How well will managers cope with a spending cut? Hardly any NHS managers have been around long enough to experience government imposed cuts like this before, although some had a warm-up session during the deficit panic three years ago.

A handful are already talking about traditional service cuts - the blood and guts of shutting wards and cancelling operations. Meanwhile consultancies and companies such as Capita smell big opportunities in everything from IT to improving the NHS’s lamentably time consuming recruitment procedures.

A handful of people, including HSJ columnist Paul Corrigan, are advocating radical changes such as using the funding squeeze to drive more care into the community and encourage vastly more patients to manage their long term illnesses. But this will require both vision and radical new approaches to commissioning, for which too few primary care trusts appear to have the stomach.