The NHS could begin to suffer serious reverses from next year as financial pressures set in, a leading health think-tank has warned.
A survey of 45 NHS finance directors undertaken by the King's Fund found deep pessimism about the prospects for the health service.
Although ringfenced from overall spending cuts, the NHS has been instructed to make £20 billion of savings by 2015.
Twenty-seven panel members judged there was either a very high or high risk that these savings would not be met.
Next year sees the end of a two-year freeze on public sector pay, making savings and productivity gains much harder to deliver.
Patient care was expected to worsen over the coming years by 19 of the finance chiefs, compared to eight predicting an improvement.
Professor John Appleby, King's Fund's chief economist, said there were signs that it would be "harder" for the NHS in future years.
"The end of the public sector pay freeze next April may add to financial pressures and increase the strain on services," he said.
"The difficulty for local providers will be finding ways to absorb these costs without compromising the quality of care for patients."
The NHS has already cut 29,000 full-time posts since March 2010, including nearly 6,000 nurses, midwives and health visitors. The number of consultants has increased by eight per cent over the whole period, but the number of managers is down by over 8,000.
Overall performance this year is generally good. Patients waiting for more than 18 weeks for hospital treatment was down to seven per cent from the peak of over ten per cent in March 2011.
But waiting times for accident and emergency showed "growing pressure in emergency care", the King's Fund claimed.
The Department for Health insisted that the NHS was on track to achieve its £20 billion savings target.
"Patients are spending longer in A and E, but they are not left untreated during this time," health minister Lord Howe said.
"In fact A and Es are providing a more comprehensive service, with specialist expertise, than has historically been the case. This means that some patients get the best treatment for them in A and E and so spend longer there."