While Alistair Darling's speech in the Commons on Monday barely mentioned the NHS, the small print of the chancellor's pre-Budget report spells the end of the era of rapid funding growth and big surpluses.

World class commissioning is no longer focused just on service quality and efficiency. It is about cutting spending - cashable savings from the£70bn commissioning budget. Alongside the mantra of "adding life to years and years to life" we now have "taking pennies from pounds and pounds from pennies".

Inevitably, assumptions about improved efficiency provide another route for cuts, with a squeeze on the tariff promised.

What all this means in practice will be spelt out in the Budget next March, and hit spending allocations for 2010-11.

This will all form part of a£5bn cut in public spending plans for that year. How much of the pain will be inflicted on the NHS is unclear, but since the health service is the biggest budget under the chancellor's spending knife, a final cut in projected health spending of around£2bn from the£106bn outlined in the last budget would be realistic.

Secure position

It is important to recognise what this is not - it is not even close to being a cash cut. It is a cut in a projection. There is barely a private company in the country that would not crawl over broken glass for this sort of financial stability over the next three years. Compared with the organisations announcing thousands of job cuts each week, the health service is continuing to drink from the well of plenty.

But adjusting to the end of big, real-terms growth will still be a challenge.

Failure to get to grips with the new financial realities will be career-terminating for managers - any organisation that slides towards deficit can expect rough handling from the Department of Health and Monitor.

PCTs are similarly going to have to get tough with their providers. Last month HSJ revealed that two-thirds of them failed to decommission any services last year. Strategic health authorities are unlikely to be sympathetic to such a "steady as she goes" mentality unless commissioners can convincingly demonstrate value for money.

But the heaviest lifting falls to providers. The uncertainty created by any new zeal for decommissioning will combine with the squeeze on tariff to test every level of the organisation. Hospital fixed costs are high, estate rationalisation can take years, and opening and closing services is expensive, so flexing the NHS's procurement muscles as well as driving process efficiency will be crucial.

Add in rising demand for health services caused by the recession - notably mental health - and the imminent stringencies of the working time directive on doctors' hours, and the size of the task facing managers becomes clear.

All this requires an even greater focus on quality, safety, staff engagement and leadership.

Costs per patient

For the overwhelming majority of routine hospital procedures, quality and safety are synonymous with driving down the cost of caring for each patient. Employing lean working principles on the ward, for example, maximises patients' contact with clinical staff to improve everything from infection control to nutrition. Anyone who thinks improving quality inevitably depends on more spending is in the wrong job.

To make all this happen and keep the organisation focused on the patients rather than the money will require exceptional leadership. Championing new ways of working, making tough decisions and winning the argument for them with staff and the public, being relentless about quality and safety, and dealing with those who are blocking change will all be part of the management canvas. Sounds like any other day in the NHS.

Read the pre-Budget report

How will Alistair Darling's pre-Budget report affect you? Email hsj.feedback@emap.com or post your comment below