Is Downing Street turning up the heat on the NHS?

With the election and the Brexit Withdrawal Agreement Bill out of the way, Boris Johnson's attention has turned to the NHS.

Sources talk of a "laser-like focus" on health as the government starts charting a path to delivering the promised new nurses, doctors and hospitals and making voters feel the service has got better.

The prime minister's interview with BBC Breakfast shed some interesting light on his thoughts.

Familiar pledges about 50,000 more nurses and new hospitals were trotted out.

The most intriguing, though, was his comment on NHS day-to-day pressures in England: "I want to see improvements in performance in A&E, in waiting times across the country."

Of course, every prime minister wants to see the health service improve and then, if possible, argue that government policies make a difference.

But, against a background of extreme stress at some hospitals with lengthening waits for patients, Mr Johnson has chosen to create a benchmark against which he can be held accountable.

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Last week, his official spokesperson had said at a Downing Street briefing that "improving the NHS is a priority for the prime minister."

Monitoring closely

There is a hint in the prime minister's words that he will be closely monitoring the efforts of NHS England.

He has instituted monthly meetings with the newly knighted head of NHS England Sir Simon Stevens.

In a sense he is throwing down a gauntlet to NHS England challenging them to reverse the decline.

Secretary of State Matt Hancock knows only too well that health service performance is under scrutiny.

The question is how might improvement be delivered as key performance indicators continue to hit record lows.

Boris Johnson made the NHS a priority during the election campaign

NHS England said it was having to cope with an increase in patient numbers, with nearly 2.2 million people going into A&E departments in November, up 6.5% on the same month a year earlier.

But even so the decline in performance over several months is difficult to defend.

For the first time, fewer than 80% of patients were treated or assessed within the four-hour target in December, a sharp fall from the 86.5% figure in December 2018.

Nearly 100,000 patients admitted to hospital were stuck on trolleys for more than 4 hours waiting for a bed to be freed up.

The waiting list for non-urgent operations in England is above 4.4 million and the number of patients waiting more than 18 weeks, at 690,000 in November, was the highest in more than a decade.

The target of 92% of those referred having their operations or treatment starting within 18 weeks has not been hit since 2016.

The target is enshrined in law yet seems to have been quietly sidelined by many hospitals which are struggling to cope with the demands of emergency care.

With some operations cancelled in the winter months because of a shortage of beds, trying to improve performance and clear the backlog looks like a herculean task.

So what about the extra money for the NHS?

This is the first year (2019-20) of the five-year spending plan announced by the government in 2018, raising NHS England's budget by 3.4% annually on average.

But as health think tanks have pointed out, this is just about enough to match rising patient demand, never mind fund any improvement in waiting times.

After several years of government spending allocations below the long-term NHS average it will take time to catch up.

Funding for capital spending (including building hospitals) and training new staff over the next few years has still not been announced.

The Royal College of Surgeons of England has argued that only more staff and at least 3,000 new beds will put the system back on track and even then it would take five years.

Health and medical leaders have argued that the government's pensions policy has contributed to the decline in NHS performance, with trust leaders claiming it has "made a bad situation worse".

Complex tax rules have left senior doctors reluctant to take on extra shifts to help clear waiting lists as the extra pay can be swallowed up entirely by tax bills.

A plan to mitigate the problem put forward by the government and NHS England has apparently had only a limited impact so far.

Mr Johnson, referring to NHS policies, said in his interview: "We are going to be working on this flat out, absolutely flat out."

Talk is one thing, delivery is another. He cannot run the health service from Downing Street - but he knows that the buck stops at his door.