In any normal year, at least in recent times, the NHS would now be gearing up for ‘winter pressures’ - that euphemism for ambulance diverts and packed A&Es, a period that seems to take up more and more of the calendar each time it comes round.

But 2020’s starting point is both stark and unique. This time the system faces not only the usual pressures, but a vast and growing waiting list following the first phase of the pandemic, as well as reduced capacity due to the need for extra infection control and the limits caused by staff sickness and self-isolation. That’s before flu season and the gradual increase in Covid cases themselves.

Figures leaked to the M.E.N, presented in private to council leaders at their emergency Covid committee this morning, reveal the scale of the impact coronavirus has already had on other areas of NHS treatment.

In January 2020, just 55 patients across the whole of Greater Manchester had been waiting more than a year for treatment - usually a key NHS England standard.

By July, that had risen to 5,549.

A message on the road outside Wythenshawe hospital in May

That list is now estimated to be at 10,600 and is expected to almost double again, to 20,400, by next March. Backlogs are highest in general surgery, followed by gynaecology, then trauma and orthopaedics.

“There is therefore urgency that this situation is addressed,” says the report, noting that people waiting for planned surgery can see a deterioration in their condition, chronic pain and mental health damage.

Even so, some trusts - although it doesn’t specify which - are not expecting to get back to pre-Covid levels of outpatient appointments for a year.

As patients seek answers, one Manchester GP surgery texted patients this week telling them not to ask for their hospital appointment to be expedited.

“Up to one in four people in Greater Manchester are currently on hospital waiting lists,” it advised.

“Unfortunately we have no control over this.”

NHS leaders are also worried about the unseen iceberg of people not yet on the cancer waiting list, because they haven’t yet been tested, as well as a backlog in certain types of diagnostics, particularly endoscopies, which are used to diagnose and monitor many types of cancer.

Veronica Devlin, chief transformation officer at Manchester Foundation Trust, told city councillors earlier this month that the concern is less those cancer patients already known to services, but the ‘invisible workload’ of those who are not.

“It’s the patients we don’t know about yet is more of a concern,” she said.

So that’s the starting point, heading into winter 2020.

“It’s grim,” admits one senior health insider, “and shows the impact of Covid on non-Covid mortality and morbidity.”

Sir Richard Leese, political lead on health for the region, has been highlighting for some time the impact Covid has had on other areas of the NHS, warning in August that thousands of operations were no longer taking place.

Sir Richard Leese

“We’re still nowhere near returning to business as usual in health services," he said at the time.

As a result of these backlogs hospitals here - as elsewhere - are under strict instructions to get back to ‘business as usual’ for planned operations by the end of October, providing 100pc of their normal surgery under what’s known as ‘phase three’ of NHS England’s pandemic planning.

However, Covid makes that difficult, even before coronavirus admissions began to rise again earlier this month.

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The size of our hospital buildings were already limited, as visitors to most A&Es in normal winters will know.

But now they have an added problem: both time and space are taken up with the measures needed to protect patients from Covid.

“Infection prevention and control limits the capacity we have available,” explained Ms Devlin at the start of September, adding that this then eats into the theatre space available for elective operations.

Boris Johnson clapping for the NHS in May

“A procedure that might have taken 45 minutes might take an hour and 45 minutes, once you factor in ‘fallow’ time - the additional time to don and doff protective equipment. So we have to reset the limits of what’s available on theatre lists.”

The latest report to leaders this morning also notes that where expanding the NHS estate is concerned, they expect there to be ‘no further capital available for development within this financial year’.

So it outlines a number of other ways the NHS here intends to deal with the situation.

One is to use private hospitals more than has been the case to date. In some parts of Greater Manchester - including Bolton - this has already been happening to a considerable extent to ease pressures.

Another is to direct certain specialist elective surgery elsewhere in the North West.

Meanwhile the ‘hot’ and ‘cold’ system that became familiar to patients attending some GP practices earlier in the pandemic will also be applied.

Trafford General

Specialist hospitals such as the Christie, the Royal Manchester Children's Hospital, the Royal Eye Hospital, St Mary’s and the University Dental Hospital will all be designated Covid-free in terms of admissions, along with specialist areas of other hospitals.

Similarly hospitals without an A&E - Rochdale, Wrightington and Leigh, Trafford General - would also be kept Covid-free as far as possible.

At A&E itself, there is also an emerging plan for people who might otherwise go straight there under their own steam.

Instead, they will now be expected to ring 111.

An internal briefing to council leaders in July stated that emergency admissions across the country had fallen by 60pc during lockdown, a drop that was ‘largely down to people with minor issues not turning up’.

