“AILING”, “sick to the bone”, not wanting “sticking-plaster solutions”—the raft of journalistic metaphors for the National Health Service can seem as crowded as a hospital emergency room. But almost everyone agrees with a report this week from Parliament’s Public Accounts Committee (PAC), that the financial health of the NHS continues to deteriorate at an alarming rate, that this is affecting the quality of care, and that the situation is unsustainable. Deficits are building up right across the NHS. Demand for health care from an ageing population continues to rise. And an erosion of funding for social care, public health and district nursing has left hospitals flooded with people who should not be there but are unable to leave.

This is the background to some intriguing briefing by the government this week. The prime minister’s office told journalists, ahead of next week’s budget from Philip Hammond, the chancellor of the exchequer, not only that there will be a cash injection for social care, but also that “significant reform” is likely later this year.

After a decade of free spending under Labour and nearly as long a period of austerity under the Tories, it seems that Mr Hammond and Theresa May, the prime minister, are considering big reforms. With cuts to social care causing such problems for the NHS, the most radical idea is to change how it is paid for, either to a form of social insurance or to a levy on inherited wealth, says Andrew Haldenby of Reform, a think-tank. Both would overturn 70 years of thinking about how the welfare state should be financed. As Mr Haldenby asks, “Who would have thought that Theresa May and Philip Hammond were welfare-state revolutionaries?”

There is little dispute about the present system’s dire condition. In January the Red Cross said the NHS was facing a “humanitarian crisis”, as 20 hospitals became so overcrowded they could no longer guarantee patient safety. Occupancy rates in some hospitals stand at almost 100%. Only 86% of those coming to hospital emergency rooms in December were treated within the desired time of four hours, the worst rate ever recorded and well below the NHS’s 95% target.

The finances look equally dire. The PAC report says that total deficits of NHS trusts reached £2.5bn ($3.1bn) in 2015-16, up from £859m in 2014-15. Two-thirds of trusts reported deficits in 2015-16, up from 44% a year earlier. An extra £1.8bn of “sustainability funding”, which trusts received in 2016-17, has not wiped out their deficits. At least the NHS gets extra money. Local authorities, which are responsible for adult social care, saw spending on it fall by 10% in real terms between 2009-10 and 2014-15.

Faced with such pressures, the health department has resorted to raiding the separate capital budget for long-term investment, moving £950m into its revenue budget in 2015-16. It says it will probably have to do this again. The unfunded commitment to introduce a seven-day NHS is making things even more difficult.

There are three possible answers. The first is just to put more cash in. Tony Blair and Gordon Brown threw money at the NHS, doubling spending in real terms in the decade to 2010. As a share of GDP, spending is now falling (see chart), but Mr Hammond has repeatedly said there is no new money available.