Going further on winter resilience plans

Classification: Official
Publication reference: PR2090


  • ICB chief executives
  • All NHS Foundation Trust and Trust:
    • Chief executives
    • Medical directors
    • Chief nursing officers
    • Chief people officers and HR directors
  • All GP practices
  • PCN Clinical Directors


  • ICB chairs
  • NHS Foundation Trust and Trust Chairs
  • All local authority chief executives
  • NHS regional directors

Dear colleagues,

In August we set out a number of steps to boost capacity and resilience, with funding ahead of winter, including providing extra bed capacity and better support for staff.

Thank you to you and your teams for the incredible hard work that is ongoing to make progress and deliver these focused actions, which remain crucial.

More than eight million people have already had their autumn booster COVID-19 vaccination in just over a month. However, we continue to be in a Level 3 incident, and services are under continued, significant pressure, with challenges including timely discharge of patients impacting on patient flow within hospitals, alongside ongoing pressures in mental health services.

Over the past few weeks this has been exacerbated by an increase in the number of COVID-19 inpatients and related staff absences. We continue to prepare for the possibility of high prevalence of flu, based on the evidence from other countries and advice from public health experts.

We therefore all need to be prepared for things to get even tougher over the coming weeks and months. We will support you in doing your best under these very difficult circumstances, including as you work with and support clinical leaders to ensure risk is managed appropriately across local systems. We are working with the relevant regulators to support this.

This clinical risk management is especially important to support the ongoing work to improve ambulance handovers and response times. Many of you already have access to the data platforms that you will need to drive performance or will be getting access in the coming weeks. These data platforms will inform national, regional, and local oversight, including the NHS Oversight Framework.

Going further on our winter resilience plans

In August we set out key actions to improve operational resilience, built in partnership with you. Following further engagement with systems over recent weeks we are now setting out a necessary expansion of these plans. These actions have been co-created with systems and clinical leaders and build on best practice that you have shared with us. They have been selected based on this evidence showing that they will make the biggest additional impact. In particular we want to work with you to ensure the NHS can:

  • Better support people in the community – reducing pressures on general practice and social care, and reducing admissions to hospital by:
    • Putting in place a community-based falls response service in all systems for people who have fallen at home including care homes
    • Maximising the use of virtual wards, and actively considering establishing an Acute Respiratory Infection (ARI) hub to support same day assessment
    • Providing additional support for care homes through reducing unwarranted variation in ambulance conveyance rates
  • Deliver on our ambitions to maximise bed capacity and support ambulance services – bed occupancy continues to be at all-time highs, and we need to take all opportunities to make maximum use of physical and virtual ward capacity to increase resilience and reduce delays elsewhere in the system. This includes:
    • Supporting delivery of additional beds including previously moth-balled beds
    • All systems setting up a 24/7 System Control Centre to support system oversight and decision making based on demand and capacity across sites and settings
    • Ensuring all ambulance services deploy 24/7 mental health professionals in emergency operation centres and on-scene
  • Ensure timely discharge and support people to leave hospital when clinically appropriate – more than 10,000 people a day are clinically ready to leave hospital but can’t be discharged, and this causes significant and fundamental issues for patient flow. In addition to maintaining focus on the high impact actions from the 100 day challenge, the Government recently announced £500m to support social care to speed up discharge across mental and physical health pathways. More details about distribution of this fund will be shared with you when

Winter improvement collaborative

In August we committed to launching new improvement initiatives to support ambulance handover and response times, in addition to the focussed work that we are continuing to do with the 10 most challenged systems and providers.

Providers, systems, and regions have done a significant amount of work on these issues, but we have heard that we need to work with you on a faster way of identifying good practice and helping you to spread it at scale. We will therefore establish a new national Winter Improvement Collaborative by the end of October. We will review the effectiveness of this programme after 10 weeks and are committed to learning and iterating the approach to ensure it has maximum benefit. This will focus on the root causes of delay in each area. It will support teams to identify, evaluate, quantify, and scale innovation and best practice in improving handover delays and response times and reducing unwarranted variation at pace, supported by a single set of metrics.

We wish to learn from providers and systems who are tackling these issues successfully and are asking all systems to participate. The collaborative will be clinically-led, and we will work in partnership with staff using an Adapt and Adopt approach.

