or closer to home, because social care capacity can't keep up with demand. For far too long, governments of all colours have dodged difficult decisions on social care reform to the detriment of patients, staff and the wider health and care system.

"And with the fiscal statement looming large, leaders will closely scrutinise announcements from the Treasury amid fears trusts will be asked to implement unrealistic efficiency measures at a time when there really is no more give. Our survey shows in stark detail that mounting pressure on tight NHS budgets is a major concern for trust leaders with a £7bn shortfall in next year's budget mostly caused by soaring inflation. They simply cannot squeeze out any more savings without negatively impacting patients.

"Our staff have worked incredibly hard to bear down on care backlogs, virtually eliminating two year waits and making real strides on other long delays. But this progress could be thrown off track with patients waiting even longer than they are currently because of the myriad pressures services face. Alarm bells should be ringing across Whitehall with warnings from our trust leaders that less than half now expect to meet key end of year elective recovery and cancer targets.

"We can't go on like this. NHS staff are pulling out all the stops in the face of severe workforce shortages, escalating demand and outdated buildings to give patients high-quality care.

"Trust leaders are working incredibly hard to prepare for winter, including working with partners across health and care. Measures to support staff wellbeing through cost of living initiatives and increasing workforce numbers through recruitment, to introducing 'patient action trackers' to help manage discharge and flow, GP link speciality programmes connecting GPs and hospital colleagues, and frailty response cars run by ambulance, community, and hospital colleagues to help vulnerable patients are just some of the innovations that have been introduced.

"It's clear trust leaders are doing all they can, but there's only so much they can do at a local level.

"We have to boost the resilience of the NHS to make it sustainable for the long-term."