So in future the system will ‘ask people to be assessed before leaving home, by contacting NHS 111’ it says.

Nurses at Manchester's Nightingale hospital, which was stood down in the summer

“This will mean that patients can have their needs assessed quickly and easily without having to leave their home. This assessment can rapidly identify people who need to attend an ED.”

It is arguably a further sign that as the NHS looks to filter non-emergency away from A&E, it has begun calling it ‘ED’ in documents instead - the American version, standing for Emergency Department.

Anyone not felt to need emergency treatment would be transferred by 111 to a local doctor or nurse, who might then refer them to a GP, pharmacy or elsewhere in the community.

“In some cases, an appointment might be booked to attend ED,” it adds.

It will be ‘much easier’ for people to do this, it says, rather than turn up to A&E and potentially find themselves pointed elsewhere, or asked to come back later.

In other words, A&E will increasingly be by appointment this winter.

Royal Bolton Hospital A&E

The approach will begin in Bolton and Wigan mid-October, followed by Salford, Oldham and Bury, before finally Manchester, Stockport and Tameside by the end of the month.

Nationally, it is due to launch in December.

At the same time, leaders here hope that the hospital system can capitalise on an approach that is arguably unusual for the ethos of the NHS, a system that tends to work within its own small empires. During the peak of the Covid pandemic, hospitals worked collaboratively here, sharing PPE through mutual aid.

“A cooperative network of hospitals is really really important,” says one senior health figure, at the same time sounding a note of optimism.

ICU admissions remain fairly low, they say, even if numbers are nevertheless up, while new treatments mean there is less need for more ventilation, as doctors begin to understand the virus better. It is a point echoed by senior doctors elsewhere in the system, too.

The latest hospital admission data for Covid patients in Greater Manchester

Nevertheless, Covid admissions here are already beginning to creep up, even if a lack of published trust-level data makes it strikingly difficult to demonstrate where this is happening most.

Tameside became an issue early on, driven by a hospital-based outbreak of the virus, which is currently subject to an investigation. But Bolton, too, saw an early translation from milder cases among young people to an older age bracket needing hospital treatment and critical care.

When testing collapsed a couple of weeks ago, people flocked to A&E, forcing ambulances to divert and raising fears around infection control. The trust issued a warning, saying it ‘couldn’t afford’ for things to get worse.

Last week there were around 30 people with Covid in the Royal Bolton, a handful of whom were in critical care.

Even so, the NHS makes it hard to report the full story. Neither trusts, Greater Manchester or NHS England publish weekly trust-level data. What we do know is that across Greater Manchester overall, admissions rose in the first week of September and, at least up to last week, then remained steady at around 35 a day.

Staff outside Trafford General in May, clapping for the NHS

One very senior hospital clinician points to a whole other concern as winter approaches, however, one that is again exacerbated by Covid.

“The thing that’s pretty much at the forefront of my mind is what’s going on with the workforce,” they say.

“I think there’s been quite a bit of intensity from the end of March, April, May and even into June and I think we’ve got a lot of exhausted staff.

“What’s different now, compared to that March bit when everyone was bracing themselves, is I think there’s a lot going on in people’s lives. You’ve got nurses who were ‘all hands to the pump’, but they are now worrying about partners who have lost their jobs or been on furlough, so there’s an added layer now.”

The impact of schools going back - which currently sees thousands of children from more than 300 schools self isolating across Greater Manchester - is also ‘starting to be felt’, they say.

“If you have a child who’s been sent home from school and in that household there’s a healthcare professional, there’s then a childcare issue,” they point out. “It’s a bit of a dangerous brew building up.”

Meanwhile the system is also going into respiratory virus season, meaning it will become harder to distinguish between a Covid and a non-Covid case. Winter flu has been a major worry for the NHS throughout the pandemic.

As a result, they add, there will now be a ‘constant process of dialling up or dialling down’ hospital activity, according to what is possible. Although at least this winter, if A&E becomes overwhelmed and Covid-infectious patients cannot be discharged home, or to a care home, the Nightingale will be on standby.

Either way, the NHS here faces a precarious balancing act in the weeks ahead: wrestling with ever-increasing and potentially fatal waits for operations, as well as a lack of capacity and an already-exhausted workforce, without knowing for sure what the current wave of Covid infections will translate into in itself.

“It has been a bit like fixing a plane engine when the plane is already in flight,” admitted Veronica Devlin to the council’s health scrutiny committee of trying to achieve that balance.

Or, a senior figure in another part of the Manchester hospital system says: “Every winter has been sold to our staff as unprecedented.

"Now what we’re going into is properly unprecedented.”