Preparing the NHS for the potential impact of the Omicron variant and other winter pressures



Classification: Official

Publication approval reference: C1487


  • Chief executives of all NHS trusts and foundation trusts
  • CCG accountable officers
  • GP practices and PCNs
  • Providers of community health services
  • NHS111 providers
  • PCN-led local vaccination sites
  • Vaccinations centres
  • Community pharmacy vaccination sites
  • ICS and STP leads


  • NHS regional directors
  • NHS regional directors of commissioning
  • Regional incident directors
  • Regional heads of EPRR
  • Chairs of ICSs and STPs
  • Chairs of NHS trusts, foundation trusts and CCG governing bodies
  • Local authority chief executives and directors of public health

13 December 2021

Dear Colleagues,

Thank you for everything you and your teams have done since the COVID-19 pandemic began to treat those with the virus, including over half a million people who have needed specialist hospital care, as well as delivering the largest and fastest vaccination programme in our history. This is while maintaining urgent non-COVID-19 services and now working to recover the backlogs that have inevitably built up, providing around 90% of pre-pandemic levels of activity this year, despite continuing to care for thousands of hospital inpatients with COVID-19 over that period.

The discovery of the Omicron variant once again requires an extraordinary response from the NHS. Last night, the Prime Minister announced the new vaccination challenge which will see the NHS deliver more vaccines over the coming weeks than ever before, and will require us to prioritise activities to deliver this.

However, even with the additional protection that vaccine boosters will give, the threat from Omicron remains serious. The UK chief medical officers on 12 December increased their assessment of the COVID-19 threat level to 4, and advice from SAGE is that the number of people requiring specialist hospital and community care could be significant over the coming period.

In light of this, we are again declaring a Level 4 National Incident, in recognition of the impact on the NHS of both supporting the vital increase in the vaccination programme and preparing for a potentially significant increase in COVID-19 cases.

This letter therefore sets out important actions we are now asking every part of the NHS to put in place to prepare for and respond to the Omicron threat.

These will:

  • Ensure the successful ramp up of the vital COVID-19 vaccine programme.
  • Maximise the availability of COVID-19 treatments for patients at highest risk of severe disease and hospitalisation.
  • Maximise capacity across acute and community settings, enabling the maximum number of people to be discharged safely and quickly and supporting people in their own homes.
  • Support patient safety in urgent care pathways across all services and manage elective care.
  • Support staff, and maximise their availability.
  • Ensure surge plans and processes are ready to be implemented if needed.

1. Ensure the successful ramp-up of the vital COVID-19 vaccine programme

You will be aware of the Prime Minister’s announcement yesterday outlining the latest situation with regards to the Omicron and other variants. The Prime Minister launched an urgent national appeal calling for people to get vaccinated and set out the commitment that all adults in England would be offered a booster jab by the end of the year.

In just over a year since the vaccination programme was launched, more than 100 million jabs have been given. In their December update, the UKHSA estimated that, as of 24 September, 127,500 deaths and 24,144,000 infections had been prevented as a result of the COVID-19 vaccination programme. This is a remarkable achievement, but the urgency of this new national mission requires the NHS to once again step up to support an immediate, all out drive to protect the health of the nation.

A separate letter will set out the immediate next steps for the vaccination programme, describing the ask of systems including:

  • Clinically prioritising services in primary care and across the NHS to free up maximum capacity to support the COVID-19 vaccination programme over the next few weeks, alongside delivering urgent or emergency care and other priority services. As the Prime Minister said, this means some other appointments will need to be postponed.
  • Delivering at scale whilst also retaining the focus on vaccination of those at greatest risk, including those who are housebound. Continuing to maximise uptake of first and second doses including through identifying dedicated resources to work alongside directors of public health locally.
  • Creating capacity, both by maximising throughput, efficiency and opening times of existing sites to operate 12 hours per day as standard, seven days per week as well as running 24 hours where relevant for the local community, and through opening additional pop-up and new sites.
  • Increasing training capacity with immediate effect to support lead employers with rapid onboarding and deployment of new vaccinators.

The letter also describes support available including a removal of the current cap on spend against the budget for programme costs, additional vaccine supply and significant expansion of volunteering and recruitment activity.

The NHS has been clear that staff should get the life-saving COVID-19 vaccination – and that is even more important now – to protect themselves their loved ones and their patients, and the overwhelming majority have already done so.

