“We are delighted that at this early stage, the NHS is on course to meet the challenging savings targets it has been set. We shouldn’t underestimate how much hard work has gone in to achieving this result.

“But the overall surplus for the NHS masks some of the major financial difficulties which some organisations are facing and many of the savings have been made through short term solutions.

“So the focus on delivering further efficiencies now needs to move to a whole-system approach. Changes must happen across the whole system and it’s good to hear the NAO confirm its view that service transformation – such as investing more in primary and community services – is essential to delivering sustainable efficiency savings in the future.

“NHS leaders are ready and willing to work together to change services, but we will need to ensure that the public understands how essential changes are, and that politicians are able and willing to clearly articulate the need for change rather than shying away from difficult decisions.”

Dean Royles, director of the NHS Employers organisation, said:

"The largest part of NHS spending is its pay bill and this makes difficult decisions about pay in the future unavoidable. The NAO is clear that these savings need to be sustained. The hard truth is that an increase in staff pay rates next year would make the required efficiency savings all the more difficult for years to come, not just in that year. I want to ensure that we minimise any detrimental impact on job security and patient services. Every one percent increase in pay equates to about half a billion pounds.

“We know this is not easy for staff and I wish the financial circumstances were different but we have to ensure we have a sustainable pay bill in the future. We know we are just at the start of a long, financially challenging journey.

“The major financial challenge faced by the NHS has strained relationships between employers, staff and unions. It is a testament to their dedication and commitment that we have all found ways to deliver efficiencies against the odds and carry on to work for the benefit of patients.”