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NHS enemies will declare the service broken. But it is not


Mid Staffs will be used to justify further reforms – and of the very kind that contributed to that horror in the first place


NHS: no one is safe, shouted the Times front page, among others in the rightwing press. The horror story of cruelty and neglect in Mid Staffs arrives as a ready-made justification for this government's fragmentation of the NHS. You don't need much political nous to detect Jeremy Hunt and his press softening up the public for the idea that the private sector now taking over many NHS contracts will better prevent such outrages in future. With 1.3m patients seen every 36 hours, the NHS, they say, is a Red Army-sized monolith beyond quality control.

The health service is painfully tarred by this appalling event – and Robert Francis QC is quite right to say it could happen again. Anywhere things can go badly awry, as five other hospitals fall under suspicion. But that frightener needs to be balanced by reading the enormous NHS patient surveys showing these things are rare: more than 90% of patients leaving hospital say their care was good or very good. Ipsos Mori's long series of opinion polling tells a story of high appreciation. The recent unprecedented drop in public attitudes towards the NHS in the British Social Attitudes survey was caused by alarm at the government's NHS and Social Care Act.

Much indignation this week has fixed on nurses: Cameron used the moment to call for performance-related pay. "Bring back Matron!" some cried, again, imagining some ubiquitous Hattie Jacques. Surely, MPs said, running a ward is easy? It's not rocket science for nice nurses to care kindly, keep people clean and out of pain, feed the frail and answer bedside buzzers? But it's not easy at all. It requires good functioning of a highly complex well-oiled machine.

On the day of the Francis report, I visited one of the nation's best hospitals, directed to University College Hospital London on the advice of both the Care Quality Commission and the Royal College of Nursing. Talking to ward sisters here, you soon see what a remarkably tough managerial job it is to care for 36 patients with different conditions, on a rapid turnover. Simple things – from ordering pens, fixing a printer or mending a bash in the wall made by a clumsy porter – take many calls and much frustration. Hiring new nursing assistants means sifting 250 applications from the inefficient NHS jobs website. What a time it takes to arrange discharging patients needing community care from different local authorities, district nurses and GPs, while doctors chafe at beds not emptied fast enough for new cases. Bed occupancy is near 100%, as in most hospitals: scrupulous care over infection control is a constant worry, as is preventing bedsores. Cleaning and housekeeping needs supervising, so do the ward's stores.

As for care, patients with dementia have red water jugs and trays, so everyone knows they can't help themselves: at mealtimes nurses stand in each bay, ensuring everyone is helped to eat and drink. No central nursing station tempts staff to hang around: they do paperwork at benches beside patients. Supervising 30 staff means watching to see they obey the hospital code: "safety, kindness, team-work and improving." Ward sisters complain they spend less than half their time hands-on nursing, but they do start each day at 7am, helping to wash and breakfast patients to prove they are not "too posh to wash".

However good they are at their difficult job, they all said the same: the system is what matters, from the top board to all those departments behind the scenes, including the "bureaucrats" politicians like to sneer at. Short-staffing wrecked decent care at Mid Staffs but the key at UCLH is the board's decision to make nursing quality the priority. The board guarantees the right number of staff for each ward, calculated on case-mix with a formula used by 10 other university hospitals. If ever nursing levels fall in a ward, beds are closed. And as that means a drop in income, the board's orders are that nursing must be kept at the prescribed level with no use of expensive agency temps.

Is everything here 100%? No, I have heard occasional grumbles from UCLH patients who say some wards are better than others: perfection amid such complexity is probably beyond human possibility. Though most NHS patients are well satisfied, let no one think it's easy.

Francis delivers a solemn warning: what destroyed Mid Staffs was the rush to cut £10m to become a foundation trust. Don't let finance drive out quality, he warns. But his wise suggestion that care and finance be regulated together by Monitor joining the Care Quality Commission has been summarily rejected by Jeremy Hunt, the health secretary.

With the NHS suffering its harshest squeeze, Sir David Nicholson, head of the NHS Commissioning Board, may rue the day the £20bn cut from day-to-day running was dubbed "the Nicholson challenge". The Mail and victims' families call for his head, for his regional role at the time of the scandal. But the government was quick to clasp him tight. As the shaky new edifice totters towards April's start day, he is seen as the one firm hand to step in whenever disaster looms.

He may face a far bigger question over the next two years: why did he not speak out against this vast and reckless re-disorganisation when he might have stopped it? He joked sardonically that it is "big enough to see from space", as £3bn is squandered on 90,000 staff moving jobs, while 6,000 nursing jobs are lost. He failed to blow the whistle, when he might have sunk this plan.

Francis calls for a new NHS culture of "candour" with fear banished and whistleblowing encouraged. But gagging clauses, self-censorship and dread of speaking out is rife. Read the press releases of the NHS Confederation, representing managers, to see just how craven they have been over the Lansley plan. They supported government all the way, despite knowing all the pitfalls in the tangled spaghetti of a management organogram they are expected to run. Royal Colleges objected, but managers blindly obeyed: this was not so in the 1980s and 1990s. Unless their attitude changes, there will be no openness for staff in the service they manage.

Balancing agonisingly tight finance with good quality will be phenomenally difficult, requiring honesty about hard choices ahead. The danger is that NHS enemies will seize on the current crunch to declare the service broken. But they should remember how Danny Boyle's Olympic spirit revealed a strength of public passion they defy at their peril.