It’s a huge relief to everyone in the NHS that the predictions of 100,000 covid infections a day, once social distancing restrictions were lifted on 19 July 2021, haven’t materialised.

The impact of such a spike on the NHS when it is working at full pelt to reduce care backlogs, cope with rapidly growing urgent care demand, and grapple with serious staffing pressures, doesn’t bear thinking about.

But covid-19 is just one of several pressures the NHS is currently dealing with. This week’s publication of the latest NHS performance data confirms what everyone on the NHS frontline already knew. Although the covid caseload may not be as large as feared, the service is under huge pressure. And, for many NHS trusts, although the pressure is differently shaped, it feels just as busy as it was in January and February.

To get an accurate picture of the pressure the NHS is under, it’s vital to look at the full range of demand and staffing pressures facing the service, not just the covid caseload. Trusts have identified six different pressures that are currently causing them significant operational problems and could make this winter even more difficult.

First, trusts are going as fast as they can to recover care backlogs. As the latest performance data shows, thanks to the commitment of frontline staff, trusts are performing really well here. In June, nearly two million diagnostic tests were completed—84,000 more tests than May and the highest figure for a year. The number of people waiting for planned care for more than 52 weeks fell by 32,000. And the number of people checked for cancer increased to 230,000, the second highest figure on record. But we also know that going at this pace inevitably puts pressure on staff, beds, and equipment.

Second, trusts are working with much lower bed capacity because of continuing enhanced infection control measures to protect patients, staff, and visitors from nosocomial covid-19 infection. We’re regularly losing around 7,500 of the NHS’s pre-pandemic 100,000 inpatient bed base. And we know that bed base was insufficient.

Third, staffing pressures have increased over the last few months and are now a major worry. Large numbers of staff are having to self-isolate due to the so called “pingdemic.” The changes to self-isolation rules to help the NHS in mid-July have had some effect, but nowhere near as big as predicted or hoped for. The next set of changes to self-isolation rules on August 16 cannot come soon enough and should, in retrospect, have been introduced much earlier.

Fourth, trusts are now in the peak summer leave period with staff also, rightly, now taking leave that couldn’t be taken in earlier waves of covid. Trust leaders are adamant this is vital to ensure the health and wellbeing and avoid burnout. It’s a real concern that the number of absences due to stress and mental health issues is rising.

Fifth, demand for urgent and emergency care is now, in many places, exceeding the levels we saw before the covid-19 pandemic. The latest statistics are stark. 2,215 patients waited over 12 hours to be seen in emergency departments in July. The demands on ambulance services are particularly concerning with the most serious 999 calls requiring an ambulance reaching 82,000 in July—a 32% increase compared to two years ago, before the pandemic. These are performance statistics we would expect to see in peak winter, not summer.

Finally, although the 5,000 or so covid-19 patients in hospital over the last fortnight are lower than many were predicting, they are still a significant pressure, particularly in hospitals with high bed occupancy for other reasons.

It’s the combination of these pressures—particularly the workforce pressures—that are making life so difficult on the NHS frontline at this point. And that’s before we reach what is likely to be a difficult winter with probable further pressure from flu, RSV, and higher levels of covid-19, all driven by seasonal factors.

The long term solutions to these pressures are clear. A properly funded NHS where capacity genuinely, and sustainably, meets demand. A fully funded workforce plan to ensure NHS staff have a reasonable workload. Capital investment in modern estates, new technologies, and cutting edge treatments.

The health secretary, Sajid Javid, openly acknowledged this week that the NHS needs more investment. We need the chancellor and the prime minister to recognise this too. Over the next six weeks the Government will set NHS funding for the next three and a half years. The decisions they make will affect the health of our nation for a generation. The stakes couldn’t be higher.

Chris Hopson is the chief executive of NHS Providers.

Competing interests: none declared.