Better care but longer waits - the NHS prescription
Intense pressures on the NHS in England have been well documented. So how do service leaders feel about the way things are going?
Today the head of NHS England, Simon Stevens, sets out his stall with his latest strategic plan.
It's billed by NHS England as "taking stock" of where the service has got to since the five-year strategy was unveiled in 2014.
Looking ahead, it sets out what they consider is achievable up until the plan's final year in 2020.
One thing very obviously not present in the 75 pages is a demand for more funding.
Mr Stevens got into a spat with Number 10 Downing Street earlier this year by suggesting the NHS had not got the money it asked for.
He has clearly decided not to risk further strife by holding out the begging bowl again.
With an eye no doubt on his critics in government, Mr Stevens sets out the "NHS 10 point Efficiency Plan".
But there is no mention of the £22bn efficiency savings target by 2020, which was announced when the first plan was launched in 2014.
The document in essence is setting out what the NHS in England can do with the money that has been allocated by the government.
Boosting cancer survival rates, increased access to mental health therapies and recruitment of more GPs are among the plans listed.
It is a pragmatic strategy contrasting with the big picture themes of the original Five Year Forward View.
The NHS England leadership clearly believes it can deliver improved performance in many areas, including A&E waiting times.
But an important line is drawn on what can be achieved with the funding available.
The waiting list target, which has been missed since early 2016, requires hospitals to start routine (elective) treatment for 92% of patients within 18 weeks of being referred by a GP.
NHS England in effect is now sidelining the target.
In the rather dry language of the document "given multiple calls on the constrained NHS funding growth over the next couple of years, elective volumes are likely to expand at a slower rate than implied by the 92%... target".
NHS England tries to put a positive gloss on the downplaying of the routine surgery target by saying that more treatment will take place away from hospitals.
GPs and local health commissioners will be encouraged to think harder about referring patients for operations or hospital procedures and to devise alternative care plans, for example quicker access to physiotherapy for patients with back pain.
But there's an acknowledgment that those needing routine operations, such as hip replacements, will have to wait longer and that may intensify concerns about waiting lists.
NHS savings challenge:
Five-year plan set out in 2014 predicted that by 2020 the NHS would face an annual shortfall in funding of £30bn because of a mismatch between patient needs and available resources
Government said it would make an extra £8.4bn available a year by 2020, leaving the NHS to make £22bn a year in efficiency savings
The NHS has set out plans to save £7bn through wage curbs and administration cuts, £9bn in hospital savings, such as cheaper contracts for medical supplies, and £6bn by treating patients outside hospitals and closer to home
The "new models of care", where local health and social care chiefs work together to ensure more patients are looked after away from hospitals, are highlighted in the document.
Some of the original schemes, known as Vanguards, have seen lower growth in emergency hospital admissions than in other areas.
As I have reported before, Mr Stevens wants leaders of some of the most joined up local plans to take full control of budgets with no split between commissioners and providers as now.
Those which are less well formed are clearly some way off completion.
It's a work in progress and in a sense NHS England is marking its own homework.
The question which is not asked or answered is whether the service needs an extra cash injection.
Ambitions seem more limited than before, demand is rising faster than expected and the message from Mr Stevens is "this is the best we can do with what we have got".