HSJ makes no apology for returning to the question of how the NHS is expected to deliver the punishing efficiency targets it has been handed for this parliament. There is no greater challenge and failure to deliver poses no greater threat for the health service.

Last week we voiced concern that there was complacency in parts of the national leadership about the work needed to deliver Lord Carter’s recommendations on NHS productivity.

That concern was promptly validated when Jeremy Hunt told MPs that the Carter programme was “really motoring”.

HSJ congratulates NHS England chief executive Simon Stevens, who was sitting next to the health secretary at the time, for keeping a straight face.

The Carter programme is not motoring, for reasons HSJ has already outlined. It’s in the garage.

At one point last week, we had an example of Mr Hunt at his best, when he directed the Nursing and Midwifery Council to urgently review its practice, following its “deficient” handling of a fitness to practise case involving two Morecambe Bay midwives.

However, his comments on Carter showed Mr Hunt at his worst, reminiscent of his declaration in late March that the matter of the junior doctors’ contract was “closed” following his decision to impose.

The need for action on efficiency was driven home last week by an NHS England briefing that breaks down how the £22bn savings required over coming years are expected to be spread across the health service. It shows that £8.6bn is expected from provider productivity, £6.7bn from “national” action including pay restraint and cuts to community pharmacy, £1bn from clinical commissioning group running costs and non-NHS providers, and the rest from demand management initiatives such as RightCare.

However, as the Health Foundation has pointed out, the briefing also makes clear that the plan requires the NHS to significantly “ramp up” its efficiency work this year compared to 2015-16, with nearly all of the gains coming from improved provider productivity. It is not at all clear that conditions are in place for the provider sector to deliver such an increase in productivity gain.

Meanwhile, the health service will take limited comfort from news that £6.7bn of the £22bn will come from national action. The bulk of those savings are likely to come from the chancellor’s decision to maintain pay restraint for another four years. This only counts as a saving because the Five Year Forward View assumed that screwing down pay for this long would not be possible.

With the NHS grappling with shortages of key staff groups, the chances of holding the line are slim.

Partial measures such as the cap on agency pay will not hold down paybill pressure indefinitely. Cost reductions from the caps are likely to peak in their first year, before people get better at gaming the rules.

The action to extend pay restraint might be taken nationally, but the consequences will be felt locally. 

If the national leadership truly believes the Carter programme can provide savings of the magnitude required of NHS providers, it needs to take concerted national action now to get it moving.

As part of this, it needs to ensure providers are having a single conversation with national bodies. How sensible is it that while NHS Improvement is charged with leading the Carter work and holding trusts to their financial targets, work on estates rationalisation – a key strand of the Carter recommendations – is being driven from the Department of Health? There are many similar examples of this fragmentation.

On the other hand, if national leaders do not in fact believe the Carter programme can deliver – and instead regard the programme as useful window dressing – let us find that out sooner rather than later. Because the savings challenge is not getting any smaller.