More than 90 percent of health and care leaders across England say they are “concerned” about their organisation's ability to cope with demand this winter, with the majority (63 percent) citing “extreme” concern.

Findings of the poll, by the NHS Confederation, mark the latest in a stream of bleak predictions of a difficult winter for the health and care system which, the group’s chief executive Niall Dickson notes, is “already in a fragile state” without the extra looming seasonal pressures.

“It is fair to say many organisations will struggle to meet expectations over the next few months,” warned Dickson.

“Last year it was said that the service was 'just about coping', but for many of our members this year looks more challenging,” he added, largely because of higher demand, higher bed occupancy, more delayed transfers of care blockages, as well as a potentially serious flu attack and bad weather.

Effective planning at local level and co-operation between all parts of the system - including commissioners, social care, all parts of the hospital, as well as community and primary care - will be essential to help the system cope with these unprecedented pressures, Dickson noted.

Also, the NHS Confederation will “continue to push the government for a comprehensive review looking at which services are needed, where they are needed, how much they will cost and how they will be funded,” and is hoping that November’s budget will contain extra provision for the NHS and social care system.

“Any additional money must be carefully targeted to produce the greatest benefit. The focus should be on additional out-of-hospital provision to free up beds in hospitals,” he stressed.

NHS Providers warned last month that the NHS could be facing its worst winter crises yet and called for an immediate emergency cash injection of between £200 and £350 million to help it manage the risk to patient safety.

“The overwhelming view of NHS trusts is that without immediate extra funding they will not have sufficient capacity to manage this winter safely,” said the group’s chief executive Chris Hopson, and patients will be “put at greater risk as local trusts won’t have the extra beds, staff and services they need to meet the extra demand they will face.”