In the red, in the firing line

It's not unusual, as someone once sang, for Local Health Boards to predict they'll be in the red come the end of the financial year. No, I know that's not how the song goes but it is how things are going in the Welsh NHS.

It is, however, unusual for them to predict a worst case scenario of a £50m deficit, despite warnings from the Health Minister that this time - unlike all those years in the past and unlike her predecessors - she will not bail them out.

The cupboard is bare, you've had what you're going to get, balance the books or come and collect your P45s.

From the moment Lesley Griffiths told the Health Committee on October 20th that she was prepared to see whole boards go (she meant the management boards who run the health boards) she knew she was inviting the whole world to look if, come the last day of March, she blinks and pays up.

What happens now then?

"There's only two things health boards can do at this point in the financial year" one health economist told me yesterday. "They can close services or sack staff." Her concern? That with a P45 hovering, some Chief Executives will be tempted to cut what they can, not what they should.

Perhaps, she added, that they still expect a few million to turn up from somewhere despite the 'no money' mantra. After all £20m turned up from nowhere last week to pay for the Lib Dem budget deal.

Another economist shook his head. "They can't turn people away, especially if it's a bad winter but if there's no money ..."

The real question, perhaps, is why can't Wales' Local Health Boards balance the books? There've been generous settlements in the past that haven't delivered the sort of service you might have expected for the money.

There've been any number of reports telling us that services aren't set up right, aren't configured in the best way possible, any number of clinicians and health economists accusing successive Welsh governments of revamping at vast expense but to no real avail.

There've been warnings - as I heard a few weeks ago from a man who made the whole room sit up - that until we as patients are persuaded to see crumbling hospitals as liabilities and not assets, nothing much will change. You'll have a long wait, said one health professional. The loudest cheer at a public meeting I was at in Llanelli about the future of local services came after someone said "I don't care if it's safe, as long as it's here".

The assembly's cross-party health committee - chaired by a Labour backbencher - has warned that an extra £83m set aside for next year may not be enough to "address the funding difficulties which LHBs have already identified in the current year".

The Conservatives argue the Welsh government is wrong not to ring-fence health spending in the budget. Plaid Cymru don't and neither do the Liberal Democrats but both say the Health Minister must take her share of the responsibility for the difficulties health boards now face. There must be better scrutiny and worthy contingency plans.

The Health Minister is - so far - sticking to her guns. NHS managers have been given an extra £103m. NHS managers will be held to account for the financial management of their organisations.