'Which of the children do we shoot first?' - the budget leaves the NHS with harsh choices

In the next few days the government will receive a very clear response to that ambition from the NHS: “you have got to be kidding”.

With the underlying provider deficit standing at around £3.6bn – and significant cost pressures emerging in supposed priority areas such as primary care and mental health – there is no confidence at all among system leaders that next year’s funding will deliver what the government wants.

More likely, the new money will stop the service running out of cash next year and cover up a few trust deficits but not provide headroom to do anything extra or, more importantly, allow the NHS to avoid difficult choices about which areas of care needed to be downgraded.

As one senior figure said to HSJ yesterday: ”This level of funding still means we’ve got decide which of the children to shoot first”.

Within hours of the chancellor having delivered his budget, senior NHS figures were warning the NHS offer would have to be further rationed. First into the fray was outgoing NHS England medical director Bruce Keogh, he was quickly followed by a number of NHS trust chief executives. But perhaps the most strongly-worded reprimand for the Mr Hammond came from national director for mental health Claire Murdoch, who perhaps fears that her sector will once again become the service’s cinderella. 

Next week’s NHS England board meeting will provide a timely opportunity for the consequences of the funding increases and, more importantly, what is being asked of the service in return, to be fully set out. The response of the organisation’s chairman, Sir Malcolm Grant, to the budget, was: “We can no longer avoid the difficult debate about what it is possible to deliver for patients with the money available.”

Expect more senior NHS figures to speak out on the impossibility of avoiding painful decisions in the coming days and for an intense debate about priorities to develop over the winter.

The most immediate concern among NHS leaders is that the amount the service has been given is both inadequate to deliver what is expected, but also perhaps sufficient to give the impression to the public, backbench MPs and the media that the service’s pleas have been met. Today most media are, for example, blithely reporting that the NHS has recieved £10bn in capital funding and that pay rises will be met with new public money. In fact, the additional capital available to the NHS in 2018-19 is just £400m and only £3.5bn is actually a done deal. The pay rises for Agenda for Change staff are dependant on productivity improvements, while any increase in doctors’ remuneration would have to be met from within the existing NHS budget. Social care, of course, got zilch.

Jeremy Hunt can feel pleased that he and Simon Stevens have wrung more money out of the chancellor than was expected just a few weeks ago. Yes, it is still less than half of what most credible commentators suggest is needed and is non-recurrent - but it has set a new benchmark for NHS funding which is unlikely to be retreated from. However in creating expectations for next year that the service will view as unrealistic, Mr Hunt has put himself and the government in direct opposition to the views of the NHS leadership.

Mr Stevens’ warnings the government may be forced to “publicly, legally abolish patients’ national waiting times guarantees” and that it would become “increasingly hard to expand mental health services or improve cancer care” are unlikely to be the only matters of high-profile controversy as the NHS heads into its 70th year.

This editorial was updated at 12pm on Thursday 23 November.