So much rests on spending review crunch day, including the limits of the health secretary’s influence

Wednesday next week will almost certainly prove the most important day for the NHS in this parliament, if not beyond.

The government’s spending review on 25 November will fix the health service’s funding envelope for the coming years – a period that will be its most straitened ever.

Given this, it is deeply worrying that, just over two weeks ahead of the review, Simon Stevens says he was not confident he would secure the “frontloaded investment” he believes is necessary in the first half of the parliament.

The contested issue is the phasing of the £8bn real terms growth that is already promised over the next four financial years. An equal spread would see an additional £2bn each year. Mr Stevens would prefer bigger chunks in 2016-17 and 2017-18.

If the frontloading is not forthcoming, it will be clear that the chancellor is falling short

The fact the NHS England chief executive was willing to comment about this problem publicly shows unusual frankness in the run-up to a spending review.

It sends a clear message to George Osborne, who has made much of the fact he is backing the “Stevens plan” – his shorthand for the Five Year Forward View. If the frontloading is not forthcoming, it will be clear that the chancellor is falling short.

Raised the stakes

There are a number of reasons frontloading is important for Mr Stevens. The one most often given in public is the need to kickstart care model reforms which will deliver savings by the end of the parliament. Drives on service and estates consolidation, and procurement and workforce costs, may have made an impact by 2018 too.

Another reason is that the health service is in a hole now, and without the money it may be impossible to stem declining standards or keep the NHS in overall balance.

By making his latest demand so clearly and directly, Mr Stevens has raised the stakes higher. If his wish for a frontloaded settlement is granted, his influence and credibility would be unquestioned. He would have a strong platform for pressing on with the forward view’s reforms, and funding wriggle room to start recovering finances and performance.

If there is no frontloading, this will be a lot more difficult – and the limits of Mr Stevens’ influence will be clear for all to see.