Brexit casts its shroud over everything. The no-dealers grow more wild-eyed by the day; though sterling drops, prices rise. Chris Grayling says we can dig for Britain. There is a cabinet at war: the Tory chancellor is denounced as a saboteur by a previous holder of the office. But all this craziness does have one political advantage: it hides all the other crises the chancellor can’t possibly solve in his budget next month. Of these, the NHS and social care is the pressure cooker likely to blow loudest. In the Brexit hubbub, an eerie silence falls before what most NHS managers – and, indeed, NHS ministers – expect to be a near-as-dammit winter collapse.

Start with this: everyone knows there’s a nursing shortage, but until a new report from the authoritative King’s Fund, no one knew it was this bad. The fund itself sounds shocked to find the number of nurses in the NHS is actually falling, year on year. Despite repeated ministerial promises, there are fewer nurses this April than last April, and the trend has continued since.

The need soars in hospitals, midwifery, care homes and care in the community. Emergency admissions have risen by 14% since 2010, so the nurse:patient ratio is getting worse. This is the first year-on-year fall in nurses since the Francis report on the scandal at Mid-Staffs hospital, which was caused by a management frantically cutting debts by reducing its staff, leaving patients cruelly and dangerously neglected.

Remember how Jeremy Hunt flourished that case with glee, because it happened under Labour in the misconceived era of forcing hospitals to dash for “foundation trust” status in another of those frenzied ministerial reorganisations imposed on the NHS every few years. But even as Hunt exploited the scandal, he refused to allow the National Institute for Health and Care Excellence or the Care Quality Commission to set a benchmark for safe numbers of nurses per types of wards or patients. However, hospitals were allowed to hire temps, and costs soared as Hunt pledged to put quality first. That didn’t last long, as NHS debts mushroomed.

Nursing numbers never recovered from George Osborne’s first budget cutting nurse-training places. Hunt has announced a magical 25% rise in training positions, but Richard Murray, director of policy and author of the King’s Fund report, says that “will take years to translate into extra nurses on the wards”. He says the government’s scrapping of bursaries for student nurses has already resulted in a reduction in successful applicants. “The fall in nurse numbers raises questions about the NHS’s continuing ability to ensure patient safety.”

Focusing attention on Brexit is a merciful distraction from all the other pressures bearing down on Hammond’s budget

The 96% plunge in EU nurses joining the UK register following the Brexit vote could have been prevented had Theresa May rushed to embrace all NHS staff with a welcome to stay for ever. New tougher language tests for foreign nurses were badly timed to add to a perfect recruitment storm. The report finds: “The number of NHS staff leaving as a result of ill-health and work-life balance has also increased sharply over the last few years.” In a vicious downward spiral of overwork, covering for about 40,000 unfilled vacancies is the reason given by 44% of those who quit. Hunt just announced an end to the 1% pay cap – but admits the money must come from squeezing “productivity improvements”: fewer nurses per ward is a statistical productivity gain.

Bullying NHS trusts about their debts has now reached such a level that Rob Whiteman, chief executive of the Chartered Institute of Public Finance and Accountancy, says that finance directors are forced to pledge entirely impossible and dishonest “controlled total savings” of between 4% and 10% – in other words, to lie. Boardroom documents leaked to the Health Service Journal suggest that Basildon and Thurrock University NHS Trust’s finance director, Rick Tazzini, was put under such “considerable pressure” that he was not prepared to agree such savings for fear of patient safety: the board went against his advice and he walked. At the same time, the NHS is telling its local trusts to “get lippy” with local councils about their failure to take old people into social care to relieve blocked NHS beds. Not long ago, joint working was the ideabut extreme cash shortages are sending the NHS and local councils back into crude warfare.

The body that forces these improbable savings, turning the screw on mounting trust debts, is NHS Improvement. A new chair has just been announced, subject to approval, and it is one of the most shockingly political appointments, even by this government’s standards. Baroness Dido Harding takes the Tory whip in the Lords, is married to a Tory MP and she’s an old Oxford contemporary of David Cameron’s. She was chief executive of Talk Talk when a hacking outbreak cost the company £60m. She walked away with shares with a value of £7.5m, saying, “I’m a really big believer in chief executives not staying for ever.”

She may be great: I’ve no idea. But yet again the government flies in a private sector executive with zero public service or NHS experience on the insulting assumption that private managers are always better than public managers. By far the most impressive managers I meet are those running the most complex public operations: if you run Talk Talk, all you worry about is the bottom line (though she didn’t do that too well, down by 30%). Try running the NHS or a local authority with thousands of conflicting objectives. It is an intellectual and managerial challenge beyond anything in the private world.

Winter is coming: the King’s Fund doubts this government’s unprecedented seven-year run of NHS good luck will hold out – no flu, no norovirus, no bitter freeze. Is the NHS infinitely resilient? Staff shortages, funds falling per patient, overused beds and intense A&E pressure are real threats. Australia and New Zealand have a flu epidemic, and it is highly likely, says the King’s Fund, to blow over to us. So maybe focusing attention on the great Brexit debacle is a merciful distraction from all the other gigantic pressures bearing down on Philip Hammond’s budget.

• Polly Toynbee is a Guardian columnist

• This article was amended on 17 October 2017. An earlier version referred to Dido Harding being announced as a new chief executive for NHS Improvement. She is to be its new chair.