Working with NHS organisations, we will continue to support staff who have not yet received the vaccine to take up the evergreen offer of COVID-19 vaccination. NHS England has released resources on how to help engage and communicate with staff to encourage vaccine uptake within your organisations. We also recommend that CQC regulated services review the new Planning and Preparation guidance which will help organisations prepare for when the regulations (which are subject to parliamentary passage) are introduced.

Flu can be a serious illness for some people and the flu vaccine provides vital extra protection as well as minimising transmission. NHS staff should take every opportunity to encourage patients, including pregnant women, to receive their COVID-19 and flu vaccines if they are eligible. Healthcare colleagues are asked to make every contact count this winter with pregnant women – and those planning pregnancy – to advise them of the benefits of COVID-19 and flu vaccination.

2. Maximise the availability of COVID-19 treatments for patients at highest risk of severe disease and hospitalisation

Having discovered the efficacy of dexamethasone as a treatment for COVID-19 and begun rolling it out just hours after trial results were announced, saving thousands of lives both here and across the world, the NHS is again at the forefront of new treatments for COVID-19.

The UK was the first country in the world to approve an antiviral (monupiravir) able to be taken at home. It will be available for use by patients at highest risk in the community from 16 December alongside other treatments including monoclonal antibodies. Arrangements for deployment of these treatments was set out in a letter on 9 December alongside the UK policy for use.

Local ICS teams should finalise preparations for COVID-19 Medicine Delivery Unit service implementation, working with regions on final assurance of delivery models.

Separately, the Government also announced the PANORAMIC national study for oral antivirals treatment for at-risk patients. The study will allow medical experts to gather further data on the potential benefits of oral antivirals for the UK’s predominately vaccinated population. General practices can refer patients into this study as per the GP and community pharmacy letter.

3. Maximise capacity across acute and community settings, enabling the maximum number of people to be discharged safely and quickly and supporting people in their own homes

The operational imperative is to create the maximum possible capacity within acute care settings to support patient safety in the urgent care pathway, which is currently under significant pressure as the data on ambulance response times and 12 hour waits in A&E shows, to maintain priority access for elective care, particularly P1, P2 and cancer assessment, diagnostics and treatment, and to create capacity to respond to a potential increase in COVID-19 demand.

To that end, you are asked now to work together with local authorities, and partners across your local system including hospices and care homes to release the maximum number of beds (and a minimum of at least half of current delayed discharges) through:

  • An immediate focus to support people to be home for Christmas. Throughout the period between Christmas and New Year, ensure there is support in place to discharge medically fit patients across all seven days of the week.
  • Those patients who do not need an NHS bed, because they do not meet the reasons to reside criteria, must be discharged as soon as practically possible. Working with local authorities, every system will need to put in place sufficient measures in order to reduce by half their own number of patients not meeting the reasons-to-reside criteria. This will necessitate senior system leaders across the NHS and local authorities meeting daily to ensure sufficient progress is made.
  • A significant proportion of discharge delays are within the gift of hospitals to solve. Hospitals should work to eliminate avoidable delays on pathway zero, ie straight home without the need for social care support. Where necessary, this could include using personal health budgets, which has been successfully piloted in Cornwall and Lancashire; or use of hotel beds.
  • Making full use of non-acute beds in the local health and care system. NHS England has today switched back on the full use of spare hospice capacity – both beds and community contacts, through the same national arrangement with Hospice UK that was in place earlier in the year. As well as making use of personal health budgets, hotel beds, and hospices, systems can also make use of independent sector capacity in the community using the following framework. We encourage systems to explore surging community rehabilitation capacity and securing spare capacity from care homes. To support safe discharge of COVID-19 patients, DHSC will be expanding the number of designated beds from CQC accredited providers.
  • Expanding the use of virtual wards and hospital at home models with the full confidence of knowing these models will be supported in forthcoming planning guidance with significant additional funding, to enable a major expansion over the next two years.

Systems already have access to resources within core funding, COVID-19 allocations and through the Hospital Discharge Programme to fund these measures. Where systems can show further funding is necessary in addition to existing budgets then, to facilitate this drive, NHS England will fund additional costs incurred. Commissioners and providers should notify regional teams of the estimated additional cost and bed benefit as plans are firmed up and claim the actual cost through the existing quarterly claims process.

