Should we be surprised that the annual report of the state of health and social care in England is pretty grim?
We've known for years the NHS is in desperate need of money and staff, so to hear that more than half of Accident and Emergency departments provide substandard care is not a great shock.
The Care Quality Commission is the NHS watchdog and it hasn't minced its words.
It found 44% of emergency departments need improvement and eight percent are inadequate.
It blames under-staffing and a rise in patients who can't get the care they need elsewhere.
In fact, there has been a 10% rise each year on the number of people going to A&E rooms.
What's most telling is the CQC's chief inspector of hospitals' assessment.
Professor Ted Baker says there aren't enough care facilities in the community, meaning patients of all kinds end up in hospital, even though it's probably not where they need to be.
How often have you read that there needs to be better child mental health care, longer GP opening hours and comprehensive social care provided in the community?
I have certainly written about it again and again and until there is a "system-wide change" he says things won't improve.
All number of bodies, medical colleges and charities have piled in to welcome the report and to agree that they are doing what they can in difficult circumstances.
The Royal College of Emergency Medicine holds its hands up and says yes, we have too few staff, so it's no wonder so many departments need improvement.
I think the most damning thing to come out of this is the scale of bad care for those with mental health problems, autism and learning difficulties.
When a watchdog says there has been a real deterioration in the quality of inpatient services for these patients it's surely time to listen?
Last year just one percent of units for people with autism were rated inadequate, now it's 10%.
What is going on that it's risen by 10%?
It's a similar story at the units for child mental health inpatients.
The CQC said too many patients are being looked after by staff who don't have the skills or training to deal with patients with complex issues.
How is this allowed to happen?
The government has promised more money for the NHS and in particular for mental health services.
It has set out a five year plan which will see services receive an extra £20 billion a year by 2023.
In response to the report, it points to the extra money and says its long term plan for social care will be set out in due course.
I have to say it feels like a lacklustre response to something quite so important.
Yes, there is new extra money but that doesn't solve the imminent, pressing concern of so many A&Es needing improvement just as we go into winter; the busiest and most pressurised time for the NHS.