George Osborne put Simon Stevens’ £8bn black hole on the backburner, as he turned attention to further decentralisation from Whitehall

Pre-election budgets don’t usually make much difference, former Tory chancellor Ken Clarke remarked shortly before George Osborne did his stuff.

I’m sure he’s right about Osborne’s sixth – especially on the NHS, which barely got a mention, apart from a welcome gesture on mental health.

Despite health secretary Jeremy Hunt’s soothing bedside manner, it’s still pretty toxic for the Tories, so being the “great unmentionable” makes sense.

‘What most intrigued me about the budget was its devolution agenda – another source of instability’

In any case we all know the diagnosis: rising demand and – at best – flat funding for the rest of the decade.

So NHS England chief executive Simon Stevens’ £8bn hole will still need to be filled, whoever wins.

Politicians have less room for manoeuvre than they pretend, as Osborne demonstrated by juggling his projected public spending totals - a big squeeze in 2016-18, followed by a spending surge in time for the 2020 campaign, when David Cameron will definitely bow out.

Scare story

It’s all scary, but it won’t happen that way – neither the spending nor the Cameron succession. In an age of growing insecurity, that much we know.

So what most intrigued me about the budget was its devolution agenda – another source of instability, albeit more creatively.

It’s an agenda Scotland’s separatists – let’s build the high speed train from our end, says Alex Salmond – make more urgent by the day and is emerging, English-style, in a pragmatic, haphazard way.

From Swansea’s tidal lagoon to Birmingham’s energy research accelerator, better cross-Pennine trains and a “city region” deal for Greater Leeds, decentralisation from post-imperial Whitehall really does seem to be kicking off at last.

But progress is never linear and centralising tendencies persist.

Whipp hand

The day before the budget, shadow health secretary Andy Burnham dragged health minister Jane Ellison to the Commons to explain the special measures forced on NHS England’s largest single employer Bart’s trust in east London, by the persistent quality failures at Whipps Cross University Hospital.

Ms Ellison presented the intervention as a success for the Care Quality Commission’s tougher new regime.

‘Manchester’s 10 combined councils have won a lot of health autonomy without much accountability’

Burnham argued that local MPs – including Iain Duncan Smith – have been nagging about the problem since at least the merged trust’s 2013 reorganisation.

Local people were begging for a new CQC inspection – vindicated by last week’s (delayed?) report.

Remember, this trust is directly managed from Whitehall by the Trust Development Authority.

X-ray vision

The exchanges took on a tit for tat dimension. It’s as bit like Labour’s “Next time they’ll cut to the bone” election posters – the Tory emphasis on lower spending in Labour led NHS Wales, while the Liberal Democrats cannibalise Labour’s poster to take credit for current NHS spending levels.

Let’s hope we get more clarity before polling day.

We certainly got a little on Manchester’s £6bn NHS devolution package this week, thanks to the coincidence that former minister Lord Warner and his sidekick, Jack O’Sullivan, were already working with the Manchester health community on a more radical agenda than mere integration with social care when they got caught up in the ambitious “Healthopolis” deal between the city and the Treasury.

‘Let’s hope we get more clarity before polling day’

Not much role here for Messrs Hunt and Stevens, although they are on board with fingers crossed. Lord Warner and O’Sullivan have written all about it this week.

But Manchester’s 10 combined councils have won a lot of health autonomy without much accountability.

With a population of 3 million (the size of Wales) they want to tackle poor mortality, save half the city region’s £1bn deficit and recycle the acute bed budget into community care.

Who pays if it goes wrong? That remains unclear.

Michael White writes about politics for The Guardian

Topics