The NHS will need to increase its effective capacity next year and we are planning on ring-fencing significant national funding for the further development of virtual wards (including hospital at home). Therefore, where steps taken now on virtual wards can have an enduring benefit to overall capacity and have recurrent costs those should be notified at the same time so that we can allow for them on top of core system allocations for 2022/23.

To facilitate this drive, and maintain it thereafter through winter and into next year:

  • the Government has announced a further additional £300 million support for domiciliary care workforce, to boost capacity, on top of the existing £162 million workforce scheme.
  • A new national discharge taskforce including the NHS, ADASS, national and local government, led by Sarah-Jane Marsh, has been established. Working to both DHSC and NHS England, it will focus on the local authority and NHS actions required to drive progress. This will dock with enhanced regional and local system arrangements that need to be put in place.

4. Support patient safety in urgent care pathways across all services, and manage elective care

Ambulance response: Systems must focus on eliminating ambulance handover delays in order to ensure vehicles and paramedic crews are available to respond to urgent 999 calls as set out in the letter of 26 October, and take action to see patients quickly and avoid 12 hour waits in emergency departments. Working with health, social care, voluntary sector partners and CQC, systems should take a balanced view of risk and safety across all parts of the health system, recognising that the greatest risk may be the patient waiting for an ambulance response.

Prioritising the recruitment of 999 and 111 call handling capacity will be crucial to ensure patients have rapid access into urgent and emergency care services when required. It is therefore important that Regions work closely with Ambulance Trusts and 111 providers to monitor progress on a weekly basis.

Community crisis response: Local systems should take immediate steps to maximise referrals from 999 to the two-hour Urgent Community Response services. Good progress has been made in developing and rolling out UCR services across England faster than planned trajectories, with 27 ICSs now providing UCR services 8-8pm seven days a week.

Further expansion and join-up with other services is needed now, as part of a wider drive to reduce ambulance response times and support people in their own homes. Systems should:

  • Where possible, accelerate coverage and capacity of UCR services in line with the 2 hour guidance, to make an impact in January. This includes supporting equipment purchases such as lifting chairs and point of care testing equipment.
  • Maximise the number of patients being referred and transferred to UCR from ambulance services.
  • Work together with local councils and providers of local pendant alarm/Technology Enabled Care (TEC) providers and reduce the demand on 999 ambulance services through the re-direction of appropriate patients.
  • Refresh your local Directory of Services (DoS) so that NHS Service Finder profiles are accurate, up to date and are updated to show that UCR teams will accept referrals from health & social care colleagues including TEC providers.
  • Ensure accurate and complete data to via the Community Services Data Set for UCR, so you can track how much the services are being used and helping reduce pressures.

Further information, webinar recordings and tools, such as legal advice, information governance documents and case studies, are available on the Urgent Community Response FutureNHS platform.

Mental health, learning disability and autism: The pandemic has had an impact on the nation’s mental health, disrupting daily routines. In response, the NHS has extended mental health support, including introducing 24/7 all-age mental health crisis support lines earlier than planned, and continued to expand services to meet growing need in line with the Long-Term Plan.

Systems are asked to ensure that access to community-based mental health services and learning disability and autism services are retained throughout the COVID-19 surge to ensure that people at risk of escalating mental health problems and those who are most vulnerable can access treatment and care and avoid escalation to crisis point, with face-to-face care retained as far as possible.

Healthcare colleagues are asked to make every contact count this winter with people with SMI and LD – to ensure promotion of health checks and interventions as well as access to COVID-19 and flu vaccination, in the context of stark health inequalities for these patients.

Managing critical care: Over the course of the pandemic, the NHS showed its determination and flexibility time and time again, not least in rapidly expanding critical care capacity. Indeed, the Health and Social Care Select Committee wrote in their recent report on lessons learned to date that it was ‘a remarkable achievement for the NHS to expand ventilator and intensive care capacity’.

We do not know what the demand from Omicron will be on critical care facilities, but it is essential that trusts familiarise themselves with existing plans for managing a surge in patients being admitted with COVID-19, with particular focus on the management of oxygen supplies, including optimising use at ward level. This work should also include a review of how critical care capacity can be expanded and of surge arrangements in critical care networks – acknowledging these will already have been activated in some parts of the country. Further guidance on surge planning will be published based on good practice from the early phases of the pandemic.

Managing elective care: As in the COVID-19 wave last winter, it is crucial that we continue to deliver elective care and ensure that the highest clinical priority patients – including patients on cancer pathways and those with the longest waits – continue to be prioritised. Once again, clinical leadership and judgement about prioritisation and risk will be essential.

