This week, the National Health Service turns 65. The problem with the Royal Assent of the Health and Social Care Bill was that it served as a symbol for substantial progress down the marketisation or privatisation route for many. This finality, or “the end of NHS”, had a sense of urgency to serve with ‘high impact’, but produced a problem for those who believed this is a battle not a sprint. It is inevitable that a Labour government will come into office and power sometime, the only question being when. Labour’s positioning on the NHS in 2013, with a view to government as early as 2015, will be to offer a rational and plausible way forward for running the NHS given the background of the Health and Social Care Act (2012). It will also have to negotiate the substantial professional and financial challenges thrown by Mid Staffs, Morecambe Bay and beyond.

The Labour Government elected in 1945 had made manifesto commitments to implement the recommendations of the Beveridge Report of 1942. The report’s recommendation to create “comprehensive health and rehabilitation services for prevention and cure of disease” was implemented across the United Kingdom by 1948. The services were initially funded through general taxation and National Insurance as part of the introduction of a wider Welfare State. They were initially free at the point of use, although some prescription charges were soon introduced in response to economic difficulties. These charges are still in place with the English NHS, but not in the other three systems. Labour has a substantial lead on the NHS in terms of popularity, and has so for a long time. It likewise has never gained credibility on running the economy. Prof Ray Tallis last night mooted the idea of people ‘holding their nose to vote Labour’, but there are mild rumblings that all the mainstream parties have failed on the NHS.

So what does it mean to ‘repeal’ the NHS? Ed Miliband MP, leader of the Opposition, and Andy Burnham MP have publicly stated many times that they intend to repeal the Health and Social Care Act (2012), however if they fail to do so nobody will be particularly surprised given the Nick Clegg ‘I’m sorry’ fiasco. One of the points made by David Prince last night, a senior academic colleague of Prof Allyson Pollock, was that the political climate had to be aligned with the views of those who opposed the Act in such a way to avoid ‘a loss of face’. I think this could mean not presenting decisions as binary. In other words, not abolishing price competitive tendering altogether, but diminishing considerably its necessity under the section 75 regulations (second version)? Or changing the cap under s.164(1)(2A) so that the maximum of private income provision in one year is far less than 50% – say 15? Or even ensuring that all entities to which NHS services have been outsourced used their own company logo – this would not only fulfill David Cameron’s “It does what it says on the tin” Ronseal approach, and also fulfill the purpose of the trademark in English law as a reliable indicator as the “badge of origin” of goods or services. It is totally unhelpful if Virgin services pretend to have a NHS logo (and actually a deception on the public).

From the perspective of a ‘fair playing field’, it makes no sense for private companies to go under the camouflage of the NHS logo either. If non-NHS services are so good, in quality, then surely they will hold their head up high in using their own branding? As it is they are simply legally being entitled to free-ride on the goodwill towards the NHS brand. Once established as a high quality provider, it will then be much easier for that provider to distinguish itself in the eyes of the patient (called in the market the “customer”). It would be perfectly easy to legislate for this. A lot of effort has going into marketing and selling the idea of ‘choice’ in the NHS, but the NHS needs to be able to do basic things well rather than complicated things badly. Patients largely do not spend much time thinking about how innovate their services are, but might notice if it takes several weeks to get a GP appointment; they might be nauseated if their out-of-hours service doesn’t know their medical history well (poor continuity of care), and get irritated if it is easier to attend a busy A&E department and wait there, than to wait for a GP out-of-hours appointment or in-hours appointment. But it has become far too easy to blame GPs and the propaganda against GPs and hospital doctors is intense; the vast majority of patients can get to see their own GP that day, and 90% of out-of-hours is done by GPs. But having said that, Labour has already made massive strides ‘behind the scenes’, how it might be able to make care more joined-up and co-ordinated as part of a drive towards “integrated” or “whole person care”, which could have a benefit of relieving some of the substantial financial pressures that the NHS finds itself. That of course should not be the primary goal of integrated care – the driver should be better quality of clinical management.

Part of the debate is necessarily about engineering the NHS well so that people do not need to struggle the use the NHS and that all persons and patients feel that the NHS is” there for them” at all times. This should also be about encouraging a culture of care with the patient safety and experience at its fulcrum. This means that both nurses and junior doctors can ‘speak out safely’, if they feel that their wards are under-resourced, under-staffed, or just unable to cope with the throughput of patients while managers meet  the Nicholson efficiency targets. The leadership shown by @nursingtimesed (Jenni Middleton) and the @NursingTimesSOS campaign has been striking, and helpful for making sure crucial people working within the NHS have their voices listened to.

Again, it’s not going to be possible for the NHS to allocate or pump huge amounts of money into this, and much of this technical problem is about changing values and attitudes as well as the codified rule book. This means juniors should not be afraid to present concerns to seniors, and not worry about their training appraisals (for example for the Doctors’ Foundation Programme) because of future employment prospects or the risk of being reported to the Regulator. The idea of Doctors or Nurses ‘shopping’ other professionals appears to be incredibly difficult to implement, and for Professor Don Berwick to consider how to implement a duty of candour might be a good initial management step. Mistakes will always happen in the NHS, and with the best will in the world will be impossible to eliminate altogether. It’s vital that the public have realistic expectations of what is possible, and this needs responsible behaviour particularly from politicians and the media.

The NHS is not a “national religion”, but this does not justify using language depicting the people in the NHS as producing one giant-cover up to maintain respect for a ‘monolithic, inefficient, organisation’ where nobody cares about anything. There is certainly a place for innovative thinking, but innovative thinking does not need to be costly, or rocket-science. Take for example the example of how workers are on the management boards of companies in Germany; this simple means of improving accountability had a massive impact on the perceived respectability of corporate governance in Germany. Likewise, having junior doctors and nurses on the boards of hospitals, provided they can find time and be rewarded for their input, could bridge the gap, as well as ensuring that groups such as Healthwatch continue to assess the environment from the perspective of patients. Selling the commissioning process in CCGs as “GP led” was always a total myth from the start as CCGs are simply state-insurance schemes, pooling risk in small populations, and the time wasted by GPs and the BMA in addressing this simple fact has been exasperating and non-productive. A relatively top-priority problem is, however, that CCGs can make patchy, fragmented decisions, not supported by current clinical evidence but by slick marketing and networking, and part of a drive for a renewed settlement on the NHS will likely to be to reinstate a statutory duty for the Secretary of State for Health in a universal, comprehensive service. One cannot hold one’s breath about what they will do next.

Despite a somewhat insidious war of attrition, the staff and work of the NHS are still held with much respect. If you’re interested further in this battle for the soul of the NHS, feel free to get involved. Last night was the launch of #NHS in Owl Bookshop, Kentish Town, with a panel comprising Prof Ray Tallis, Dr Jacky Davis and David Prince. You might enjoy these videos.