Simon Stevens" NHS gamble is probably the right choice - but price could be high | Richard Vize

The NHS plan for the next two years represents a perceptible contraction of the health service’s offer to the public.

The proposals in Next steps on the NHS Five Year Forward View, published on Friday, are shaped by shortages of money and staff.

Simon Stevens, the NHS England chief executive, has burned through much of his political capital in disputing government claims about whether the NHS has been given all the money it asked for, so this was not an opportunity to push for further cash.

So in the face of the unrelenting pressure of the government’s austerity programme and barely controlled hospital debt, he is gambling that politicians and the public will stomach longer waits for routine surgery if the health service can deliver better performance on cancer treatment, A&E waits, mental health services and GP appointments.

In the wake of slipping cancer treatment times and the recent outcry over the death of a child waiting for urgent surgery, this is probably the right choice. But the price could be high.

Allowing elective surgery times to slide over many years was what led to hundreds of thousands of patients waiting months for operations by the time New Labour came to power in 1997, elected partly on its pledge to slash waiting lists. It would be a serious blow if the NHS returned to the days of people dying while waiting months for heart surgery, and many more forced to endure avoidable pain and disability.

Access to some of the latest approved drugs is also to be delayed – in breach of a commitment in the last Conservative manifesto to speed up access.

Stevens is anxious to reassure the public that performance will not slide back to that of the 1990s, but it is difficult to see how growing waiting times will be arrested and reversed in the coming years.

The plan makes some brave assumptions about the ability of the NHS to expand its workforce, including 4,000 more nurses through improving staff retention – turning round a recent trend – and up to 2,000 more nurses returning to practice.

There is yet another pledge to increase the number of GPs substantially, despite little discernible progress. However, concerns are growing that staff shortages will be exacerbated by EU staff heading back to the continent in the wake of the Brexit vote.

More promisingly, the plan may well mark the beginning of the end of the internal market. It names nine areas being considered as pioneering “accountable care systems”, with NHS organisations and local authorities working together as an integrated health system.

These areas will have considerably more control over how they deliver their healthcare, and will be effectively freed from the endless focus on contracts rather than patients imposed by the purchaser/provider split.

However, doing so will require ever greater legal contortions to simultaneously stay within the law while circumventing it. This is a necessary bodge, as it will be years before anyone attempts another NHS reform bill, but these workarounds cannot be sustained indefinitely.

Everyone will now be working in Sustainability and Transformation Partnerships, and NHS England makes clear that anyone who fails in their duty to collaborate can expect to be handled roughly.

In the absence of more money, the alternative to Stevens’ plan would be a steady atrophying of performance across the entire health service. Instead, NHS England is pushing forward on the key priorities of emergency care, cancer treatment, mental health and primary care, and allowing routine surgery to pay the price.

But many of its promises look optimistic, and there is a danger that the slide in surgical performance will eventually reverse years of progress.

For the time being this can be portrayed as a tactical move, but with austerity set to last well into the next decade, there is a risk that the NHS will cease to be a comprehensive service.

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Simon Stevens" NHS gamble is probably the right choice - but price could be high | Richard Vize