Pressure intensifies on squeezed NHS
There have been yet more reminders this week about the intense pressures on the NHS.
New drugs, treatments and therapies are coming on stream and patients understandably want them.
The burden of chronic disease continues to rise and that has a price tag.
Then there is the familiar underlying trend of an increasing and ageing population.
All this adds up to a financial squeeze on the NHS in England and there have been new warnings about the impact of that in the next few years.
The debate over the HIV prevention drug PrEP focused partly on how to meet rising patient expectations with a constrained budget.
The Aids campaign charity that won the High Court battle over the NHS funding the drug (though there will be an appeal) argued it was cost-effective, with the bills for lifetime care of an HIV patient greater than the cost of the preventative medicine.
NHS England, however, said if it did decide to fund PrEP it would have to be assessed against other requests for new specialist drugs, including one for children with cystic fibrosis.
The thinly veiled message from NHS chiefs was that if voters want the service to provide more, then higher funding will be required.
As patient expectations increase, so too does the requirement for the NHS to cope with chronic diseases across the population.
A report from NHS England has laid bare the financial consequences of diabetes.
It said that in the last financial year (2015-16) there were nearly 50 million items prescribed for diabetes at a cost of more than £950m, compared with about 27 million and just under £515m a decade earlier.
The bill last year made up about 10.5% of all primary care prescribing in England, compared with about 6.5% in 2005-06. A continued increase in those numbers seems inevitable.
Few would doubt that the pressures will intensify and a new appraisal of the financial implications has been drawn up by the Nuffield Trust think tank.
Author Sally Gainsbury returns to the thorny issue of the £22bn of annual efficiency savings that have to be made in England by 2020. She argues that even if hospitals and other trusts manage efficiency improvements of 2% per year there will still be a £6bn gap in 2020.
More ambitious efficiency improvements will be required but that has not been achieved at a sustained rate at any time in the history of the NHS.
Nuffield's conclusion is that curbing the growth in demand for services will be required, which will be a big ask for local health commissioners.
The bleak alternatives, according to the think tank, will be extending waiting times, narrowing the range of patients eligible for treatment or cuts to services.
Chris Hopson of NHS Providers, representing trusts in England, argued that the report was another important piece of evidence that the service faced deep-rooted systemic problems: "We need to be honest with the public about the consequences of the longest and deepest financial squeeze in NHS history. The NHS will be performing heroically well to just maintain existing standards of care."
Further scepticism about the £22bn of efficiency savings has emerged with a survey of health professionals who have signed up to attend the UK Health Show in September.
Of the 400 who responded, 85% said they were not confident the savings could be delivered in full. Only 10% were confident that the £5bn of hospital cost savings identified by the government adviser Lord Carter could be achieved.
NHS England recently unveiled plans to help trusts control spending this year, including a relaxation of the fines regime.
A carrot-and-stick approach has been adopted to link additional funding for trusts to efficiency savings. Chief executive Simon Stevens talked of stabilising the finances and "kick-starting wider changes".
But the financial challenges for the NHS are immense.
They are likely to occupy an increasing amount of Theresa May's time once the holiday season is over and the new team at No 10 Downing Street have their feet fully under the table.