It has become clear as we enter the new financial year just how serious the financial situation facing trusts has become. Many have made it clear that they will not be able to deliver the targets outlined in the NHS plan and the national service frameworks.
The additional funding allocated over the last year may have been generous compared with the recent past but it has also come with an unprecedented set of demands attached. Striving to continually improve clinical standards and to find new and better ways of working is the 'core business' of the NHS, but to continually ask more from the service inevitably means that more resources are needed.
Managers and staff are genuinely worried about the consequences of not meeting targets - witness the efforts made to conceal breaches of waiting-list times, while some trusts are employing 'creative accounting' techniques to ensure numbers waiting are seen to be in decline. But without yet more funding the consensus is that the pledges contained in the plan cannot be delivered.
There may be a chink of light at the end of the tunnel with promises of new money for the south of England and cash being released through the establishment of the NHS's own agency for staff. Radical ideas such as the proposal to end the traditional system of outpatient referrals could also increase efficiency. There is a genuine effort in the NHS to ensure services are patient-focused. But being courageous needs to go hand in hand with having the resources to make things happen. It will become increasingly clear between now and early summer how big the gap between vision and reality is: ministers should listen to the voices of those who know.