The NHS is entering the new financial year facing the biggest challenges in recent history, a report has warned.
Staff morale is low, the financial deficit is high and performance is continuing to deteriorate, with key targets being missed with increasing regularity, according to think tank the King's Fund latest quarterly review.
While many found last year difficult, this one looks like it will be even worse, director of policy Richard Murray said.
Waiting times for A&E are at their worst level since 2003, with 8.2% (more than 440,950) of patients waiting for longer than four hours in the final three months of 2014/15.
The number of delayed transfers of care - where patients are ready to return home or transfer to another form of care but still occupy a bed - has also risen by more than 20% compared to the same quarter last year, with the figure now at its highest level since 2008.
The report also highlighted how the proportion of inpatients waiting longer than 18 weeks for treatment in February rose to 13% - the highest level since the target was introduced.
It said it now seems certain that hospitals and other NHS providers in England overspent their budgets in 2014/15 by more than £800 million - despite nearly £900 million being provided by the Treasury or switched from capital budgets to plug the growing black hole.
"The financial outlook for 2015/16 is even gloomier, with two-thirds of hospitals concerned about staying within budget over the next year," the report added.
Other key findings were that for the third consecutive quarter, staff morale topped the list of concerns raised by trust finance directors.
It also found that fewer than half (45%) of trusts feel confident that they will achieve the productivity targets for 2015/16.
Mr Murray said: "The health service enters the new financial year facing some of the biggest financial and performance challenges in its recent history.
"If last year was the most difficult for some time, this year promises to be much worse, with little confidence that the alarming deterioration in NHS finances can be arrested.
"Looking further ahead, while there is still significant scope to improve productivity in the NHS, efficiencies are becoming harder to generate and there is considerable scepticism that the £22 billion in productivity improvements outlined in the NHS Five Year Forward View can be achieved."
NHS Providers, which represents hundreds of NHS trusts, said the report's findings were a "reality check".
"The harsh reality is that NHS providers are being required to meet a level of demand for which they are not fully funded," Siva Anandaciva, the body's head of analysis, said.
"While the proposed £8 billion by 2020 in extra funding outlined in the Five Year Forward View has received much attention, the challenges highlighted in today's report are the immediate funding and demand pressures facing NHS providers in 2015/16, and the increasing certainty that the required £22 billion in efficiency savings simply cannot be delivered through the same approach we have used in the last few years.
"Nearly 70% of NHS providers expect to be in deficit next year, many for the first time in their history.
"To break free of this downward financial spiral we need all political parties and senior officials to acknowledge the scale and cumulative impact of the challenges faced by NHS providers and their partners across the health and care system, and we need the national bodies to work with the provider sector to ensure the policy, funding and regulatory conditions enable NHS providers to continue to improve performance and give patients the health service they deserve."