The biggest challenge to NHS managers comes from money-saving measures and balancing the books, a new study has found.
Just under 300 health service chairmen and senior executives said their main concern was keeping their trusts stable in a financial sense.
The NHS has been told to cut between £15bn and £20bn each year from its budget, with unions warning this will mean as many as 50,000 job cuts.
The body that represents 95% of health service bodies, the NHS Confederation, asked its members to reveal its most important issues of the year.
Almost two-thirds said that cutting costs, making savings and balancing books would be one of their top issues, while 31% highlighted this as the most important factor.
Just under half (46%) said maintaining service quality was in the top three, while another 46% said supporting general practice commissioning was in its top three – with 13% placing it at the top of the list.
A total of 32% claimed that understanding the forthcoming abolition of primary care trusts and strategic health authorities was in their list of top priorities.
The NHS Confederation's Nigel Edwards said: "These results should set the alarm bells ringing. They show that while the Westminster village is focusing on NHS reform, finance is the issue keeping NHS chairs and chief executives awake at night.
"Our members are focusing on this issue because they know that good patient care depends upon financial stability – the two are inextricably linked. I worry that there may be a significant finance problem coming down the track.
"We are already picking up worrying signals from a number of hospitals and primary care trusts about significant money pressures emerging, and this is before the very challenging rigours of next year's tight financial settlement."
A government spokesman said: "We agree with the NHS Confederation that good patient care depends upon financial stability.
"That's why we're investing an extra £10.7bn into the NHS. We also need to cut out tiers of bureaucracy, saving more money to invest in patient care and enabling services to be more responsive to patients, instead of bureaucrats."
Copyright © Press Association 2011