The NHS hasn’t been an election-winning issue for quite a few general elections now. It’s unlikely to be one in 2015 either, which seems set to be an economy election.

However, after promisingly mature responses from both the main leaders in the Commons in response to the Mid-Staffs 2 Report, its use and abuse during Prime Minister’s Questions today (transcribed below) could give Mr Cameron a nasty political headache.

There are silly things for political leaders to say, and then there are very silly things for political leaders to say.

And then there is the PM’s concluding extrapolation from citing various data about the NHS in Wales that “that is what you get under Labour: cuts to our NHS, longer waiting lists and all the problems we saw at the Stafford Hospital would be repeated all over again”.

Oh dear, Mr Cameron.

For the majority of the time during which the appalling care was delivered at Mid-Staffs, the cuts at Mid-Staffs were largely self-inflicted wounds of under-staffing to achieve foundation trust status. Longer waiting lists were nothing to do with the real problems at Mid-Staffs.

It is wildly unwise for a politician who has read even the executive summary of the Francis Public Inquiry report to be confident that the problems there could not be happening elsewhere in the NHS under their tenure. Of itself, publishing a public inquiry report changes very little.

The NHS continues to perform remarkably well in recent times, which is a tribute to its hard-working staff. But signs of trouble are emerging in acute care, especially in A&E. This is well-reported by Health Service Journal’s Ben Clover here, and the subject of their latest editorial.

Demand is rising in real terms, and funding is not.

CCGs are new players on the block. Some are already getting onto demand management and capacity planning to address these challenges. Is this happening in the majority of CCGs? It needs to be, urgently.

Social care is a big part of the issues facing the hospital system – and its funding has been it hard by the cuts in local government spending imposed by the Coalition. Last June, a survey by the Association of Directors of Adult Social Services found that in the two financial years 2011-12 and 2012-13, the cumulative reduction in adult social care budgets was £1.89 billion.

Integration is supposed to be the answer to improving care for the frail elderly – the group who use hospital services most expensively and who probably require support on discharge.

Yet uncertainty abounds over the impact that the Office of Fair Trading and Competition Commission may have over the Torbay health economy’s plans to integrate even further.

Totnes 'open primary' MP Conservative Dr Sarah Woolaston quizzed Health Secretary Jeremy 'Bellflinger’ Hunt about this at yesterday’s Health Select Committee (16.24).

Dr Woolaston mentioned the barriers threatening Torbay’s health economy, and their being forced to put their care trust into the FT pipeline (for which it is not viable), and the OFT becoming involved, rather than Monitor, as to whether the FT could take over the care trust.The Bellflinger told her “we really do want to address those issues”, which is not quite a way of saying he can or will actually do anything.

This isn’t an issue that can be left alone. There are evident issues with the OFT’s interventionist approach to mergers. More broadly, providers and commissioners say in private that they are fearful that integration will be deemed anti-competitive.

In terms of actual policy in integration, Labour’s policy ideas are more developed, though the risk of yet another system-wide reorganisation and its opportunity costs are high.

Politics is a risky game, and the NHS will face yet more financial and operational pressure over the next two years leading up to the general election if demand keeps rising.

Most of the available options for dealing with these pressures are messy. There is no more money because there’s no real economic growth. The public don’t even know that there are plans to start reconfiguring provision, which may look and feel and will certainly be called ‘cuts’. Local government will stay squeezed, as will social care. (And we haven’t had a big flu epidemic for, oh, years now.)

To expect no or little impact on the NHS from all of this is to be extremely optimistic.

The NHS is a political creation and decision about how we fund our healthcare. It’s absurd to be surprised when the issues are politicised. Mr Cameron seems to want a fight on the NHS. He is sure to get one.

The NHS exchanges at today’s PMQs
Leader of the Opposition Ed Miliband: Mr Speaker, people are hearing about patients waiting on trollies in A&E, in some cases for more than 12 hours, and we even heard of one hospital pitching a treatment tent outside its premises. What has the PM got to say to those patients waiting hour upon hour in A&E?

Prime Minister David Cameron: First of all, this Government believes in our NHS and it is expanding funding in our NHS, and we will not take the advice of the pary opposite, who thought that increases in spending on the NHS were irresponsible. That is their view.

We will go on investing in our NHS: we need to make sure that with a million extra patients visiting A&E every year, we need to make sure we hit the important targets that we have that people get treated promptly.

EM: Mr Speaker, the PM doesn’t seem to realise that he is singularly failing to meet the targets he has set himself. The number of people waiting more than four hours in A&E is nearly three times higher than when he came to office. And first he downgraded the A&E target, and now he’s not even hitting that. As he approaches his third anniversary as Prime Minister, he needs to explain why an A&E crisis is happening on his watch.

