It is likely that Number 10 did not choose to go to war with NHS England chief executive Simon Stevens over NHS funding. But they have had numerous warnings to avoid their “NHS has had more money than it asked for” line and have also continued to privately badmouth Mr Stevens in the vicinity of political journalists, so should not be surprised by the turn of events.

Mr Stevens’ appearance at Wednesday’s Commons public accounts committee hearing shows he is particularly keen to stop the “more” line becoming an accepted part of public discourse on the NHS. It effectively lets the government off the hook for the NHS’s problems and allows them to avoid the difficult decisions to come. It also breaks the unwritten compact agreed around the 2015 spending review, that both sides would stick to the line that the NHS had received (just) enough funding.

Simon Stevens would walk away if he felt he could not secure the government’s backing

The sense of theatre created by The Times’ “blame Stevens” splash on Wednesday morning guaranteed prominent coverage of his parliamentary broadside and laid bare the tensions between Downing Street and NHS England.

So what happens now? Will the prime minister abandon the “more” line and what will be the consequences if she does not?

The new PM is hard to read, but she seems unlikely to U-turn if pressed on past comments about NHS funding. Mr Stevens will also not retreat.

HSJ is confident he also will not resign – yet.

Strategy remains the same

The negative briefing he has had to endure for the last few months must seem amateurish to someone whose time at Number 10 coincided with the Tony Blair/Gordon Brown fratricide – so that will not unduly worry him.

However, HSJ is equally sure Mr Stevens would walk away if he felt he could not secure the government’s backing for his plans for the NHS.

The events of the last few days have therefore hugely raised the stakes around the forthcoming Five Year Forward View update.

Originally this publication, due in March, was simply meant to be a restating of the forward view’s aims and a refining of the success criteria. It will still to do that, but it will also calculate how much that success would cost – and allow the government, NHS, media and anyone else with an interest to compare that sum with the funds available.

In other words, Mr Stevens finds himself renegotiating the 2015 spending review at least six months before he planned.

The strategy is still the same – convince the government that an NHS celebrating its 70th birthday in 2018 in the midst of widespread service failure would be bad for all concerned. Better to provide a present in the form of some emergency funding to get the service through the lean years to come and a long term commitment to higher annual growth as the economy recovers.

This is still possible. But the government will want it to look like their idea and not something they have been forced into.

The best leader for the NHS

The two sides may achieve peace with honour through such an agreement – but it is very likely that Theresa May might demand Mr Stevens’ head in return for her largesse. It does now appear that Ms May’s view of what a quango chief should say and do is more in line with that trod by Mr Steven’s predecessor Sir David Nicholson.

So – and there is much water to flow under the bridge – perhaps the price the NHS England chief will have to pay for getting the NHS the money it needs is to cut short his ambitions for leading the service into the next decade.

The souring of the relationship with Number 10 will irritate such a seasoned political operator

Make no mistake, this would be a tragedy. Mr Stevens has not got every call right – but he remains the best leader for the NHS. And the service needs stability more than ever for the next few years, not the distraction of an unnecessary change at the top.

The souring of the relationship with Number 10 will irritate such a seasoned political operator. He had recognised that this was a government that you do not persuade by directly confronting it and will know that, by having to do so, he has lost some influence.

However, there is a silver lining for him in that the Stevens vs May headlines will have shored up his support within the NHS – which had begun to fray as the sustainability and transformation plan process ran into trouble.

To date the first instinct of Ms May’s Number 10 is to attack – a simple denial of The Times story could have killed the issue, instead they tried to claim Mr Stevens has changed his mind on whether the NHS funding deal was adequate.

High stakes

So it is entirely possible that they could choose to escalate the dispute; for example to try and further shift blame for the service’s woes. And if the financial news from the service in the final quarter of 2016-17 is bad they may have useful ammunition to stage their assault.

They would be unwise to do so. Not only because of Mr Stevens’ has shown he is willing to inflict damage on the PM if provoked, but because any noise around the NHS always rebounds on the government of the day.

Senior figures within the Department of Health know this and are dismayed by the furore created by Downing Street’s loose lips. The health secretary will also realise that if the funding controversy carries on it will be hard for him to continue to stay out of it.

For all concerned the stakes are high – for the service itself they are higher still.

Simon Stevens hits back after apparent criticism from Number 10