One in four NHS trusts in England ended 2004 in deficit. The impact of current NHS reforms will be to magnify financial imbalances at a significant number of trusts, with the risk that some of them will fail. But there is no real plan for dealing with failure in the NHS. This paper outlines proposals for dealing with financial instability by heading off failure before it happens and introducing a regime to manage those failures that cannot be averted. It emphasises the need for mechanisms that not only restore financial viability, but also protect the quality of patient care. [Summary]