NHS Fife has warned it may have to pause non-urgent services as it faces unprecedented demands this winter.
The risk of increasing coronavirus cases combined with a possible flu or norovirus outbreak could leave staff stretched.
Chief executive Carol Potter said the challenges of winter would be more significant than ever this year.
She added however that any decision to stop elective procedures would be taken very seriously.
“We are, along with every other board in Scotland, preparing ourselves for the possibility we may have to pause elective services,” she said.
“Any decision on that would not be taken lightly.”
Elective surgery is the term for operations planned in advance that are not considered emergencies, and covers a wide range of procedures.
NHS Fife staff are working on the backlog but it could take five months to clear.
Director of nursing Helen Buchanan said this year’s winter plan was as flexible as possible to cope with additional pressures.
“The focus is very different this year because we have lots of priorities and lots of things going on across the healthcare system,” she said.
“It’s an integrated response across acute hospitals, outpatient services, community hospitals and community social care services.”
Ms Buchanan said pressures on staff already included an enhanced flu vaccination programme, the roll-out of the Covid-19 vaccine, the test and protect system and urgent care.
“The winter plan is absolutely flexible in its approach and it has to be as these differing priorities come up,” she said.
“One of the priorities for health and social care is home first to make sure people get home as soon as possible or remain in their home where possible.”
Staff wellbeing a priority
Staff wellbeing hubs will remain in place throughout the winter to help NHS Fife workers deal with the demands.
These have been set up at sites across the region to allow staff to rest or seek support.
Bosses are also developing a new service at Victoria Hospital in Kirkcaldy, to offer psychological support.
Ms Potter said: “The executive team absolutely recognises the impact on the resilience and mental and physical health of our staff,” she said.
“That remains a priority and we have a range of health and wellbeing advice and support available.”