There are now 6 million patients waiting for elective care, of whom 16 thousand have been waiting over 104 weeks, as a result of the inevitable disruption caused by the COVID-19 pandemic. It is therefore even more important that diagnostic, first outpatient, elective inpatient and day case capacity should be maintained as far as possible, recognising the requirement to release staff to support the vaccination programme and respond to the potential increase in COVID-19 cases. Systems and NHS trusts should work collaboratively, particularly using the provider collaborative arrangements you have in place to prepare elective contingency plans against different COVID-19 scenarios for discussion and agreement with Regions.

A key feature of plans should be the separation of elective and non-elective capacity where possible, and the use of mutual aid between trusts and across systems and regions where necessary to maintain access to urgent elective care. You should maintain your focus on eliminating waits longer than two years, as set out in H2 planning guidance as far as possible.

Independent sector (IS): Local systems need to significantly step up use of available capacity in the independent sector to help maintain services. IS capacity should be one of the main protected ‘green’ pathways for treating elective patients during the final quarter of this year. Systems should take action now to agree plans with your local IS providers, building on existing H2 plans, to maximise use of local IS capacity so that as many patients can be treated as possible through the IS route. This should include, where clinically appropriate, additional pathways including cancer.

Any work will be funded consistent with original H2 planning guidance.

Primary care: The vaccination ramp up is the current priority for primary care, supported by the additional funding already announced and changes to GP contract arrangements. Continued access to general practice remains essential for those who need care and the £250 million Winter Access Fund remains available through systems to support general practice capacity more generally, including through the use of locums and support from other health professionals.

Cancer: local systems should stress test their plans to confirm that the elements that helped to sustain cancer services in previous waves are in place, and to ensure that:

  • rapid access, including tests and checks for patients with suspected cancer, as well as screening services, are maintained
  • provision for P1 and P2 cancer surgery is prioritised
  • cancer surgical hubs have been established with cancer surgery consolidated on COVID-19-protected sites, and that centralised triage is in place across local systems to prioritise patients based on clinical need
  • arrangements are in place to centralise high volume or high complexity work such as upper GI or head and neck surgery
  • local systems have adapted cancer pathways in line with the advice on streamlining cancer diagnostic pathways and keeping them COVID-19-protected
  • local systems are maximising the use they make of IS capacity for cancer services, where clinically appropriate
  • effective communications with patients and safety netting is in place, and patients are involved in decisions around their care, including when they chose to reschedule
  • anyone with concerning symptoms is encouraged to come forward, in line with our ‘Help us, Help You’ messages.

5. Support staff, and maximise their availability

The experience of the pandemic has shown, once more, that the NHS is nothing without its exceptional staff. NHS staff have been severely tested by the challenges of dealing with the pandemic and its of vital importance that we collectively support them over the months ahead.

Support for staff to stay well and at work: We also ask you to revisit your staff wellbeing offer to ensure it has kept pace with the changing nature of the pandemic, with a continued focus on ongoing health and wellbeing conversations taking place for staff. Health and wellbeing conversations are the best route for exploring the many drivers and root causes of sickness absence and for offering individualised support to staff where it is needed, including with work pressures, worries and relationships.

Employers should be ready to communicate any changes in testing and isolation guidance associated with Omicron as we learn more, as these may well evolve, and to offer staff options wherever possible to continue to contribute when they are unable to come into work, if they are able to do so. In addition, organisations should consider contingency options for significant staff absences to ensure essential services can be maintained.

The pandemic has had a disproportionate impact on our staff from ethnic minority communities. It is therefore vital that as we prepare for this next phase, we take action to address systemic inequality that is experienced by some of our staff including by allowing staff network leads the dedicated time they need to carry out this role effectively. We will continue to collect and publish data on the experiences of our ethnic minority colleagues via the Workforce Race Equality Standard (WRES).

Mental health and wellbeing support: We have strengthened the mental health support offer for health and social care staff to ensure they can get rapid access to assessment and evidence-based mental health services and support as required.

This includes your own occupational health services as well as the 40 local staff mental health and wellbeing hubs across the country which provide proactive outreach and clinical assessment, and access to evidence-based mental health services and support where needed.

Please continue to promote the mental health hubs and the confidential helplines that are available for all staff, and in particular the bereavement helpline (0300 303 4434, 8am-8pm) to support staff who may have been affected by the death of patients and colleagues.

