Ease up on targets and give the service a chance to deliver reforms Just in time, as the flu season officially begins, ministers have agreed to release the substantial amount of money for which social services departments have been begging. The 50 lucky councils will breathe a sigh of relief, as will their neighbouring hospital trusts who will find their own NHS plan targets considerably easier to achieve.

The announcement came not a moment too soon for areas such as Birmingham where hundreds of elderly people remain in hospital beds, when they should be cared for elsewhere.

But the government cannot be complacent and assume that by making some inroads into the problem of what is termed 'delayed transfers of care' it will avoid those nasty winter crisis headlines.

Behind the scenes, ministers and civil servants are struggling with the realisation that they have ploughed substantial amounts of cash into the NHS, opened hundreds of extra beds and appointed more staff (though perhaps not as many as they would like people to think) for - apparently - very little return.

Latest waiting-list figures confirming that the upward trend in waiting lists is more than just a blip will give them even greater cause for anxiety. Activity across the service is virtually flat.

Now Whitehall has been forced to think beyond the NHS plan. Downing Street, Richmond House and the Treasury are faced with two options - plough in a great deal more money, regardless of the uncertainties of the current global situation, or take another look at where the NHS is going.

So Downing Street's policy unit - the centre of all new initiatives - has commissioned work which may feed into yet more change to NHS structures while the 'money men' work out whether the health service really is a bottomless pit.

The NHS plan itself continues to be broadly supported across the NHS - the majority applaud the direction of change and the enduring principles on which that change is based.

But the most pressing problem the service faces is coping with the pressure placed on it by the relentless onslaught of government initiatives. A survey conducted by Birmingham University's health services management centre (see this week's cover feature, pages 20-23) on Shifting the Balance confirms what many have been saying for some time - the demands of major structural upheaval, combined with performance management pressures and the entire modernisation agenda, may be just too much for NHS organisations to take at one time. None would want to contemplate a new direction and yet more upheaval.

What the NHS needs is not 'blue-sky thinking' but an easing back on some of those endless targets. Slowing down the pace of change rather than contemplating more is vital (where have we heard that before? ).

But perhaps this is too much to ask of a government nervously recognising that the improvement in service delivery on which it has asked to be judged is proving to be very slow in arriving.

When the report of the Bristol inquiry was published in the summer, health secretary Alan Milburn pledged an early response to its recommendations. Some integration and streamlining of audit, standards and performance management work is necessary and should be hastened. And clarification is still needed on the future roles and remit of some of the newer organisations, including care trusts and the four planned regional offices.

However, what the NHS does not need - and what would drive managers beyond exasperation to despair - is yet more structural upheaval.

If managers were asked what they needed in order to be able to achieve real improvements in the NHS that are felt by patients and acknowledged by a sceptical voting public, few would choose more reform: 'We'll take the money, thanks.'