There is a very real and worrying common reality emerging across the Acute Trust sector, in that many are facing concurrent deficit positions and/ or declining financial health, coupled to variable or declining clinical quality. Whether we have a system sliding towards financial failure or clinical failure (or both) and whether one is a worse crime that the other are all secondary debates to the more important one of ‘why’, unless you believe the overly simplistic explanation of insufficient funding. Whereas intuitively we know that the issues of clinical quality and overall financial health are linked, we continue to approach them as if they are separate domains, with responsibility lying with different groups of people. This makes it extremely difficult to address issues in one without affecting the other, creating the system-wide conundrum of how to achieve sustainable performance in each, concurrently – the Holy Grail that eludes so many. I want to take a look at some of the lesser considered but highly impactful causative factors.