Less than 150 miles west of Liverpool, recent developments in the Irish health system offer a salutary warning to English managers, politicians and GP commissioners wrestling with unpopular choices and the “Nicholson challenge”. Welcome to the world of James Reilly, former GP and now minister for health in Ireland’s coalition cabinet.

Dr Reilly perhaps wonders whether August’s decision to cut support for people with disabilities - namely, withdrawing funding for personal assistants and home helps - was wise. Television footage of people in wheelchairs demonstrating outside of government buildings, as well as mounting candlelit vigils, was undoubtedly damaging enough. The juxtaposition of these protests with positive images from the 2012 Paralympic Games, however, was especially unfortunate.

And then there’s the politics. Left-leaning coalition partners are deeply unimpressed. The knives are out. 

In Dublin, just as in London, the over-riding government priority is the deficit. This is not merely about coalition policy though, but what’s demanded by the international bankers who effectively run the country. So balancing the health budget is essential. But most spending goes on pay, which is protected by broader pan-government agreements. 

Faced with outcry, Reilly retreated. Savings will instead be found from administration, training and travel budgets. Popular? Not a bit of it. The wheelchair-bound demonstrators, mistrustful, want it in writing; the media, knowing that cutting support for the old and those with disabilities is the fast route to clogged hospital beds, wonder why such budgets weren’t the first port of call. They hint that the minister isn’t fully in control. And political opponents start braying about U-turns.

But there’s no U-turn, just an agonised wriggle. Another option emerges: freezing planned investment in community mental health. Credible, maybe, but hardly comfortable, given the entrenched reliance on low-quality institutional care. The predictable protests begin.

Ruefully, Reilly reflects: that’s just this year. What about the 5 per cent or more that is scheduled to come out of health spending in 2013?

Welcome to the challenges facing doctors engaging in the strategic direction of health services during times of austerity. Welcome to unpopularity.

It would be churlish, of course, to mention this summer’s embarrassing public probing of Dr Reilly’s tricky nursing home business ventures. But then scrutiny - which can, on occasion, be hostile - also goes with the turf.

Noel Plumridge is an independent consultant and former NHS finance director, noelplumridge@aol.com