As heavy as it is, there is little doubt that the burden of delivering the NHS’s £20bn savings target rests more heavily on the shoulders of some than others. Specifically, it rests heaviest on London and Manchester.

This is why it was alarming that a Department of Health “deep dive” examination in January found Greater Manchester was the area of the North West where there had been “least progress in working collaboratively” to deliver the savings that “cannot be delivered by organisations working in isolation”. NHS North West rated Greater Manchester’s QIPP plans “red” and the DH said they had an “extremely high” risk of failure.

The city’s health managers have clearly worked hard since then, managing to have their plans’ risk rating downgraded to “amber” in April, and the newly formed Greater Manchester cluster seems keen to push forward collaborative approaches. On the face of it, a lack of collaborative working looks like one problem that might actually be helped by the “clustering” of primary care trusts.

But, as the first finance report to the cluster’s new board reminds us, the development of clusters will “inevitably create additional risks which to date are not yet understood”. In other words, there is “concern that the restructuring of the NHS will mean there is insufficient resource in support departments to ensure delivery of the capital and revenue plans”.

And the savings look no less daunting farther down the food chain. For example, Trafford Healthcare Trust’s board was told in May it had not yet been able to set a balanced budget for 2011-12, due in part to “commissioners’ expressed intention” to cut the trust’s core funding from £75.5m to £39.5m over the next five years.