BRITAIN’S health service is no stranger to crises, but lately predictions of a particularly big hole in the budget have plagued Jeremy Hunt, the health secretary, and Simon Stevens, the new boss of the National Health Service (NHS). Sources at NHS England told the BBC on June 18th that there was a gap of around £2 billion ($3.4 billion) in funding for the fiscal year ending in 2016. Monitor, the health regulator, predicts a shortfall of £30 billion by 2021.

Many countries have seen their health-care budgets strained as a result of the financial crisis (see article), but the challenge facing the NHS is particularly daunting. It is already struggling to find £20 billion in savings which the government demands by 2015. Doctors responsible for primary care (known in Britain as general practitioners, or GPs) warn that squeezing budgets in one part of the NHS can raise pressure on another. A study by Imperial College in London found that in 2012 more than 6m visits to emergency wards in hospitals were a result of delays in seeing a GP.

Sarah Wollaston, a Conservative MP and doctor, argues that the growing number of people living with chronic illnesses, along with cost inflation caused by new technology and expensive drugs, means the health service needs more cash. With an election due next year, the coalition will probably be prepared to cough up, at least for a little while. Yet it is unlikely that large gaps can repeatedly be filled from the public purse. The NHS also had two serious crises under Labour in the 2000s, even though spending was then rising at its fastest rate since its founding.

Nigel Edwards, head of the Nuffield Trust, a health-care think-tank, believes that a bigger efficiency drive is overdue. He wants a more concerted effort to even out disparities in the quality of service provided by GPs and other people who deliver primary care. That could save money—but it could also save lives, which are often lost because busy or careless doctors fail to refer patients to specialists early enough. A typical local doctor, Mr Edwards adds, will see “two or three cancer cases a year”—nowhere near enough to improve strategies or timelines for diagnosis.

Bringing in the private sector to help with data crunching and to manage contracts and facilities might help, but such ideas are often forestalled by shrill charges of creeping privatisation. Mr Stevens is avoiding this fraught political territory, but he does want to deal with uneven provision. He points out that the clinical-commissioning group in Liverpool (a doctor-led outfit that procures services for the NHS) might be able to save over 400 lives a year if it were able to match the best outcomes reported in areas with similar demography. Yet innovators find it difficult to scale up their successful experiments. Heads of high-performing hospital trusts complain that there is very little incentive for them to take over weaker ones or to franchise their expertise.

Among the most worrying problems for the NHS boss is that his workforce has ballooned, without vast improvement in services to show for it. Even though the number of full-time hospital consultants in the NHS has increased by 76% since 2000, many hospitals still retain large teams of junior medics, a hangover from days when senior staff were scarcer.

The newcomer wants the beloved, beleaguered NHS to be “respectful of our history, but not hostage to it”. That is a polite way of saying that the service is slow to shake off accretions that have long stopped being useful. The NHS will continue to make heavy demands on Britain’s budget, due in large part to factors beyond its control. But it badly needs to heal some self-inflicted wounds.