Dr Bruce Keogh, Medical Director of NHS England is a man of measured words.

So, his reaction to Chancellor Hammond’s budget boost for the NHS was characteristically balanced. His well-publicised tweet said, “Budget plugs some, but definitely not all, of the NHS funding gap.” But then he perceptively goes on to say that the situation “will force a debate about what the public can and can’t expect from the NHS.”

In reality, that debate is already up and running, especially where proposals are being developed to change patient pathways and the design of NHS services. And that is almost everywhere. Few of the Sustainability & Transformation Partnerships (STPs) are going to preside managerially over a status-quo service. Most will make significant service changes in the next three years, and not just because of money. Local public and patient involvement is already under way in many of these, and if it isn’t yet … it soon needs to be.

On Wednesday, the Chancellor announced the go-ahead for 12 schemes, representing 10% of the promised funding for STP initiatives. Now we imagine that some of these are what civil engineers call ‘shovel-ready’ – everything in place and everyone able to start implementation at a flick of a switch. But a quick look at the list of projects and a search to see if there had been a formal consultation with local people mostly drew a blank. So, the next step for NHS Managers will be to enter into dialogue – as required by statute and to meet NHS Guidelines. They also have to meet common law requirements for fairness (eg the Gunning Principles) and meet the ‘legitimate expectations’ of key stakeholders.

Responding to the Budget, the chief executive of NHS Providers, Chris Hopson, said that “Tough choices are now needed and trade offs will have to be made.” The question is who makes these trade-offs – and based on what criteria? Managers must resist the temptation to put speed before everything else, as Parliament – and Ministers – have consistently committed to full public consultation before such changes are made. Legal duties to involve the public will undoubtedly apply to the new Accountable Care organisations, and we expect Overview & Scrutiny Committees to be particularly vigilant where STPs cover the areas of multiple CCGs – with different styles and quality of public engagement.

What happens if public consultation reveals flaws in the projects which the Government has approved this week? The announcement boldly asserted that these were ‘the highest quality schemes with the strongest potential to help STPs meet future demand and develop local clinical and financial accountability.’

Then it says, ‘This is subject to business case approval’. Fair enough, but where the service change is significant (and/or if the Overview & Scrutiny Committee so advises) it is also subject to consultation, and if these schemes appear to be inflexible fait accomplis, the Courts would surely declare them unlawful on the grounds of pre-determination (Gunning One).

So, we join Bruce Keogh in welcoming the money that enables well-planned changes to go ahead, we mark the moment as the time when STPs move from theory into practice and embark upon serious dialogue with their communities. It has to be good.