The NHS in England is facing even tougher challenges now than when Covid-19 struck, the service’s boss has said. The many problems confronting the health service meant it was harder now for it to do its job, and it would become even more difficult, said Amanda Pritchard, NHS England’s chief executive. “When I started this job I think I said at the time I thought that the pandemic would be the hardest thing any of us ever had to do. Over the last year I’ve become really clear and I’ve said a number of times: it’s where we are now. It’s the months and years ahead that will bring the most complex challenges,” she said. “And that isn’t to take anything away, by the way, from just how tough particularly some of that early period of the pandemic was. But … I think it is harder now. Why? Because, partly, we no longer have a single unifying mission.” Instead, she said, “we are dealing with paradoxes, we’re dealing with complexity and we are dealing with uncertainty”. The NHS is struggling to deal with an array of problems including long waits for A&E care and a hospital bed, ambulances delayed when responding to 999 calls, lack of access to GP appointments and declining public satisfaction. Bodies such as the Association of Ambulance Chief Executives and Royal College of Emergency Medicine, which represents A&E doctors, have begun warning that potentially thousands of patients a month are being harmed – and some are dying – as a result of having to wait in the back of an ambulance before getting into a casualty unit or a hospital bed to start treatment. Speaking at the King’s Fund health thinktank’s annual conference in London, Pritchard admitted that the enormity of the NHS’s problems meant patients did not always get the best care. “It’s the question that’s most likely to keep you up at night, it’s most likely to motivate you in the morning. Are your patients getting the standard of care they deserve? We know we can’t always answer yes to that question.” The huge pressures bearing down on the NHS have helped persuade the new prime minister, Rishi Sunak and the chancellor, Jeremy Hunt, to exempt it from their fresh round of planned Whitehall spending cuts. However, Pritchard made clear that she was lobbying ministers for the service to get an even bigger budget to cover up to £7bn a year of unexpected costs it is being expected to absorb. The NHS was facing unfunded extra costs of £5.6bn this year alone, Pritchard said. That was from having to cover some of the costs of the NHS staff pay deal, ongoing Covid costs, and inflation driving up the cost of energy, food and basic supplies. In addition, NHS England has already agreed to make £12bn of “efficiency savings” between now and 2024-25. Asked if she was seeking an increase to the NHS’s budget, which is due to be £152bn this year and to rise to £162bn by 2024-25, she replied: “That is something that we’re in conversation with government about at the moment. They are aware that NHS budgets will only stretch so far.” A government spokesperson said: “The NHS is concentrating on new ways of working to increase efficiencies, save staff time and ensure value for money. Our Plan for Patients sets out the next steps, including removing unnecessary bureaucracy to help improve access for patients and speeding up hospital discharge.”