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The Guardian view on NHS funding: hospitals are hurting | Editorial

King’s College hospital in south London
King’s College hospital in south London. The truth is that London hospitals in general, and King’s in particular, have historic funding challenges and also face particular difficulties in recruiting and retaining top-class managers. Photograph: Andy Hepburn/PA

Bob Kerslake has been a big figure in public service for most of the past 20 years. He was a successful chief executive of Sheffield city council, before he was enticed to Whitehall where he became permanent secretary at the Department for Communities and Local Government, and for a time head of the civil service. In 2014 he left Whitehall to run King’s College hospital foundation trust in south London, and in 2015 he was made a member of the House of Lords. His public image is of a combative man who is not afraid to speak his mind and who is passionate about public service. It is little surprise that the opposition have sought his advice.

On Sunday night, Lord Kerslake announced in these pages that he was resigning from King’s in protest at what he called – correctly – the failure of government to face up to the depth of underfunding in the health service. Such a high-profile resignation by a well-respected figure is profoundly embarrassing, and he correctly anticipated a counter-attack. On Monday morning it was widely reported that he was expecting to be asked to step down by NHS Improvement, the regulator created by the Conservatives to monitors trusts’ financial management, because King’s is spending way over its budget, and has been since before he took over. King’s is now a hospital in special measures, adding to the impression that Lord Kerslake jumped before he was pushed.

This is not the whole story. He was immediately backed by NHS England and the organisation that represents all hospitals, the NHS Confederation. On the other hand, the newly departed chief executive of NHS Improvement, Jim Mackey, used an interview marking his departure with the specialist NHS publication, Health Service Journal, to denounce King’s failure to meet, as Mr Mackey put it, “any of the numbers it had put to us” in the two years he was at the NHSI. He suggested the problem was less underfunding than the “comply and lie” culture that is quite often used in the NHS as an alternative to making the sums add up. Mr Mackey was also critical of the way NHS bosses had demanded more money – a call echoed by all the leading health policy thinktanks – in the run up to the autumn budget, and then collectively criticised the chancellor’s failure to deliver. He warned that in difficult times the extra £2.8bn for revenue spending that Philip Hammond had announced was a significant amount, and criticising it would only confirm the Downing Street poor opinion of the health service’s serial ingratitude.

Mr Mackey appears be attacking not just the management of King’s but the decision by the boss of NHS England, Simon Stevens, and his board, to try to start a public debate about rationing care in a time of cuts. The NHS England board, which met in public at the end of November, is courting confrontation with ministers when it suggested the obligation on waiting times that is enshrined in the NHS constitution might not be met if other priorities – for example on accident and emergency – were to be fully funded.

In response, the health secretary, Jeremy Hunt, reiterated his commitment to waiting times. This is the kind of damaging ferrets-in-a-sack row between parts of the health service that would do better to stay on the same side (as Chris Ham of the Kings Fund argues). The truth is that London hospitals in general, and King’s in particular, have historic funding challenges and also face particular difficulties in recruiting and retaining top-class managers. But this should not disguise the other truth: that the health services across the UK are facing the worst squeeze they have ever endured as demand and costs both increase sharply. Rather than criticise each other, it would be much wiser to try to present a clear, coherent argument about what can and can’t be done that unites all NHS leaders. In effect, the Treasury is imposing a brutal decline on the health service. Unless there’s a change of heart, the only real argument is whether that decline will be managed – or, in a recipe for greater disaster, left unmanaged.