Workforce planning, flexibility and training: System leaders and NHS organisations should review workforce plans for the next three months to ensure that, as per your surge plan testing, you have the appropriate workforce in place to deal with an increase in the number of COVID-19 patients and are able to support the ramp up of the COVID-19 vaccination programme. Organisations should continue to use their staff flexibly to manage the most urgent priorities, working across systems as appropriate.

Where staff require particular support or training to enable their potential redeployment, including for vaccination or to support critical care services, please use the next few weeks to provide this.

Recruitment: Trusts should seek to accelerate recruitment plans where possible, including for healthcare support workers, and where possible bringing forward the arrival of internationally recruited nurses, ensuring they are well supported as they start work in the NHS.

Volunteers: Volunteers play an important part in supporting patients, carers and staff over winter months. In particular, there are a number of high-impact volunteer roles which free up clinical time for clinical tasks, improve communication with families and assist with discharge, and support staff wellbeing. Although volunteers have been active in many NHS trusts, many more experienced volunteers are willing to help yet remain inactive. Trusts are encouraged to take advantage of the available support to restore volunteering and strengthen volunteer management in ways which can contribute significantly to reducing service pressures, including NHS Reserves.

6. Ensure surge plans and processes are ready to be implemented if needed

Incident Co-ordination: In light of the move to a Level 4 national incident, systems and NHS organisations will need to review incident coordination centre arrangements, and should ensure that these are now stood up, including to receive communication and act as the single point of contact.

Surge Plans: As we have done previously, we are asking all systems and NHS organisations to review and test their incident management and surge plans to assess their number of beds (G&A, community and critical care), supplies and staffing, learning the lessons from previous waves of COVID-19, and making preparations to have the capacity in place to meet a potentially similar challenge this winter.

Systems should ensure that preparedness includes making plans to deliver the services needed to vulnerable groups within systems as well as maintaining essential services in primary, community, mental health and learning disability and autism services.

To support regional and national planning, we will ask you to submit your identified maximum capacity, including your plans for critical care capacity, by 17 December.

These plans should detail the incident coordination arrangements, including leadership roles and responsibilities, hours of operation of the incident coordination centre, including out-of-hours contact arrangements. The plans should also detail how organisations will deal with timely information/SitRep reporting.

We will keep under review the timing and scope of the regular sitrep returns and we ask for your cooperation in continuing to make timely returns as requested.

Supplies: As a result of the work undertaken over the past 18 months, nationally held stock levels are more than adequate to respond to any additional increases in demand caused by a new variant. You should maintain normal ordering patterns and behaviours. In advance of the Christmas period, you may wish to review your local current stock levels particularly oxygen supplies, medical equipment and relevant consumables and it is key that you connect into the regional incident arrangements as and when needed.

Oxygen: In addition, through the testing of your surge plans, trusts must ensure that their oxygen delivery systems and infrastructure are able to bear at least the same level of demand when COVID-19 inpatients were at their highest point, and that any improvements or adaptations identified as necessary have been put in place.

Infection prevention and control: Staff and organisations should continue to follow the recommendations in the UK Infection Prevention and Control (IPC) guidance. According to research, IPC measures prevented 760 in-hospital COVID-19 infections each day in wave 1. Organisations must ensure that application of IPC practices is monitored using the IPC Board Assurance Framework and that resources are in place to implement and measure adherence to good IPC practice.

The past two years have arguably been the most challenging in the history of the NHS, but staff across the NHS have stepped up time and time again to do the very best for the nation – expanding and flexing services to meet the changing demands of the pandemic; introducing new treatments, new services and new pathways to respond to the needs of patients with COVID-19 and those without; pulling out all the stops to recover services that have been disrupted, whilst rolling out the largest and fastest vaccination programme in our history. The Omicron variant presents a new and significant threat, and the NHS must once again rise to the national mission to protect as many people as possible through the vaccination programme whilst also now taking steps to prepare for and respond to this threat.

Thank you for everything you have done and continue to do – as we have said before, this is a time when the NHS will benefit from pulling together again in a nationally co-ordinated effort, but please be assured that within the national framework you have our backing to do the right thing in your particular circumstances.

We look forward to speaking to you at the virtual regional events later this week and will keep in regular contact over the coming weeks and months.

Yours sincerely,

Amanda Pritchard | NHS Chief Executive

Professor Stephen Powis | Chief Executive of NHS Improvement