The King’s Fund has found further signs of financial stress on the health service – and warned that “cracks are starting to appear” in its performance against key targets.

In its latest quarterly report on the state of the NHS, the think-tank says that a quarter of the NHS finance directors surveyed expect to end the year in deficit, and three in five expect to miss their cost improvement targets.

At the same time, 3m people had been waiting at least 18 weeks for hospital treatment at the end of the quarter. This is the highest figure since 2008, and might have been higher if IT problems at seven trusts had not stopped them submitting returns.

Although there is always intense focus on the NHS waiting list and the 18 weeks referral to treatment time target, the King’s Fund argues that there are other signs of strain.

It says the number of patients waiting more than six weeks for diagnostic tests has risen to 18,600 – an increase of more than 12,000 on the same time last year – and that very nearly 10% of inpatients have breached the RTT target.

Both figures suggest that trusts are struggling to clear their waiting lists early, and that pressure is building up in the acute system. Overall, the NHS just managed to hit the four hour A&E waiting time target; but hospitals with ‘major’ A&E departments have now missed it for 51 weeks in a row.

At a breakfast meeting at the King’s Fund this morning, chief economist John Appleby was due to repeat the call of an earlier report for more money to be found for the NHS, both to bail out viable trusts in immediate trouble and to fund long-term change.

In common with policy makers and management bodies, the fund has argued that the NHS now needs to rationalise hospital services, and reduce demand on the acute sector by creating more integrated community and social services.

Both moves would require a substantial investment in IT to enable information to flow effectively around the new system; and would need to be underpinned by new forms of access and support for patients, including telehealth and online services.

However, today’s report suggests that re-organisation is not only not happening across the board, but that the short-term plans of hospitals and commissioners are at odds.

It reports that 55% of clinical commissioning groups are planning a reduction in emergency admissions, but only 8% of trust finance directors are doing so, and that 32% of CCGs are planning to reduce elective activity, while only 31% of trust finance directors are planning to do so.

“The disparity in the plans of providers and commissioners points to a worrying mismatch between activity and funding, which could have serious financial consequences,” Appleby will say.

Despite these pressures, the King’s Fund has found that the nursing workforce has increased by almost 9,000 over the past six months to 315,000 – the highest on record.

This is in response to inquiries into care failures and the requirement to start publishing information on ward staffing this autumn. However, the King’s Fund says it is not clear whether hospitals will be able to maintain this improved staffing as finances get even tighter later in the year.