CHANGE is afoot in England’s NHS. After years of demand growing faster than funding, the government looks poised to loosen the purse strings. On March 21st a cap on pay rises for NHS staff, which had been in place since 2010, was lifted. Four days later Jeremy Hunt, the health secretary, repeated his call for a ten-year spending plan and suggested that cash could be raised through “innovative models of taxation” like an earmarked NHS levy. Then, on March 27th, Theresa May told MPs that she wanted a long-term funding plan for the health service. “In this, the 70th anniversary year of the NHS’s foundation, we need an answer on this,” the prime minister declared.

If the taps are loosened, new funding might initially be used to balance the books. About half of hospital trusts are forecast to be in deficit at the end of this financial year, to the tune of a total of around £4bn ($5.7bn), once one-off extra funding is accounted for. Sanctions for those in the red are not exacting, providing little incentive to be thrifty, notes Nick Bosanquet of Imperial College London.

But if there is any money left after making up these shortfalls, where should it go? Health services can aim at various targets, like patient satisfaction or life expectancy. A starting point might be to look at how Britain compares with other countries.

In an ideal world politicians would be able to direct money to target specific maladies. High on that list would be cancer. Britain ranks in the bottom quarter of the OECD, a club of mainly rich countries, when it comes to five-year mortality rates for cervical and colon cancer. One reason is late diagnosis. Compared with other countries, those with cancer symptoms in Britain are more reluctant to seek out medical help and less likely to be referred to a consultant by their family doctor. As a result, cancers are caught later, when mortality rates are higher.

Britain also performs badly when it comes to obesity, points out Anita Charlesworth of the Health Foundation, another think-tank. Some 27% of British adults are obese, the sixth-highest proportion in the OECD, up from 14% in 1990. And rates are expected to rise over the next ten years.

The NHS is also something of a laggard in child health. Britain has the ninth-highest rate of infant mortality out of 33 OECD countries, a deterioration of about ten places since 1990. Breastfeeding rates in England are among the lowest in rich countries, and the prevalence of neural-tube defects, which can be avoided by giving expectant mothers folic-acid supplements, are among the highest. This is partly because public-health measures in England do not put enough emphasis on the young, argues Ronny Cheung, a paediatrician at the Nuffield Trust, a think-tank.

Another area of concern, for which international data are patchy, is mental health. It takes up around 25% of the disease burden of the NHS, but roughly 12% of the budget. That is partly due to historical stigmas. Obtaining treatment can be slow, particularly for children. Patients often get a “second-class experience” compared with physical health treatment, says Paul Farmer, the boss of Mind, a charity.

Diagnosis and prescription

But politicians cannot just throw money at particular diseases. Instead, they can only boost funding in different bits of the NHS and hope that helps. General practitioners (GPs), or family doctors, are one such part. Britain has fewer per person than other rich places. And they are quitting faster than they can be replaced, partly because of harder working conditions. By contrast, since 2014 annual growth in the number of hospital consultants has averaged 4%.

Studies show that hiring more GPs boosts myriad health outcomes, such as survival rates for heart disease. Moreover, increasing their number reduces the strain on other, more expensive bits of the health service. The average trip to the GP costs the NHS about £38, compared with £140 for a visit to an accident and emergency ward. Hospital admission rates in Britain for asthma, a condition which can usually be treated in primary care, are 50% higher than the OECD average.

Capital investment—that is, spending on equipment and buildings—could do with more money, too. Stroll through most hospitals and it will not take long to find out-of-date equipment or a building that needs repairing, says Matthew Kershaw, a former boss of East Kent Hospitals University Foundation Trust. Britain spends 0.3% of GDP on investment in health, compared with an OECD average of 0.5%. The NHS has a building-maintenance backlog that would cost £6bn to clear. A surgeon reports that in one hospital, budget cuts were so severe that there were no surgical pens to mark which bit of a patient to cut up.

Though almost all health experts are keen to see the NHS get a cash injection, many, including Mr Hunt, worry about the long-run pattern of feast and famine. Between 2000 and 2009, NHS spending grew at 6% per year in real terms. Since then it has slowed to 1%. In the fat times, managers could be careless with money; staff complained about spending on fripperies, such as making surroundings more pleasant. But the lean times have also become inefficient. Some of the savings that hospitals have been forced to make have become counter-productive, such as laying off nurses who care for patients immediately after surgery, meaning fewer operations can take place.

That is why Mrs May’s endorsement of a longer-term settlement is a relief to those who work in the NHS. Simon Stevens, its chief executive, called it “very welcome, timely and significant”. The question now is how generous the long-term plan will be—and where the promised money will come from.