For all the carping, at the age of 60 the NHS is looking in rude good health

The NHS might never have lived to see its 60th birthday this year. Often its ill-wishers could point to its failures as good reasons to disband it. Remember the out-of-control overspends, brutal underfunding and annual winter ward closures. Soaring waiting lists have suited consultants' private practice and union strikes have locked patients out of hospitals. It's never good enough - but the NHS is in surprisingly robust health.

Alan Johnson visits a hospital a week: this time it was Nottingham University Hospital Trust, which had a hair-raising year at £60m in the red, shedding 700 posts and screeching in on target, now in surplus. (Johnson is generous in gratitude to Patricia Hewitt, who took the flak for squeezing debt out.) Staff were despondent last year, but are picking up now. There is an infection problem, but a specialist team was called in and 40 more cleaners hired. Overall this is a typical hospital, up in the top 40 - and a good a place to take the NHS pulse.

Here, two projects signal the NHS's new direction. No more turbulent Blairite restructurings, but attention instead to the detail of treating patients. Take the productive ward scheme. The ward manager, a nurse, has reorganised everything so that colleagues spend 40% more time nursing - no longer interrupted on average 115 times a shift, with less form-filling and no more hunting for supplies.

Next, the stroke department, which now has ambulance drivers who suspect someone has a stroke bringing in patients direct, bypassing other hospitals and A&E. Instant scans and thrombolytic drugs save hundreds of lives and prevent crippling disability - a reason why centralising specialism works.

Out of the minister's earshot, a cancer doctor complains that hitting targets can mean missing the point, but still he concludes: "I wouldn't be without them. We'd never have had the resources to see all patients within two weeks without a target." Some 99.7% of suspected cancers nationally now hit the two-week mark; it was only 63% before 1997.

David Cameron this week made targets a key battleground, promising to abolish them, leaving it to the market to choose the best treatments. But hospital staff shook their heads: however infuriating they are, abandoning targets would mean backsliding.

Are targets good for governments? Labour wanted progress to be visible, and benchmarks were set high. Waiting times were the top complaint in 1997, but with the targets all but achieved and the average at nine weeks later this year, worry about waiting has plummeted. Infection is the top concern, but if that continues to fall something else will take its place. Voters don't do gratitude.

Labour forgot that targets can't measure vital things. Neither Nottingham's better nursing, nor the stroke unit that saves so much disability, would appear on any scale of NHS improvement. Office for National Statistics measures of "productivity" count numbers in and out, not quality.

So when Cameron claims the NHS shows too little value for triple the money spent, for the 79,000 more nurses, 30,000 hospital doctors and 6,000 more GPs, there is no real proof either way. Nor can patients tell, because they weren't the same patients 10 years ago. Research shows patients tell at least 10 people about a bad treatment but only one or two about a good experience. Bad anecdotes ricochet around for years, yet polls show 80% of hospital patients report good treatment. It's hard to find any professional observer who doesn't think the NHS is better - if, alas, not measurably so. A report to be published soon shows the UK moving up international league tables for avoiding treatable deaths.

If the year ahead is easier than the last, with surpluses replacing deficits, Johnson still has plenty on his plate: the hardest is controlling infection. He wants a three-year pay deal with NHS staff - but it can't stay within 2%. He will make GPs open on Saturdays or evenings, and 60 hospital amalgamations now on ice must be resolved.

Gordon Brown's NHS "rights and responsibilities" constitution may be extra trouble. If it suggests elections to local PCTs, that's of less public interest than nice receptionists and kindly nursing. If it sets legal rights so patients can sue, that will be disastrous for all but the lawyers - but it risks looking spineless if it doesn't. Meanwhile, pollster Mori reports that public perceptions of the NHS now track what people feel about the government, not the other way around, which is discouraging.

However, Cameron won't score such easy NHS hits this year. He faces tougher scrutiny. He promises local control, with a market deciding locally on standards as patients vote with their feet. Yet he warns on the BBC's Today programme that his candidates will make war over all closures. These are clearly incompatible. Would he support a campaign to keep open a hospital that has lost some patients so it is no longer viable, though still beloved by other patients? Who chooses in the end - markets, local patients or local professionals, who know where results are best? Johnson now refers every contested closure to a doctor-lead independent reconfiguration panel; will Cameron ignore their recommendations and fight for every unit regardless of both medical evidence and markets?

Cameron promises an "independent" NHS at the top, but who accounts to parliament for taxpayers' money? As Bevan observed glumly, every bedpan bounces back to Whitehall. One NHS managers' leader recently had to struggle through protesters to visit the Hungarian health minister, who grumbled he had no say over the closure of a small hospital. It was owned by the local authority with patients sent there by an entirely independent insurance company, but still patients came protesting to his door, as they always will. This is the year Cameron can no longer get away with populist hit-and-run phrases on "choice" and "independence". On the NHS as on everything else, he must spell out the detail or look increasingly frivolous.

So 2008 will be a plum year for NHS politics, as Cameron and Brown both recognised this week. Battle lines have been blurred by Labour's espousal of markets, choice and independent treatment centres. Brown's needless fear of being seen to do a U-turn on Blair reforms weakens Labour's cutting edge. But clearer differences will emerge as Cameron lets the local market rip, and Labour focuses, at long last, on what happens to patients.

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