• Question over £550m earmarked for next stage review

  • Concerns SHAs will be less able to support financially troubled trusts

  • Potential refocusing on capacity over quality and choice

  • Fears national work to define quality measures and legislate on compulsory quality accounts will be neglected

  • Possible funding problems for social care reforms

NHS quality reforms could slip because of tighter funding and uncertainty over finance, it is feared.

Policy makers and managers are being urged to stick to commitments despite the fresh focus on spending and efficiency.

Supporters of quality and safety reforms said any tightening would test whether they had become enough of a priority.

Health Foundation chief executive Stephen Thornton said: "When the going gets tougher people tend to focus on survival. Quality needs to be seen as part of survival. It should not be a luxury that is only on the table when times are good."

NHS North West chief executive Mike Farrar said it was too early to know the impact on the NHS but that tighter spending "must be anticipated".

Bail-outs for poor trusts would be "completely and utterly off the table", he said. Quality care could remain a priority because of its "clear relationship" with lower cost.

But he urged caution over "sweeping generalisations" about trust and PCT surpluses: "They are a product of good financial management, and we do not want to send the signal that good financial management is not worthwhile.

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