HSJ’s interviews with a panel of finance directors have begun to flush out where managers are planning to make savings as the financial noose tightens.

NHS suppliers can expect a mauling, while there is also a strong focus on productivity and quality.

The threat of redundancies is surprisingly modest, with barely a tenth of those interviewed expecting to cut posts this year. But recruitment freezes are creeping in, and more can be anticipated next year as preparations for the cold wind of the 2011 settlement gather pace.

The misery of the anticipated cuts in posts spreads across the spectrum of the healthcare workforce, from managers to porters to clinicians, with managers often bearing the brunt. Doctors are not immune.

But even in the midst of some human resource bloodletting a handful of organisations are planning to increase their staff complement.

The most curious feature is what organisations are not doing. For example, hardly any are reviewing their back office functions, with many of the rest claiming they are already as efficient as possible. That is hard to believe.

But the debate on costs is shifting, with Audit Commission chief executive Steve Bundred pushing for a public sector pay freeze as a relatively painless way of making desperately needed savings.

There are now calls from within the NHS to reopen the three year pay deal signed in 2008, a move the unions reject out of hand.

While last month’s NHS Confederation conference was abuzz with talk of cuts and savings, there is still an undercurrent in the service

of people who have not faced up to the enormity of what is about to hit them.

The billions of savings needed will not be delivered by simply culling a manager here or a porter there. Redesigning clinical pathways to drive up quality and efficiency will go a long way, but still won’t achieve what is required.

Radical solutions are needed, and that means having the courage to consider whether pay freezes have a part to play. The alternative could be thousands of compulsory redundancies.