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Cooler weather and the first sniff of autumn in the air have been accompanied by the familiar opening salvo of warnings about a difficult winter ahead for the NHS.

The body representing hospitals and other trusts in England, NHS Providers, has said that without an emergency cash bailout the service will face unprecedented pressure.

At the same time the issue of longer waits for routine surgery has jumped up the political agenda.

The government was defeated in the Lords over the failure to meet the 18-week waiting time target in England.

So there was plenty to talk about when Theresa May sat down in Downing Street with Simon Stevens, head of NHS England, and Jim Mackey who runs the regulator NHS Improvement.

Hospital long waits in England highest since 2008

Long waits for surgery 'have tripled in four years'

It was billed as no more than a regular "situation report" meeting.

Demands for more money from health providers are nothing new and the Prime Minister is known to take a dim view of special pleading in the public sector at a time of financial restraint in Whitehall.

Are things different this time?

As one source put it "no health secretary over the last decade or more has ever been comfortable ahead of winter with the risk of flu, norovirus and cold weather pushing the system close to the edge".

Recent winters have seen some months when one of those factors has caused problems, but not all three at once.

The Department of Health stressed that winter preparations were more extensive than previous years and NHS England said more than 3,000 extra beds would be opened in coming months.

There will be a vacuum in the leadership of one part of the service when Jim Mackey leaves his post at NHS Improvement during the autumn.

An experienced hospital boss, he knows all about the nuts and bolts of A&E and local social care and how to get the system working effectively in the depths of winter.

Mr Mackey is known to believe strongly that more money is urgently needed on the frontline.

As he is about to move back to the hospital sector he may have felt the Downing Street meeting was a good opportunity for some straight talking.

Simon Stevens, in contrast, is playing a longer game. He will not want to rock the boat too much ahead of the Chancellor's Budget in November and the chance of a higher public spending allocation by the Treasury.

The government message conveyed to the NHS leaders is that extra money invested in social care in England will mean councils can get older patients out of hospital more efficiently and so relieve pressure on trusts. But it's a hope.

Making preparations to deal with the winter flow of emergency patients, however, is only one part of the challenge.

The waiting list for routine operations has been rising steadily and is now above 4 million in England for the first time in a decade.

Government defeat

Simon Stevens has given the nod to hospitals to sideline for a while the 18-week waiting time target, which has been missed for nearly a year and a half. But that has drawn widespread criticism.

The Labour peer Lord Hunt of Kings Heath argued in the House of Lords that failure to meet the waiting time target was a "breach of the rights of patients outlined in the NHS Constitution".

He questioned why the government had not instructed NHS England to ensure that the 18-week target was delivered.

In reply the health minister Lord O'Shaughnessy said the government remained committed to the waiting time standard.

He added that record numbers of people were seen by the NHS, the vast majority within waiting time targets.

Lord Hunt's motion was passed by the Lords, inflicting a defeat on the government.

Such votes are not binding and defeats for ministers in the Upper Chamber are not unheard of.

But this was an important moment in the NHS debate.

It demonstrated that hospital performance and the handling of it by the NHS leadership and the government is now under firm scrutiny.

The Prime Minister has a lot on her plate with Brexit strategy and the party conference approaching.

The Downing Street meeting with NHS chiefs will have given her plenty to think about even before the autumn leaves are falling and the nights drawing in.