When Jeremy Hunt was asked about the precise sum to be invested in the NHS, doctors’ fears that the much-publicised figure of £10bn was not all it seemed to be, were realised.
‘Whether you call it £4.5bn or £10bn, it doesn't matter. It is what the NHS said they needed and it was extra money going to the NHS frontline.’
So came health secretary Jeremy Hunt’s rather astonishing retort to a question as to the precise extent of health service investment posed at the health committee’s evidence session into NHS finances last week.
The inquiry, having been preceded by months of concern over health service funding by doctors, providers and the BMA, had opened with repeated queries over the Government’s long-disputed figure of £10bn increased investment into the NHS.
Committee chair Sarah Wollaston and the Labour MP and former health minister Ben Bradshaw both challenged the figure, correctly pointing out that, far from £10bn, total health spending in England will rise by only £4.5 billion in real terms between 2015/16 and 2020/21.
Dr Wollaston made clear that she and her committee believed that continued use of the £10bn figure was misleading, while Mr Bradshaw said the Government’s investment had come at the expense of slashed public health and social care budgets.
‘What we delivered for the NHS was after exhaustive discussions both with NHS England and with the treasury [and was] what the NHS said they needed to get going [and] kick start the [Five Year] Forward View,’ Mr Hunt had maintained.
‘We've always been completely clear, as we talked about earlier, that some of the way we funded that was by making savings to the Department of Health central budget.
‘I wish we didn't have to do that but in the constrained financial circumstances that we are in, that was the only way to fund the NHS's plan,’ he added.
Since the June referendum on Britain’s EU membership, it is often said that UK politics have moved into a ‘post-factual’ era; one in which rhetoric and sound bites hold greater currency than inconvenient truths and factual minutiae.
Mr Hunt’s performance before the health committee will, however, come as a vindication, albeit a joyless one, of what thousands of NHS doctors and the BMA had already known for months about health service finances.
In November 2015 the then chancellor, George Osborne, announced a real terms increase that would ‘fully fund’ the NHS's Five Year Forward View of £10bn between 2014-15 and 2020-21.
It didn’t take long for the figure to be debunked, with £2bn of the total figure revealed to be ‘old money’ announced in the previous year's autumn statement.
However, the lion's share of Whitehall sophistry lay in the terms used to define what exactly was being invested in.
The money, it became clear, applied only to NHS England's budget rather than the Department of Health as a whole.
This artful redefining of what constitutes NHS spending was crucial, as it meant that £3bn of the overall investment had to be sourced from cuts to health services outside of NHS England’s budget.
As a result, areas such as medical education, social care and public health were exposed to what ministers would diplomatically term as ‘efficiency savings’.
Speaking at the time of the announcement, BMA council chair Mark Porter warned that Government plans did not go nearly far enough.
‘The NHS desperately needs investment, to help integration and service improvement, but next year, and perhaps beyond, the vast majority of the extra money will pay off the deficit caused by the year-on-year squeeze of health service income — paying off last year's cuts.
‘The NHS will be £30bn per year short of what it needs within four years. No one believes that target can be met through the small but welcome increase in spending, leaving the rest to efficiency savings — more cuts.’
Fast-forwarding to the committee hearing, Mr Hunt insisted that the Government had ‘never pretended’ that the £10bn represented an increase in the overall Department of Health budget.
He further added that there had been no denial either of the fact that funding would come in part via savings in the ‘non-NHS England parts of the budget’.
Yet despite assurances that he understood the pressures faced by NHS frontline staff, Mr Hunt said he would have no truck with the suggestion that health providers had no choice but to ration services to make ends meet.
‘I completely understand that people working in hospitals recognise that they have never been busier, people working in GP surgeries and social care sector the same.
‘What I don't accept is that in order to make those efficiency savings, you have to make changes that will impact negatively on patient care.
‘There are ... easy ways to make savings, which is to reduce the availability of care for patients, and there is the harder way, but the right way, which is to find ways that improve care and improve efficiency at the same time.’
This position is in marked contrast to the picture painted by NHS Providers chair Chris Hopson, whose letter outlining the ‘stark choices’ facing a health service in financial crisis, arguably proved to be the catalyst to the hearings.
In it, he made clear that unless additional funding could be found, many providers would ultimately have to begin making choices over what services would need to be reconfigured or rationed.
Mr Bradshaw expanded upon this reality, in light of Mr Hunt’s meeting with Theresa May, in which, it is alleged, the prime minister confirmed there would be no additional future funding for the health service.
‘The providers, all of those involved professionally in healthcare, have given us in their evidence the warning that if there's not to be any extra money … that there has to be more rationing,’ he explained.
‘We understand from your meeting with the prime minister last week that there is going to be no extra money … so which is it as far as you're concerned?’
While declining to confirm the outcome of his conversation with the prime minister, Mr Hunt said that he would never wish to see rationing, and that such practices could be avoided through careful management and judicious cost cutting.
‘What we have to do is have a structured and planned way to find efficiency savings in a way that improves care for patients rather than makes it worse, he said.
‘If you look at best practice from around the NHS you actually see the two go together ... hospitals with the best CQC ratings are the hospitals with the lowest deficits not the highest deficits.
‘Good management tends to mean better care for patients allied with better management of resources. I don't want to pretend that is an easy process but that is a message that we focus very hard on sending out from the centre.’
Patient demand, financial restraint
Mr Hunt’s apparent answer, essentially that of simply doing more and better with less, betrays a worrying disconnect between the health secretary’s reality of the NHS and that of the staff working daily on the ground.
Prior to the health committee’s hearing, BMA representative body chair Anthea Mowat wrote to Dr Wollaston, urging that she use the session to determine future levels of funding and the ability of the NHS to provide universal access to high-quality care.
‘I ask you to seek assurances from the panel... that they will indeed ensure the NHS receives the funding it needs to continue to provide universal access to high-quality care. Under the current funding settlement this is being called in to question.
‘The NHS is, as you know, barely coping with unprecedented rising patient demand against a backdrop of crippling financial restraint.
‘This is not financial mismanagement, this is a legitimate inability to cope in the face of unprecedented rising demand; it is not simply a choice of doing more with less.’
Definitions of reality aside, there remains an almost grim determination from among the key players seeking to deliver their five-year vision for a revitalised health service.
NHS England chief executive Simon Stevens, sitting alongside Mr Hunt, denied that he was destined to be a fall guy of failure.
‘The NHS is going to carry on,’ he said: ‘the NHS needs to continue looking after the people of this country. I think that's what all of us want to see.’
Read more from Tim Tonkin and follow on Twitter.