Continuing to support elective activity

We have proved we can deliver the ambitions set out in the elective recovery delivery plan with the virtual elimination of 2 year waits in July. Now we are in the second phase of the elective recovery plan, we need to continue to have a strong operational grip across both overall long waits and care for patients with suspected cancer. It is essential that all elective procedures go ahead unless there are clear patient safety reasons for postponing activity. If you are considering cancelling significant levels of elective care you should continue to escalate to your Regional Director for support and mobilisation of mutual aid where possible. We will be writing shortly on the next steps in recovery of elective and cancer services for our most challenged providers.

We are asking every Trust providing elective and cancer services to have their Board review the relevant performance data and delivery plans for the coming months. The Board should reflect on whether the assurance mechanisms are effective and in line with your elective recovery plan. Delivery should be managed in line with the plans and trajectories that have been agreed with NHS England regional teams. These plans should also be shared with your ICB.

On cancer, the key drivers of the cancer 62-day backlog are clear. The hard work of GPs and their teams has meant that the proportion of cancers diagnosed at Stage 1 and 2 has now fully recovered and is higher than pre-pandemic. Urgent cancer referrals are at 118% of pre-pandemic levels, while cancer treatment and diagnostic activity levels are nearer 100% of pre-pandemic levels. Three pathways (Lower GI, Skin and Urology) make up two-thirds of long waiting patients and have seen the largest increases.

Given this context, there are priority actions we are asking you to implement:

  1. Faecal Immunochemical Testing (FIT) in the Lower GI pathway including for patients on Endoscopy waiting lists
  2. Best Practice Timed Pathway for prostate cancer including the use of mpMRI
  3. Tele-dermatology in the suspected skin cancer pathway
  4. Greater prioritisation of diagnostic and surgical capacity for suspected.

Infection prevention and control (IPC) measures and testing

Existing UKHSA guidance on the management of COVID-19 patients remains in place, along with the appropriate IPC measures detailed in the IPC Manual. Ahead of winter, providers should self-assess their compliance with this guidance using the IPC board assurance framework.

This guidance will continue to be reviewed based on advice from UKHSA, in line with the latest scientific evidence including the impact of COVID-19 and other respiratory diseases in the coming months. Local healthcare organisations, with clinically appropriate advice, may also continue to exercise local discretion to test specific individuals or cohorts in line with broader IPC measures.

Symptomatic testing is continuing for patients and staff, based on the current list of symptoms. Symptomatic staff should test themselves using LFDs at the earliest opportunity. Staff testing positive should follow UKHSA’s return to work guidance.

Staff vaccination

It is important that health and social care workers receive both the COVID-19 and flu vaccines to protect themselves and their patients; the viruses can be life-threatening and getting both flu and COVID-19 increases the risk of serious illness. The vaccines offer the best protection for staff to better support patients and the people we care for.

All frontline healthcare workers should be offered both vaccines by their employer. Employers will confirm where both vaccines can be received, either at place of work, or, at a neighbouring provider. Health and Social Care workers can also book on the National Booking System by visiting www.nhs.uk/get-vaccination or calling 119.

Systems should continue to look at sections of their community where vaccine uptake is lower and focus significant efforts with partners to ensure community-based support is provided, building on approaches that have proved successful in the past. Trusts should also ensure that those attending for other reasons are signposted or offered vaccination.

Oversight and incident management arrangements

We will work with ICBs to ensure that oversight arrangements and associated support are appropriately focused on winter resilience and the delivery of elective recovery, including cancer, as set out above. This includes updating the NHS Oversight Framework metrics to reflect those set out in the Board Assurance Framework.

The NHS continues to operate at Level 3 Incident Response. Local systems will have their own response arrangements in place, and it is important that these continue, with robust escalation processes. There will be an opportunity to test these arrangements with a desktop exercise on winter pressures and escalation planned for November. This will be led by Regions working with ICBs, though participation will be open to all local partners. Seven day reporting against the UEC sitrep will start from Monday 31 October. Arrangements for the COVID-19 sitrep remain unchanged.

Thank you again to you and your teams for your continued hard work, and the leading role ICBs are playing in strong partnership working across the system. Since we published the winter plan in August, you have shared excellent examples of best practice

taking place across the country, and this good work has been used to inform the actions set out in this letter. The coming weeks and months will be difficult, but we will continue to support you in these challenging circumstances to ensure that we collectively deliver for patients and support our staff.

Amanda Prichard, NHS Chief Executive, NHS England.

Julian Kelly, Chief Financial Officer, NHS England.

David Sloman, Chief Operating Officer, NHS England.

Appendix A – Further actions ahead of winter

Relevant service specifications for the actions outline in the letter can be found here.

New variants of COVID-19 and respiratory challenges

  • Systems should actively consider establishing Acute Respiratory Infection (ARI) hubs as part of preparing for managing increased ARI in the community.

