As the NHS world has fixated on the Francis report, other key issues have receded into the shadows. But the day-to-day pressure which is having the greatest impact on service planning and performance remains the drive to save £20bn.

‘It is no longer simply enough to arrive at a savings target, it is necessary to know how you will get there’

The Nuffield Trust has revealed what many HSJ readers would have instinctively known − that NHS productivity has not noticeably improved since 2006-07. This is not for the want of trying, but reconfiguring service models and their cost bases is hard and the outcomes uncertain.

Our HSJ Local Briefing this week on the Birmingham and Solihull health economy outlines a range of innovative initiatives, but also shows that savings did not always arrive in the shape and scale expected.

In the second city they know next year will not only require a similar scale of efficiencies, but also a greater grip on what will deliver them.

As the savings number gets bigger and the low-hanging fruit drops, the danger of unintended impacts on quality increase. It is no longer simply enough to arrive at a savings target, it is necessary to know how you will get there.

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