What choices must the NHS make in a period of financial restraint? That is the primary question facing the service in 2016 and the response to NHS Improvement chief executive Jim Mackey’s HSJ interview and following conference speech shows there is little consensus yet in how to handle this challenge.

While various interest groups continue to hammer on about the need for more money, they do so more to keep their constituencies quiet than in any realistic hope of it being delivered.

The economy is now even more fragile and that leaves the new chancellor with little room for manoeuvre, even as he relaxes the deficit reduction target.

We might get a “Brexit boost” to help meet public expectations – but it is not going to make any fundamental difference to the NHS’s financial position.

Theresa May is often described as a “serious” politician and the “serious” leaders in the NHS are wrestling with how they can continue to deliver services within the cash envelope set last year.

It is an oft repeated truism that the NHS would implode if it complied with every piece of guidance. Mr Mackey is being typically honest about that fact that the NHS does not comply with everything

Previous debates on this issue have focused on what the NHS should stop doing – and NHSI’s search for unsustainable emergency and, especially, elective services will provide a sharp edge to those discussions.

What Mr Mackey’s intervention has done last week is to ask another question; namely what is “good enough?” In other words, at what point should NHS organisations cease to try to improve a service and instead switch its resources elsewhere.

The regulatory regime introduced by the recently restored health secretary is geared to identify areas of improvement – even in organisations rated good or outstanding. Media and public scrutiny intensifies, as does the number of “standards” developed by professional, trade and government bodies continues to proliferate.

It is an oft repeated truism that the NHS would implode if it complied with every piece of guidance. Mr Mackey is being typically honest about that fact that the NHS does not comply with everything – while adding that it cannot afford to begin trying now.

He wants the service, at a local and national level, to openly acknowledge that and make its choices in a transparent and balanced fashion.

Yes, he was unwise to use the 1:8 nurse/patient ratio as one of his examples – it is evidence based – but overall his is a brave and important statement.

Had Brexit not happened, the plan was for David Cameron to make a major speech this month about how preserving the NHS meant making sure it learned to live within its means.

Now that message is being transmitted, last week and this in a lower key, more piecemeal fashion that will – with everything else that is going on – be missed by the great majority of the public, media and national and local politicians.

This is a great pity. Many interest groups, and HSJ, have called for greater honesty about what the NHS can achieve in this period of financial austerity and it is especially disappointing that those most likely to make unrealistic demands on the service will not now be made aware of the consequences of their asks.

Even had the PM-fronted initiative gone ahead; can we really imagine him – or any politician – being brave enough to state: “yes, our maternity care is not up with the best, but it’s OK; but where we’re really struggling is paediatrics, so that’s getting the cash”.

That is why Mr Mackey’s straightforwardness is so welcome.

The reaction to the NHS Improvement chief executive’s thoughts have – mostly – been a disappointing mixture of suggestions that he is telling trusts to endanger safety and/or is only concerned with meeting financial targets.

What he is actually asking of NHS leaders is that they identify what is really not acceptable – and then tackle that with alacrity – and to realise and then explain that almost everything else will have to wait