One of the most important consequences of the listening exercise on the Health and Social Care Bill and the government’s response has been to draw both the prime minister and the deputy prime minister into the heart of the debate about NHS reform. Even more important have been the commitments made by the prime minister during recent weeks to increase the NHS budget in real terms during this parliament and to keep waiting times low. The success of the government will be judged in large part by its ability to deliver these commitments in an increasingly cold financial climate.

Keeping waiting times low will be a much bigger challenge for the government than ensuring the budget increases in real terms. The NHS did well compared with other areas of public spending in the government’s spending review and the Treasury can always be persuaded, albeit reluctantly, to find extra resources if there is any prospect that the prime minister’s commitment will not be fulfilled. Maintaining recent improvements in patients’ access is much more difficult because of the pressures on the NHS to improve performance as well as to hold on to the gains made under the previous government.

In relation to waiting times, the prime minister emphasised the importance of maintaining the 18 week target for patients to be treated in hospital after referral by …