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Editorial Saturday 15 October 2016: The bed of nails, leaking from the top and sucking it up

In the world of health policy, life imitates art: the first time as tragedy, the second time as Yes, Minister.

'The Bed Of Nails' is an iconic 'Yes, Minister' episode, in which civil servant Sir Humphrey Appleby observes that "the ship of state is the only one that leaks from the top".

Today's Guardian has an exclusive report from Denis Campbell on the meeting between NHS system leaders Simon Stevens and Jim Mackey. health secretary Jeremy Hunt and Prime Minister Theresa May.

The PM told the meeting that the autumn statement would have no extra money for the NHS, and that money would have to be saved through efficiencies.

Mmmmm. Or as we say in the trade, mmmmmmmmmmmm.

This meeting wasn't wildly secret, but most people informed about it were told under heavy manners to keep it schtum. That being defenestrated, here are some thoughts.

Cui bono?
The Prime Minister has been really quite stupid here, arguably less in the decision (as it is now pretty widely agreed that as Simon Stevens noted in June, social care needs any spare cash more) than in the delivery.

The first rule of Political Leak Club is to ask yourself the simple question cui bono? Or to put it in Latin, who benefits?

The NHS side of the table don't. They pretty much knew before the meeting that HM Treasury will not agree any extra money for the NHS until it has hit its financial envelope for 2016-17. It's probably scrape-through-able, as 17-18 might be.

I have previously remarked that 18-19 and 19-20 are the financial years that absolutely nobody who's Scooby-positive believes are achievable.

This was just confirmation of that news. "Strong message here!"

Does Jeremy Hunt benefit? Not particularly (and his office deny being the source of this leak, which is thought plausible). He did get a strong endorsement in the PM's party conference speech - "one of the most passionate advocates for patients and for the doctors, nurses and others who work in our health service that I have ever known".

Mr Hunt is staying as long as Mrs May stays - or until a ministerial human sacrifice is needed when an NHS care quality scandal follows from the financial or organisational disruption ahead.

That leaves Mrs May (in practical terms, her team of Nick Timothy and Fiona Hill) as the dysfunctional faucet. They will be well aware that the Commons Health Select Committee's NHS funding inquiry will hear from Mr Hunt, Mr Stevens and Mr Mackey (and DH's David Williams) on Tuesday.

This leak is partly about getting Number 10's retaliation in first.

It is rather more a piece of media megaphone diplomacy about who's in charge.

And of course, the PM is not wrong there: she is in charge.

And Brexit means Brexit.

(Brexit meaning a tumbling pound, storing up significant inflation. Which is nice to know. And which of course affects the NHS.)

So, yes, Theresa May has that nice, warm feeling of having told those NHS spendthrifts who's in charge.

Of course, you also get a nice, warm feeling if you shit in your nappy. Temporarily.

The problem being that fairly quickly, that starts to feel clammy and uncomfortable. And it smells awful.

And there may not be a grown-up along to change your nappy as soon as you'd like. Which can lead to another kind of leak.

For every action, there is an equal and opposite reaction.

Mrs May and her team would be well advised to look at the data for Ipsos MORI and The Economist's latest Issues Index. It finds the NHS has moved up to first place in the concern rating of the sample surveyed.

As chief economist of the Nuffield Trust Professor John Appleby observed, "like last year, the NHS will end up having to print its own money".

Yep. Quite so.

It's worth re-reading Simon Stevens' comments on funding from our recent interview, in which he said "the then-Chancellor's deficit reduction target meant we didn't get our proposed funding profile for 2017/18, 2018/19, and 2019/20.

"So as things stand, the middle years of the SR are obviously going to be tougher than what we originally asked for following the Five-Year Forward View.

"That's why it's so critical we do everything we can to sort our finances this year, ahead of next year and the year after.

"Our previous evidence to the Health Select Committee also made clear that we've got less capital investment than envisaged by the Five-Year Forward View; social care isn't keeping up with demand, and local authority prevention services are under pressure.

"So it's a mixed picture. Given the circumstances facing the country, these are choices for elected governments to make, weighing up what the NHS has asked for versus other priorities.

"But as I said at the NHS Confederation conference in June, let's not rewrite history in the process.

"And let's acknowledge that since we're now facing a tougher challenge than set out in the Five-Year Forward View, there will inevitably be pressures, choices and controversies as the NHS copes with these constraints. Frontline staff, clinicians and local NHS leaders need full national backing and support in doing so".

The last lines above send a subtle signal for STP authors and politicians alike: tin hats on, because if this has to be done, it can only be done with some closures that people really aren't going to like.

Expect turbulence, pressure and serious unpopularity. We can and will suck it up.

How about you?