With Philip Hammond’s autumn budget setting out an ‘exceptional’, one-off settlement for the NHS all eyes now turn to Simon Stevens

Arguments between the NHS and the Treasury in the run-up to a budget are nothing new, but the run-up to this budget was notable both by the arguments which were being had in public – and who was making them. And how.

Make no mistake, it is normal for the NHS to request significant sums of money. And it is normal for the Treasury to take the view that meeting the request is like pouring water on sand.

But it is not normal for the head of the NHS to stand on a public stage and demand £4 billion extra a year for the NHS as a down payment on an extra £350 million a week. And it is not normal for the Chancellor of the Exchequer to accuse the head of the NHS of failing to deliver his plan for the NHS in a television interview.

Which brings us to today’s budget, and to the feeling that the NHS has – once again – got a fairly good deal compared to other government departments, but not compared to the sometimes-dire situation that the NHS finds itself in.

There is the widely-expected extra investment in the NHS capital budget, although the presentation of £10 billion in the budget statement was stretching the truth a little. There are increases in revenue spending, which the government expects will be used to recover performance. The prospect of money for pay increases is there, conditional on reform. And the NHS has some extra money for winter.

But it is not £4 billion a year.

And nor is there any mention of social care, which will worry not just the NHS but councils up and down the country too.

We will hear more about the budget over the coming days – and indeed may see anonymous (and probably unplanned) briefings as the two protagonists get their excuses in. Whatever we read, remember that it benefits the Treasury to claim that Simon Stevens’s posturing resulted in a worse settlement than might have been achieved.

Remember too that the politics may not have driven the reality as much as the reality drove the politics. The truth of the matter is that the Chancellor had very little freedom to borrow significantly more money, to raise significant new money in taxes, and therefore no real chance of giving the NHS the money that it needs.

And without any more money Simon Stevens has no real prospect of halting the slide in the NHS’s performance.

In this situation, what NHS leader wouldn’t call vociferously for more money? And what Chancellor wouldn’t demand the NHS needs to do more for the money it has? For all the posturing in recent weeks, something like it probably had to happen – and probably didn’t make that much difference to today’s outcome.

But the nature of the posturing does demonstrate that the relationship between the Government and NHS England has broken down: NHS England was even excluded from discussions on the budget (and rumours abound that it was even denied sight of the settlement).

So all eyes now turn to Simon Stevens, and to the NHS England board meeting on 30 November (at which Malcolm Grant is already hinting at fireworks). He certainly will not warmly welcome today’s settlement, because it is nowhere near what he asked for. But equally, the Government has not been so miserly that it gives him the easy excuse he might have needed to walk. Conceivably, it might give Simon Stevens just enough to say that the NHS should now be able to find its way through winter (for which, remember, he has been made personally accountable) – but even if the NHS gets lucky with winter, he will already be gearing up for the battle to come next year. And the arguments then may be even uglier.