It is the struggle to shift the trusts hanging around near the centre of the annual health check which is most perplexing the Healthcare Commission.
After just two years it has hit the same wall that the Audit Commission has been banging its head against with local government - the best will always fly, we can sort out the basket cases, but how do you inspire those apparently coasting in the middle to strive for excellence?
One problem is that what might look like coasting on paper feels like flat out hard work for those struggling with the day-to-day challenges.
The fallout from last year's financial instability, the impact inside and outside the primary care sector of PCT mergers, the over-prescription of targets and the impact on morale and improvement of proposed acute hospital reconfigurations all play their part in dragging down performance.
But, despite all that, the key issues are leadership and focus. Are there enough top-quality managers to make it all work?
As NHS chief executive David Nicholson has pointed out (for more background, click here), several trusts in recent years have struggled to fill their chief executive post. He sees the quality of managers as the biggest barrier to service improvement.
This is a tough week to be an NHS manager. The scores of infection deaths at Maidstone and Tunbridge Wells trust have made it open season for the media, with the sins of the few being used to bash the reputations of the many. Today's health check results will only add to the criticism, with the nine trusts that missed their MRSA targets for the second year in a row likely to attract far more column inches than the 19 with double excellent ratings. But those 19 prove what first class management can achieve.
For more HSJ coverage of this year's healthcheck, click here