The chancellor's lady friend will be upset by predictions that the brave new NHS reforms will bring soaring deficits, writes Mark Gould

'Prudence is a rich, ugly, old maid, courted by Incapacity.'

Chancellor Gordon Brown might do well to heed the words of the poet and visionary William Blake.

At 4.10pm last Tuesday, Mr Brown sat down after telling the House of Commons that Britain was a rock of enterprise, prudence and steady growth.

It is heading for a surplus of£9.5bn, debts are being paid, tobacco barons will be taxed for the NHS, and pensioners will get a free television licence.

Yet a day later those harbingers of doom, the Healthcare Financial Management Association, reported that with all the prudence in the world the NHS is heading for financial trouble.

Year-end deficits look set to top£200m as the NHS tries to deliver a people-carrier full of Blairite initiatives. HFMA chair Eric Morton says the NHS 'hit the bullseye' last year, with a deficit of just£12m - as near zero as makes no odds.

Yet a survey of 50 per cent of trusts and 60 per cent of health authorities shows that they are already forecasting a deficit higher than the£93m target set by the NHS Executive for this year.

And the deficit is set to grow, despite 'non-recurrent' attempts to cap appointments or transfer capital money into the revenue budget.

The biggest problems for trusts are overactivity, pay and the workingtime directive. HAs are facing massive rises in the prescribing budget for both branded and generic drugs.

Meanwhile, the HFMA has calculated that the 4.4 per cent increase due to the NHS next year under year two of the comprehensive spending review is already more or less accounted for by superannuation payments, the working-time directive, prescribing and increased activity.

Even in 'the most optimistic scenario', Mr Morton believes HAs will have less than 1 per cent to deliver the national agenda or cope with unknowns such as pay restructuring.

And some of that will be earmarked for pet government initiatives.

The Greek chorus is joined by NHS Confederation chief executive Stephen Thornton. He warns the chancellor that a big pay rise next year could mean that NHS finances 'reach the end of the road'.

He says extra cash from the comprehensive spending review has already been 'eaten up' by higher than expected pay awards.

And he warns that the people-carrier of modernisation might have to jettison some of its load. 'Many organisations will overspend this year while the service continues to be under pressure to deliver output targets which arise directly from modernisation policies set by government.

'The Department of Health expresses these as critical 'must do' priorities. We are clearly not going to be able to achieve all this with the money available.'

The BMA has called for extra funds to tide the NHS over the winter and a 'thorough review' of the services the public expect under the NHS, the level of resources required and how to pay for them.

But the NHS Confederation says this is unnecessary and is looking to the final year of the first comprehensive spending review to address a range of specific cost pressures.

The second comprehensive spending review - which will come to be known over the next few months as SR2000 - is set to be unveiled next summer.

Mr Brown said last week: 'In our second comprehensive spending review, we will match investment with reform - increasing the amount of resources available for the NHS and education in our public services.'

Health secretary Alan Milburn should have a fair idea of the scope of SR2000. He was involved in the preliminary stages as chief secretary to the Treasury in the far country of two months ago. A Treasury spokesperson said Mr Milburn was a member of the Cabinet committee involved in seeking details of public service agreement targets with other departments.

SR2000 will dovetail with the third year of the existing spending review and run until 2004. It will set out a three-year plan with new money available over the three years, according to the Treasury.

But economist John Appleby, director of the health systems programme at the King's Fund, says more money for the NHS would mean more strings attached and less flexibility.

'SR2000 will be connected with old and new initiatives in much the same way as the modernisation fund is tied in with specific initiatives like cancer, heart disease and coronary care - the key Downing Street priorities.'

He is more sanguine about the current deficit -£200m is not all that much. The HFMA does not disagree - but Mr Morton is concerned that it is the start of a period when the NHS will deliver on headline government announcements at the expense of underlying financial stability. And, he points out, it is much easier to halt a slide than to dig your way out of a hole.

The HFMA also warns that a decade of efficiency savings has pared the cheese down to the rind and the NHS will struggle to find further efficiency savings.

Mr Appleby says: 'I don't really buy that. I would have to see the evidence.

In a system with a turnover of£45bn a year there are still bound to be savings.

'This year the NHS is expected to make 3 per cent savings and for two years after. You would presume that the Department of Health accepted that figure on the basis that it was attainable.'

But he says it is time to take a microscope to efficiency savings.

'It is time to have another look at what they mean and what comes out of them. Every finance director worth their salt knows how to 'deal' with them so they make the right efficiency savings.'

Chancellor Brown gets one cheer for his attempt to make a simple tobacco tax rise sound like Labour wanted to become the party of hypothecated taxation.

Stephen Thornton says an extra 5 per cent tax on tobacco would generate£300m, but this will only pay half of the additional 2 per cent pension contributions, which will cost the NHS£600m.

'It's not really hypothecation. All taxation goes into a big pot - the politicians make decisions about how the money is spent. They could have said yes here is an extra£300m - and by the way it's coming out of the tobacco tax pot, ' says John Appleby.

While claiming rights to the idea of hypothecation, Evan Harris, the Liberal Democrats' former health spokesman, said tobacco taxes are not ideal.

'Either you get more revenue for the NHS from increased taxes on smoking or you get the price of tobacco going up so far that less people smoke, which is a good thing, but means less revenue is going to the NHS. Either way you can't have both.' Just like Prudence and Incapacity.