Daily case rates for new positive covid-19 tests have now reached around 35,000 a day and the government is predicting they could reach as many as 100,000 a day. The good news is that, for this pattern of variants, vaccines have significantly weakened the link between infection and the high levels of hospitalisation and mortality we saw in previous waves of covid-19.

When we saw 35,000 positive tests a day on the way into the last phase of covid-19 (16 December 2020) and on the way out of it (20 January 2021) we had nearly 19,000 (16 December 20) and 39,000 (20 January 21) covid-19 patients in hospitals. At the moment, we have less than 3,000 covid-19 patients in hospitals in England. This should give us confidence that, as covid-19 infection rates rise, the NHS will see significantly lower numbers of patients in hospital than in previous waves. 

But that doesn’t mean that the NHS won’t be under huge amounts of pressure. Just focusing on the potential level of covid-19 admissions completely misses the broader picture. You can only see the full picture of what’s happening across the health and care sector, by looking at the total demand the NHS is currently coping with and the significant capacity constraints the service is juggling at the same time. Trust leaders are saying that it’s a combination of five different elements that is currently causing them significant operational problems. 

First, trusts are working flat out to tackle the backlogs of care that have built up thanks to the disruption caused by the pandemic. The size of the elective care backlogs are well known and were aired again at the weekend by the new secretary of state. Trusts are currently operating at maximum capacity, including extended use of theatres and weekend working, to tackle this backlog and that is bringing significant pressure. It’s also important to remember that there are other backlogs too—backlogs in cancer care, but also in community services, for specialist dentistry and some children’s services for example, and in mental health services with particular issues in crisis and eating disorder services for children and young people. 

Second, trusts are experiencing huge pressures on the urgent and emergency care pathway. We understand that in many instances, this reflects an increase in the complexity and severity of some patients’ conditions, as well as considerable pressures on primary care. Last week’s NHS data release showed that last month was the busiest June on record for urgent care. Ambulance services were showing 27% increases in category one incidents—the most serious incidents—compared to the last pre-covid June (June 2019). Acute hospital emergency departments were under similar pressure and it’s important to note that in April 2021, the latest month where data was available, the number of people in contact with mental health services also hit record levels. Everywhere you look, the NHS is seeing demand not just return to pre-covid levels but, often, in greater numbers than before we hit covid-19.

But the trust task is made even more difficult by two key capacity issues. The third factor trusts are grappling with is the continuing loss of capacity as a result of the need to protect patients, service users, and staff from nosocomial infection. According to the Health Service Journal, in May, acute hospitals were having to operate on around 12% fewer beds than between 2015-19. Unsurprisingly, more than a third of hospitals were operating at bed occupancy levels of more than 95%, way beyond the 85-90% that is considered to be safe, appropriate and effective. 

Over the last few weeks it’s been staff capacity, the fourth factor, that has most been worrying chief executives. Many staff are still exhausted after over a year’s commitment to frontline service during unprecedented times. In addition, as covid-19 community infections rates have been rising, increasing numbers of staff have needed to self-isolate, exacerbating existing pressures. One trust told us last week that it has lost 500 of its staff to self-isolation. This problem is only going to grow as infection rates increase, exacerbated by the fact that the service hits the peak summer leave season. Trust leaders are predicting that the impact of summer leave will be significantly higher this year given how much leave has been held over from previous covid-19 waves. Trust leaders are adamant that staff have to take their leave or they risk burnout. One trust was predicting last week that, in three weeks’ time, it would have an overall absence rate of 20%, which would necessitate the cancellation of 900 operations. 

If a river is full and the ground is sodden, it doesn’t take much extra rain for the banks to burst. Hence, the impact of the fifth element—the increasing covid-19 caseload, driven by the increasing rate of infections. Even though covid-19 hospitalisation rates will be much lower than previous waves, we know that some trusts are already having to dial back on the speed of backlog recovery to cope with the rising covid-19 caseload as infection rates rise. The impact of long covid is still unknown, but demand for these packages of complex services, also continues to grow. 

What can we do about this? Trust leaders know that it is their job to juggle these very difficult pressures and continue providing the best quality of care to all who require it, prioritising on the basis of clinical need if that is necessary. But there are three things the government can do. 

First, in the immediate term, it can review its approach to NHS staff having to self-isolate if they are double jabbed. Second, it can be honest, open, and clear on the pressures the service is facing and the trade-offs that will have to be made. But, most importantly of all for the long term, it can use the forthcoming spending review to ensure that there is a proper match between NHS demand and capacity, and an appropriate reward settlement via NHS pay.

Chris Hopson is the chief executive of NHS Providers, the membership organisation for all of England’s 215 ambulance, community, hospital and mental health trusts. 

Competing interests: none declared.