It's interesting to see that the two centre-left 'broadsheet' newspapers start the week of the Comprehensive Spending Review with stories about threats to NHS funding.

The Guardian focuses on the £15-20 billion productivity improvement, and quotes Mark Porter of the BMA consultants committee as saying that every hospital department is facing a 8-9% cot in 2010-11.

It also reports Kings Fund chief economist Professor John Appleby highlighting his recent "experimental" work with colleagues on on variations in cost per procedure.

Another Guardian piece quotes a Whitehall source to the effect that "A fifth of everything the NHS does today will stop".

Meanwhile, The Independent has a not-very-exclusive exclusive repetition of the RCN's figures on NHS staff job losses.

More sensibly, The Indy has the aforementioned irridescent Professor John Appleby warning that cutting jobs is a less good idea than managing variation in performance, cost and outcomes.

Appleby drops a neat little management hand-grenade into his article, suggesting that "Renegotiating incremental increases built into staff contracts, for example, could save £1bn and protect jobs". This is one of those wonderful points that is a) true, b) interesting and c) very difficult indeed to do.

So. Is the NHS hospital sector (the bit people worry about most) cutting spending and jobs?

Of course it is. And was always going to be doing so, since tariff was revised to cut payment for emergency admissions over the 2009-10 baseline to 30% of tariff.

What the Indy article in particular fails to tell us is whether the ward closures are due to planned transfer of acute services into community settings.

The Whitehall source of the "fifth-will-stop" quote for The Guardian encapsulates a bit of the situation that seems remarkably poorly-understood in many parts. The £15-20 billion 'cut' is best understood as planned funding growth foregone.

Nor is it a surprise - the hit to public spending (or for the NHS, standstill) has been explicitly on its way since the summer of 2007, when queues formed outside branches of the all-too-friable Northern Rock. It has been explicitly acknowledged for over two years by NHS chief executive Sir David Nicholson.

There is a real crisis coming – probably two-fold. It will come in the guise of a winter admissions crisis, compounded by cuts to the funding of local government in the Comprehensive Spending Review.

One of the things a local authority can cut is social care.

That is what is going to happen.

The NHS Confederation has warned that the NHS will bear the brunt of this cut. That is the real story here.

Acvting CE of the Confed Nigel Edwards warned in a statement of ”a potent cocktail of financial pressures” and called for “a frank and honest debate about the implications of the decisions being taken”. Translated into layman’s English, this means it’s brown-trouser time.

Nigel Edwards is no fool: he does not talk lightly of the ”need to be realistic … that there are no pain-free choices if we are going to make all this happen”. There is going to be both tough politics and challenging economics in this.

The Confed statement quoted a recent survey by Community Care which showed that two-thirds of councils were only providing social care for people in either critical or substantial need.

Edwards rightly observes, “Some will present as emergencies in A&E departments and GP surgeries, others will find themselves trapped in hospital unable to get home, blocking the bed from someone else who badly needs it. Everybody loses: the users of services, those who care for them, the taxpayer and the NHS. It’s a classic false economy.”.

And if you need cheering up after all that, as well you might, then we have a fresh dose of The Maynard Doctrine for you.

Have a good week (except probably on Wednesday).