Demand and capacity

We will work with local systems to:

  • Support delivery of additional beds available to admit patients to across England to reduce the number of patients waiting in ED for a suitable bed, ambulance handover delays, and ambulance response times.
  • Deliver their agreed contribution to the winter planning ambition of delivering an additional 2,500 Virtual Ward (VW) beds. VW capacity must be included within overall bed capacity plans and monitoring and all local VW providers must submit timely, high-quality data through the national sitrep by 24 October 2022. Systems should ensure that virtual wards are effectively utilised both in terms of addressing the right patient cohort and optimising referrals. 
  • Ensure all systems establish 24/7 System Control Centres (SCCs). SCCs will balance the risk across acute sector, community, mental health, and social care services with an aim of ensuring that clinical risk is appropriately dispersed across the whole ICS during periods of surge. SCCs will need to be supported by senior operational and clinical decision-makers to proactively manage clinical risk across the country in a 24/7 format for 365 days per year. The expectation is that systems will develop the operating model for approval via the BAF and that all systems will have an operational SCC by 1 December 2022.
  • Improve the accuracy of information provided in the capacity tracker. The accuracy of information submitted to the capacity tracker will be key to ensuring that we can effectively manage demand and capacity at a system, regional and national level. We will work with regional teams to ensure that all providers have plans in place to submit accurate data to the capacity tracker, and that updates are submitted in line with the collection timetable.
  • Continue to invest into acute-workforce training in managing mental health need (including paediatric acute) and embed the integration framework with associated resources for systems to support children and young people with mental health needs within acute paediatric settings.


  • We know that discharge challenges are causing significant issues for flow and are impacting emergency care for patients. The 100-day challenge work will continue, as local systems continue to embed the 10 best practice interventions. We will work with regions to understand the specific actions where national support is required to go further, and a similar programme will be extended to community and mental health trusts. Intensive discharge support will also continue for a small number of our most challenged systems and Trusts. A national data focus, beginning with a drive to improve data quality, will support real-time operational decisions.
  • We are working with cross-government colleagues through the National Discharge Taskforce to explore further options to reduce delays to discharge. This includes supporting the £500m fund to recruit and retain more care workers and speed up discharge. Looking ahead to next year, with colleagues in DHSC and DLUHC we are selecting a number of discharge Frontrunners to identify radical, effective and scalable measures for improving discharge processes and joint working between and adult social care.
  • Mental health remains a challenge for UEC activity and delayed discharge. It is important that systems continue to invest in mental health as planned in crisis alternatives, community transformation, primary care, and liaison services in acute hospitals, and that 12 hour delays are avoided.

Ambulance service performance

We will work with local systems to:

  • Ensure all ambulance services deploy 24/7 mental health professionals in emergency operation centres and on-scene and implement new models of improving flow out of emergency departments. Staff may be employed on a rotational or joint basis with mental health trusts. This additional capacity will prevent unnecessary mental health related ambulance trips to A&E and enable more people in mental health crisis to access the right support in their Further guidance will be shared shortly.

Preventing avoidable admissions

All local systems should:

  • Have a community-based falls response service in place between 8am and 8pm for people who have fallen at home including care homes. The service should be in place by 31 December 2022 and be available as a minimum 8am-8pm 7 days per week.
  • Address unwarranted variation in ambulance conveyance rates in care homes working collaboratively with care homes to identify and access alternative interventions and sources of support.
  • Consider targeted, proactive support for people who have high probability of emergency admission, sometimes called High Frequency Users. For example, work in one area identified that 1% of people (~600 people) accounted for 1,925 ED attendances and 54,000 GP encounters over a 12 month period.


In July we wrote to you asking you to prioritise five high impact actions to maximise the retention and experience of nursing and midwifery staff. Significant progress has already been made and we are asking you to continue working across key areas, including:

  1. Nursing and midwifery retention self-assessment tool – completed self- assessment tool and retention improvement plans should be shared with your ICS retention lead or
  2. National Preceptorship Framework went live on 10 October. The framework includes a core set of standards and a gold standard for organisations wanting to further develop their preceptorship
  3. Flexible working – Your staff should be made aware and encouraged to explore flexible working options. Information and tools are available on the NHS Futures site.

We are now extending our workforce support by:

  • Re-launching the National NHS reserve campaign to bolster local surge capacity.
  • Launching a staff offers hub to support spread of local good practice over winter.
  • Providing a full list of recommended workforce solutions for Integrated Care Boards.
  • Providing targeted support teams to any region or system that falls into difficulty.