How much money for health?

The head of NHS England Simon Stevens has warned that "the rubber will really hit the road" for the NHS in England in the next financial year 2016/17 and the year after.

Even by the standards of normal spending round rhetoric, Mr Stevens' comments will raise eyebrows in Whitehall. There is nothing new about high spending departments defending their territory in the face of pressure for economies from the Treasury. But it seems that even in negotiations over a protected budget like health, stress levels are rising.

Mr Stevens wants the path towards the £8 billion extra for the NHS in England by 2020 to be "frontloaded" - in other words a large increase for the next couple of years and a flatter trajectory thereafter. He also wants assurances that the social care budget wont be cut.

In comments to Health Service Journal, Mr Stevens says that "considerably more progress is going to be needed before we can say we have a genuinely workable NHS funding solution". He acknowledges that spending reviews usually come down to the wire, but there is a strong hint that there is much work to be done before he can be content with the allocation for the NHS.

It's easy to assume that as an increase above inflation for health spending has been guaranteed by this Government then NHS chiefs are relaxed about life. A real terms annual addition of £8 billion by 2020 was promised by the Conservatives in the election campaign. It sounds straightforward but what does that pledge really mean?

Neither before nor since the election have ministers spelled out how they wanted to get to that £8 billion.

There is a big difference between a flat budget for a couple of years and then a big hike in 2020 and a significant increase in 2016/17 followed by smaller annual additions. Ideally, NHS chiefs would like £4 billion extra in real terms for next year, followed by steady annual top ups to get to the magic £8 billion in 2020. Christopher Smallwood, chairman of St George's University Hospitals NHS foundation trust, has argued that without that £4 billion next year, the NHS could suffer "widespread financial collapse".

Mr Stevens can hold up his Five Year Forward View text, published last year, and point to references to "investment in new care models". Translated, this means money up front to invest in new methods of working which will allow the NHS to become more efficient. His argument is that the Government signed up to the Five Year Forward View at the time so they must accept the financial consequences.

In a recent speech, Mr Stevens said there were tests, including the need for front-loaded investment, by which he would judge the Chancellor's health announcement in the spending review. Protection for social care, in contrast to cuts seen in the last parliament, is another test.

There's another detail which is being watched closely by health analysts, including Anita Charlesworth of the Health Foundation. Only the fine print of spending review documents will reveal whether the pledge to "protect" health covers the Department's entire budget. Might the Treasury add £8 billion to NHS England's budget in 2020 and leave other areas of health spending unprotected? Ministers might decide that higher spending at NHS England can be offset by cuts at other bodies like Public Health England and Health Education England. Such a move might be consistent with the text of the Government's pledge, though hardly the spirit.

Clearly there is much work to do. Treasury mandarins will say they have heard it all before with special pleading by the NHS and that health chiefs must realise their privileged position compared with the pain being experienced in the unprotected departments.

George Osborne has a big decision to make. He could water down the demands of the NHS with an eye to his overall deficit reduction plans. Or he might set sights on the next election and his reported desire to be Prime Minister with the need to minimise any bad news emerging from the NHS in the year before polling day.