DC: First of all, let me give him the figures. For the whole of last year, we met the target for A&E attendance. That is the fact. If you take the number of occasions on which it was breached, 15 times, that is lower than the 23 times it was breached when he was in power in 2008. Those are the facts.

The other point I would make to him is that there is one part of the country where Labour have been in charge of the NHS for the last three years. That is Wales, where they haven’t hit an A&E target since 2009. Perhaps he’ll apologise for that.

EM: Mr Speaker, let me give him the figures. In 2009-10, 340,000 people waited longer than four hours in A&E. Last year, it was 888,000 people. And if he wants to talk about records, this government left office with the highest patient satisfaction than ever before in the NHS, the lowest waiting lists than ever before in the NHS and more doctors and nurses than ever before in the NHS. Now part of the problem is that his replacement for the NHS Direct service is in total chaos. He’s now got a patchwork, fragmented service where over Easter, 40% of calls were abandoned because they weren’t answered. What’s he going to do about it?

DC: If anyone wants to remember of Labour’s report in the NHS, they’ve only got to read the report into Stafford Hospital. He mentions the fact – he mentions the number of people waiting a long time for NHS operations – that number has come down since this Government came to office. The fact is, which he cannot ignore, since this Government came to office, there are 1 million people more walking into A&E, there are half a million more people having inpatient treatments and the fact is that waiting times are stable or down, waiting lists are down. The NHS is performing better under this Government than it ever did under Labour.

EM: Let me just say that what happened at Stafford was terrible, and both of us talked about that on the day. But Mr Speaker, what a disgraceful slur on the transformation of the NHS that took place after 1997, and the doctors and nurses that made that happen.

Now the main reason why he is failing to meet his A&E target month after month is because he decided to take £3 billion away from the front line in a top-down reorganisation that nobody wanted an nobody voted for and as a result, there are four and a half thousand fewer nurses than when he came to power. Can he explain how it’s helping care in the NHS to be giving nurses their P45s?

DC: Well first of all, the Rt Hon Gentleman is clearly in complete denial about what happened to the NHS under Labour. And let me just remind him what his spending plans are. His health secretary was asked does he stand by his comment that it’s ‘irresponsible’ to increase NHS spending and the Rt Hon Gentleman said “yes I do”. That is Labour’s official policy: to cut spending on the NHS just like they’re cutting spending on the NHS in Wales where waiting times are up, waiting lists are down - er, up and quality is down too. That is what is happening in the NHS under Labour.

Now, he also mentions what we have done in the NHS in terms of reorganisation. That reorganisation is going to see £4.5 billion put into the front line, compared with the cuts from Labour.

EM: Mr Speaker, let me just say to him, he’s the guy who cut NHS spending when he came to office and was told off by the head of the UK Statistics Authority for not being straight with people about it. A&E is the barometer of the NHS, and this Prime Minister might be totally out of touch but that barometer is telling us it is a system in distress.

According to the Care Quality Commission, one in ten hospitals do not have adequate staffing levels. And during the winter, Mr Seaker, every hospital was operating beyond the recommended safe level of bed occupancy. Hospitals are full to bursting. He’s the Prime Minister. What’s he going to do about it?

DC: His answer is to cut NHS spending whereas we are investing in it. But let me give him some simple facts about what has happened to the NHS under this Government. 6,000 more doctors under this Government. 7,000 fewer managers under this Government. A million more treated in A&E, half a million more day cases. Mixed sex wards, commonplace under Labour, virtually abolished under this Government. Infection rates in our NHS at record low levels under this Government. Waiting times for inpatients down, waiting times for outpatients stable. All of this happening under this Coalition Government: a far better record than he could boast.

EM: Mr Speaker, people up and down the country will have heard that this is a Prime Minister with no answer for the crisis in our NHS A&E services across the country. There is a crisis in A&E. And it’s no surprise. He’s cut the number of nurses. His NHS helpline is in crisis. And he’s wasting billions of pounds on a top-down reorganisation that he promised wouldn’t happen. The facts speak for themselves. The NHS is not safe in his hands.

DC: Let us examine the NHS in Labour’s hands in Wales. Here are the figures. The NHS Budget: is it being increased? No, it’s being cut by 8% by Labour. Last time the NHS urgent cancer care treatment was met, anyone? 2008. Last time A&E targets were met: 2009. The Welsh Ambulance Service has missed its callout tagrget for the last ten months, and of course there is no Camcer Drugs Fund.

That is what you get under Labour: cuts to our NHS, longer waiting lists and all the problems we saw at the Stafford Hospital would be repeated all over again.