Political issue: protesters demonstrate against a hospital closure. Photograph: Rex Features
Sixty-six years after Aneurin Bevan launched the NHS at Manchester's Trafford General, the future of this small, now rather bleak, hospital, with its peeling paint and malfunctioning automatic doors, once again became a political issue of national importance in February.
The decision to downgrade Trafford's A&E department became the focal point of a parliamentary byelection in the neighbouring constituency of Wythenshawe and Sale, where the local hospital had suffered a huge, debilitating influx of the stricken and walking wounded who would, in times past, have turned up in Trafford.
The new Labour MP, Michael Kane, who made much of the plight of 1,000 people stuck in queueing ambulances outside Wythenshawe hospital's packed A&E over the winter, declared his victory "a result that demonstrates that people know the NHS is not safe in David Cameron's hands".
The electorate can expect a lot more of this. In last month's local elections Labour did not do as well as it hoped, with a general election less than a year away. But one thing the party high command, and senior figures from other parties, noticed was that, where the NHS was the central issue, Ed Miliband's message, so often lost on the public, got through. "In London, in particular, looking at Hammersmith and Fulham and places like Merton, Labour had full-on 'save our NHS', 'save our local hospital' campaigns," said former health minister Paul Burstow MP, a Liberal Democrat. "They credit that with sweeping the Conservatives aside, quite unexpectedly. It will become a big part of the debate at the general election, partly because Labour will want it to be."
The past few months have provided more grist to Labour's propaganda mill. In April the number of people waiting more than 18 weeks for an operation hit three million, a six-year high. In May the cancer treatment target was missed for the first time since it was introduced in 2009, and there was a record number of delayed discharges, where patients were kept in hospital often because of a lack of social care options in the community.
This month brought talk of a GP recruitment crisis, with figures showing a fall in the number of family doctors since the coalition came to power, and the worst ever take-up of GP training. Then last Friday official NHS data revealed that 299,031 patients had arrived at hospital A&E departments that week – the highest number on record. The A&E four-hour waiting time target was also missed for the 49th consecutive week. And all this with a £2bn shortfall discovered in the NHS budget for next year.
"It's basically a winter crisis in the NHS every day now," one senior hospital official told the Observer. "The pressure and demand is unrelenting and overwhelming. The service is running hot the whole time. There are practically no spare beds at any time. When a patient is admitted to a bed, they can probably feel the warmth from the patient who used it just before."
Last week Dr Mark Porter, head of the doctors' union, the BMA, accused the government of bleeding the system dry and listed ways in which ministers were failing the NHS. He asked an appreciative audience at the BMA annual conference in Harrogate: "Who should the public blame? The people who work in the NHS, or the government that holds the purse strings? And with the general election just 10 months away, we could be fighting like this every day."
Stephen Dorrell MP, a health secretary in John Major's government, is a veteran of NHS politics. For the past four years, before his surprise resignation earlier this month, he also chaired the influential Commons health committee, scrutinising the system and the government's reactions and reforms. He said: "All prime ministers have one requirement of the health secretary – and this is just as true of Tony Blair, as Gordon Brown, as John Major and David Cameron – the only thing they want the health secretary to deliver is to keep the NHS out of the newspapers. If the NHS is in the papers, it's bad news for the government. It's as simple as that."
Clearly, an attempt to find £30bn of efficiency savings in the NHS by 2020, which can be redistributed to meet the NHS's needs, is failing. A 4% annual increase in demand is being driven by an ageing population, advances in medicine that are keeping patients alive longer, and more people suffering from long-term conditions, such as diabetes, kidney problems and breathing trouble. That adds up to big problems, notwithstanding the government's commitment to ringfence the NHS budget from real-term cuts. "Historically we have met it [increased demand] by 3% cash and 1% efficiency gains," Dorrell said. "And then suddenly, because the government has run out of money, we are supposed to meet the 4% by efficiency gains."
The difficulty – some say impossibility – of this challenge has forced ministers to provide emergency funds – some of which has been shouted about, and some of which, curiously, hasn't. Last summer saw an extra £500m announced to help the NHS cope with last winter and the next. And in November another £150m was made available. But then earlier this month another £400m was handed over – without ceremony or press release.
A source close to the negotiations over the extra cash, to be spent on relieving A&E pressures and 100,000 extra operations this July and August, told the Observer: "The Department of Health wanted to announce it but No 10 told them not to. Most people would consider additional funding for the NHS to be praised and welcomed. But the fear in government was that if they did that, it would draw attention to and give credence to the notion that the NHS is in crisis and needs to be bailed out. No 10 is much more anxious about the state of the NHS than the DoH."
Dorrell can see that the battle is on, and is pleased to have the controversial political strategist Lynton Crosby on his party's team. "Electoral politics is one of the reasons I am an admirer of Lynton Crosby," Dorrell said. "He understands that a general election is not a competition about policy; it is a competition about which issue is most important in the electorate's mind. The higher salience the economy has, the better the government does. The higher the salience of health the better Labour will do – not because they are Labour but because they are the opposition. It depends which one is a higher priority in the mind of the voter in that quarter of 2015. That is what the election campaign is essentially about."
Back in Manchester, Joanne Harding, who was campaign coordinator for the ill-fated campaign to save Trafford General's A&E department, predicts that the NHS will play a huge role in the election in this city. "A new consultation on restructuring all the hospitals in central Manchester is due to be launched soon," she said. "It's a bit hazy at the moment what this will mean but we're all watching out for it."
Labour will no doubt seize on uncomfortable changes. But Burstow, who was minister for social care between 2010 and 2012, wonders whether ultimately Labour will regret its strategy. "The problem is that those save-the-local-hospital campaigns will sow the seeds of real difficulty were there to be a Labour majority trying to govern – because it would then have to do nothing to change the NHS. Yet their analysis, quite publicly, is that it does need to change."
Dorrell says that is why he resigned from the health select committee. He regarded health secretary Jeremy Hunt's decision to offer extra emergency cash to the NHS as "good politics but not particularly good policy". While adamant that it would be unthinkable for the NHS not to receive a real-terms increase in funding as the economy picks up, he wants to champion the case for money not being the only solution. He worries that amid political game-playing – Hunt keen to avoid contentious system change and Labour jumping on any sniff of it – necessary reforms will fall by the wayside.
"In a perfect world I would want them to address the real issues," Dorrell said. "The reason I stepped down from the committee is because of the central challenge in the care system … the system is not merely dysfunctional and inefficient but it also delivers bad care." He added that what is required is a system that prevents people needing to turn to hospitals – and that means moving money and focus away from expensive buildings and into keeping people out of them. Rather than spending more and more on the increasing demand on A&E departments, and then worrying about the costs of treatment, Dorrell wants a system that prioritises the need to stop people, often the elderly who take a fall, or are left in a parlous state due to neglect, ending up there.
"You will never solve the urgent care demand by chasing demand upwards. And why would you want to? We call it the National Health Service but actually it doesn't invest in health, it invests in rationing medicine. If it spent more time on improving health, it would find it relieves the pressures on medicine."
Is that change of focus possible in a country where the closure of a hospital can be wielded to great effect as a political weapon? "You have to be an optimist to be involved in politics," Dorrell says. Maybe. But this is an election year and, when it comes to the country's most cherished institution, the gloves are coming off.
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