By Adam Brimelow
BBC News health correspondent
Health trusts across the NHS are coming under enormous pressure from the government to balance their books by the end of this financial year.
The Royal Free faces big cuts
This is despite running up deficits totalling hundreds of millions of pounds for the year just ended.
Hence the almost-daily announcements of job cuts and ward closures.
How will the 're-organisation' of the NHS be handled, and what are the likely consequences for patient care?
The Royal Free hospital is a towering bleak concrete edifice that looms over its neighbourhood in north west London.
But like so many NHS hospitals it enjoys great local support and loyalty from staff.
Its zero-star rating hasn't dented its reputation as a leading teaching hospital, renowned for its specialist services.
But earlier this month it announced that nearly 500 jobs would go - as part of measures to save £25 million pounds.
The chief executive Andrew Way says the closure of more than 250 beds and three operating theatres is the equivalent of a small hospital, now sitting idle. He is pressing on with further efficiency savings.
"It isn't true that all change is bad change.
"If we look at somebody coming for a routine elective surgical procedure, and organise it in a way that means they can come to hospital before their admission, where all the issues surrounding their admission are discussed and their discharge are planned so that they're ready to go when they should go, then we can probably bring them in and out on a day basis.
"This would mean they come in in the morning, have their surgery, and go home later in the afternoon.
"That's got to be better for the patient than being in a hospital for two or three nights."
New ways of working
This is a change that has been taking place across the NHS - and it is something the government's been pushing hard.
It means new ways of working for staff, but it frees up beds and saves money.
For patients it means fewer cancellations, and a quicker, more convenient process.
Peter, who recently had day surgery on his chest, was impressed.
"I was in to the operating theatre far earlier than I thought I would be, and was given enough time to rest.
"Then they said I was free to go and it made a great difference, because I was expecting to spend the whole night, and have family and friends to stay with me in the evenings keeping me company."
Health unions though say far from easing pressure on hospitals by reducing the time patients stay, this approach is often more demanding for staff.
Karen Jennings, from Unison, says standards of care - with fewer nurses on the wards - are bound to suffer.
"It means you can't go and test somebody's vital signs, or you can't turn them over to stop them getting wound-sores on their hips.
"You can't take them to the toilet as often as they need to be taken.
"And that's because the staff are stretched and so standards do begin to slip."
Some doctors at the Royal Free will tell you they are deeply alarmed by the effects of the cuts, which they see as arbitrary.
They are particularly worried about a lack of specialist nurses, and other support that's needed to sustain complicated and expensive treatment.
Teaching hospitals like this one expect to be penalised under the new NHS financial regime of payment by results, where money follows patient according to a tariff set for each procedure.
Steven Hamilton, a consultant plastic surgeon at the Royal Free, says the system is unfair.
"We have noticed that the tariffs, which tend to reflect an average across the country don't necessarily reflect the complexity of these cases.
"And therefore these are more costly and more difficult cases that take a lot of resources from the hospital".
Another challenge for all hospitals is the push towards more care provided in community settings.
Fewer patients in hospitals mean cuts in revenue.
The government's support for this was set out in its recent white paper on out of hospital care, and nowhere is the pressure to reduce referrals from GP stronger than in London.
So for hospitals, good relations with GPs are crucial.
In this new era of patient choice, GPs are vital in influencing where they go for treatment.
Andrew Way at the Royal Free says the links with local GPs are good.
But Dr Laurence Buckman, whose practice is nearby, says there is a lot of room for improvement.
"I think the hospital needs to communicate with me more. I want them to listen to and understand what I want from them.
"And I want them to answer the telephone in a timely way. When they take a message I want them to answer it properly.
"I want them to respond to me and the patients in a way that sounds like they're interested in our custom."
The surest route back to long-term viability for the royal free is to get those spare beds and operating theatres working again.
It's casting a predatory eye over some other local NHS hospitals with a view to a takeover.
Andrew Way accepts this is bound to meet strong opposition, but he says the decisions must be guided by what's best for patients.
"What we're trying to do is find clinical synergies, which for us means looking at what we do here in terms of research and teaching and clinical care, and saying are there services elsewhere that would benefit from that environment?
"And if the doctors and nurses who run that service think it would be a good opportunity to be part of the Royal Free in relatively modern purpose-designed accommodation, then they will lead their service to us."
That is the emerging brave new world of the NHS.
These mergers, acquisitions, and of course closures will test the mettle of politicians who urge local decision-making, but will inevitably face fierce public protests as the service evolves.