Welcome to HSJ’s Performance Watch expert briefing. Our fortnightly newsletter on the most pressing performance matters troubling system leaders. Contact me in confidence here.

Our revelations today that system leaders are rolling out an urgent action plan to try and rein in the alarming deterioration in elective performance lays bare the perilous position the NHS is in ahead of winter.

It also highlights the rapidly growing concern among those in charge that the NHS is already set to miss its year-end flagship waiting list target.

The difference in mood amongst senior NHS leaders compared to this time last year is stark.

Ahead of and into last winter senior NHS and government figures from prime minster Theresa May downwards parroted the same line. “The NHS is better prepared for winter than ever,” they said. This was repeated in a manner verging on the hubristic, even as the system was heading into meltdown in January. But the proof of the pudding however is always in the eating.

A&E performance, the main target system leaders had tried to protect at the expense of others, slumped to below 85 per cent in March, its lowest position since records began, and the neither emergency or elective performance has fully recovered since.

It would of course be wrong to place all this at the door of system leaders. A witches’ brew of years of austerity, a brutally cold winter and high levels of Flu conspired to create almost unplayable conditions.

This year the “best prepared ever” mantra has been notably absent and there is no pretense from system leaders - at least in private - that the NHS is in anything other than a very sticky place. Furthermore senior figures, centrally and locally, increasingly raise concerns privately that they fear the NHS is not as well prepared for the coming winter as the previous one.

This is naturally hotly disputed by others, who point to the undoubtably relentless efforts of national urgent and emergency care director Pauline Philip’s team downwards to frontline staff. But it is notable nonetheless. And consensus among NHS leaders is growing that this winter could be as bad as the last winter – and possibly worse.

“There is a growing nervousness about how well prepared the NHS will be for the coming winter,” NHS Providers chief executive Chris Hopson told me.

The provider-side anxiety has not been helped by the fact that a review of last winter, which was expected by providers in May or June, so that learning could be incorporated for the coming winter, has still not been published. The review has been discussed at recent NHSI board meetings, but the item has always been restricted to the private part of session.

One thing this winter does have in common with winters of recent past is a ludicrous Mexican stand-off between commissioners and providers, of which the electives issue is a prime example.

NHS Improvement and local commissioners insist, with some evidence, that “extra” money to address elective backlogs is being given to providers. However, some senior commissioner sources privately accuse providers of ferreting away some of the cash to plug financial holes. NHS trust sources meanwhile say it is the local commissioning groups who are using the cash to sustain their bottom lines, and that not enough is being passed on for them to hit their trajectories.

There is most likely an element of truth in both in a further illustration of the impossible positions on both sides of the purchaser-provider split.

Health secretary Matt Hancock will be given an unenviable choice when he gets back from recess. Would you like to buy extra private sector capacity and send the NHS trust finances south, or, not do so, and see the elective list to lengthen further?

The system should also be mindful that after the government made a significant show of the funding boost announced in June ahead of the NHS’s 70th birthday the public perception is that things should get better, not worst.

This would appear highly unlikely, and the lack of messaging to prepare the public for a rude awakening once the days shorten and the temperature plummets may also come back to bite those in charge.