Despite promised cash injections, the NHS is heading towards instability

Every health minister comes to realise sooner or later that, no matter how apparently generous an increase in resources they secure for the NHS, they will continue to have to manage an underfunded service. Despite the much trumpeted extra£21bn for the NHS in the chancellor's comprehensive spending review, ministers in Richmond House must already be uncomfortably aware that enough is never enough.

Now the Healthcare Financial Management Association is warning that the NHS is heading towards financial instability - ironic given the promised cash injections for the next three years.

Yet the HFMA is able to marshal weighty evidence to support its claim. Pressure on the system is intense and increasing, not only from the aggressive stances on pay adopted by the doctors and nurses, but from rising activity levels. For example, one finance director reports that his trust faced demands in its casualty department similar to those of a severe winter - but in August.

Many trusts still have underlying deficits and are not at all clear how they will resolve them, given the government's propensity to earmark funds for specific purposes.

And all of this is taking place against the background of fundamental reforms to the system itself, the details of which have yet to be explored. To pile irony on irony, though chief executives are fed up with a surfeit of guidance from the centre - as we reported recently - their finance directors complain of too little. The NHS Executive seems not yet to have worked out the nitty gritty of ensuring money flows through the NHS fast, efficiently and without fear of it going astray. This is a dangerous position to be in: without a national methodology in which the service can have confidence, the NHS could grind to a halt, rapidly giving rise to headlines about patients denied treatment which constitute New Labour's worst nightmare.