Published anchor
Copied or directly derived from an official source for the stated period.
Model & sources
The country is fictional. The arithmetic isn’t.
National Triage Service is fictional, but its reference opening state is calibrated to England in 2024/25. Published quantities set the scale; transparent rules determine what follows.
Model reconciliation
Evidence-constrained, but not itself an official statistic.
Gameplay assumption
Transparent and tunable; not a fact or forecast about England.
The reference opening.
The Under Strain file begins at the calibrated reference point. New Era and State of Peril vary the Treasury grant and inherited acute and mental-health waiting stocks, but do not secretly change beds, workforce, demand, service commitments or incident odds.
Population58,620,101ONS 2024-based projection · published anchor
Game grant£204.945bnConsolidated reference envelope · model reconciliation
Acute RTT list7,415,796March 2025 · published anchor
Mental-health stock989,305March 2025 construction · model reconciliation
General & acute beds106,068Q4 2024/25 average · published anchor
Beds occupied98,14692.53% opening occupancy · published anchor
One simple grant. The game combines £193.301bn resource DEL and £11.644bn capital DEL into one comprehensible £204.945bn envelope. The real accounts keep them distinct; the consolidation is an explicit interface simplification.
The waiting list is not a slider.
Each week, patients arrive into distinct planned-care, mental-health, 999, ambulance, A&E and emergency-admission streams. Capacity clears them—or does not.
Delivery is limited by commissioning, workforce, diagnostics, theatres, estate and staffed beds. Unserved pathways remain in stock. The waiting list therefore emerges from arrivals minus completed care rather than moving because a scripted event says it should.
A call is not assumed to become an ambulance incident; an incident is not assumed to receive a face-to-face response; a response is not assumed to become an A&E attendance; and an attendance is not assumed to become an admission. Those stages remain separate constraints with separate levers.
- 999 call
- Incident
- Response
- A&E attendance
- Admission
- Staffed bed
Six separate constraints · six separate levers · nothing passes automatically.
Long-run paths are assumptions, not promises.
The model applies the exact ONS population projection first, then adds the residual growth needed to reach each all-in structural path. Capacity does not receive the same growth automatically.
| Gameplay assumption | Annual real path |
|---|---|
| Neutral Treasury grant | 3.0% growth |
| Acute RTT arrivals | 2.2% growth |
| Mental-health referrals | 4.4% growth |
| Urgent and emergency activity | 1.3% growth |
These are evidence-led gameplay assumptions. They are not official NHS England or government forecasts.
Comparisons preserve the absolute record.
At the start of each tenure, the game deterministically simulates the inherited service course with opening settings held unchanged. Comparative outcomes show the difference from that baseline.
The comparison does not erase absolute harm. It answers “what changed because of this tenure?” while the service record still shows the outcomes that occurred.
Known limits stay visible.
- Adult social care is outside the playable model.
- There is no separate post-acute or social-care discharge gate.
- GP activity is represented through access and workforce, not a complete appointment model.
- Mental health uses one broad referral stream.
- Background acute occupancy is aggregated.
- Dental care remains outside the workforce and capacity model.
- Long-run demand rates are assumptions, not official forecasts.
The model is not clinical guidance, an official forecast or evidence that any policy should be adopted.
Source groups.
Opening anchors draw on public releases from the Office for National Statistics, the Department of Health and Social Care, NHS England and NHS Digital. The detailed calibration record links every represented series and explains how it is used.
Population and funding
Access, activity and capacity
Contains public sector information from NHS England, the Office for National Statistics and the Department of Health and Social Care, licensed under the Open Government Licence v3.0. Use of this information does not imply endorsement by any public body.
Test the model.
Every lever is waiting at the command desk.