What is the difference between a cut and an efficiency saving? And will patients be able to tell the difference?

Last week’s spending review has confirmed that the NHS is in an apparently privileged position. It is one of few areas of public funding not only to be protected from cuts but to receive a real terms increase. On the other hand, to meet future demand from existing costs the service has to find unprecedented efficiency savings.

Will the NHS’s efficiency savings be seen as cuts and will it get sucked into the looming French-style protests?

Will those savings be seen as cuts and will the NHS get sucked into the looming French-style protests? At a strategic level, there is confidence that the NHS can deliver. Patient groups, clinicians and NHS managers share in a vision of “better care for less”. Asthma UK recently joined a group of 10 charities, working with the King’s Fund, to produce a manifesto for high quality, cost efficient care. It was remarkable for its consistency with both the NHS’s QIPP reforms and the vision behind Liberating the NHS.

Yet there are three reasons to worry that efficiency savings may get just as rough a ride as the cuts in spending elsewhere.

First, the NHS has become political once again. The general consensus on policy during the election has been replaced with a rapid polarisation of views. What health secretary Andrew Lansley sees as the best way to deliver quality care at lower cost, Andy Burnham denounced as “a catastrophic error of judgment”. While patient groups and clinicians support the vision for change, there are growing concerns about implementation. And giving GPs final say over reconfigurations could make some PCT plans less likely to run. The political cover for change is now much less certain.

Second, although the NHS budget is protected, demand on its services will be hugely affected by cuts in other public spending. While social care is receiving an extra £2bn (£1bn of which will come from the NHS), adult social care is facing a greater crisis than ever before, with services almost uniformly only available to those in critical need. And the emotional and practical support offered locally by charities risks being swept away by the 28 per cent cut in local government funding. And while NHS managers were first to recognise the health service will have to pay for more social care, this will be politically charged, without a national policy framework to explain decisions about who will benefit and who won’t.

Third, some of the NHS “efficiencies” look very much like cuts. Patients have reported specialist nurses not being replaced on retirement, removing what they see as the linchpin of their care. As figures from the Royal College of Nursing show, 3,000 nurses retire every month; with “natural wastage” on such a scale there will quickly be a significant deterioration of service. Specialist nurses also report being asked to do more general ward duties, taking them away from preventive risk management to make the service more productive. The Chartered Society of Physiotherapy has also warned that services are being cut, leaving patients less able to support themselves and more dependent on the NHS. PCTs working on mergers and planning transition to GP-led commissioning have also served redundancy notices on teams building community solutions to improved public health.

Such developments take us further away from the shared vision of better care for less.

What will opposition to cuts look like? At the moment, it is fronted by a pencil cartoon nurse on Facebook. She stands in an operating theatre, next to a bed and some equipment; above looms a hand holding a pair of scissors. The campaign, called “Frontline First” is designed to encourage nurses to report cuts to local services and suggest alternative ways the NHS can save money. The information is validated by the RCN. It is proving a success and has won the backing of 15 patient and health professional groups, including Asthma UK.

Patient groups and clinical leaders are backing the campaign because it is about protecting services, not opposing change. RCN chief executive Peter Carter has made clear that the campaign will support changes which are evidence based. NHS managers know it is vital to demonstrate the case for change before withdrawing any service. That is advice the government regrets not following when it announced its changes to NHS Direct.

The NHS may be protected from cuts, but proposals for change to improve its efficiency will be subjected to as much scrutiny and challenge as the money-saving slicing of services elsewhere in the public sector.