Not feeling so courageous, eh, minister?

William Hague is not the first MP to put loyalty to a local hospital before government policy, and h

The Sun reports today that William Hague is lined up to speak at a rally in opposition to the downgrading of a maternity unit at a small hospital in his Yorkshire constituency. A spokesman for the Foreign Secretary is quoted as saying this has nothing to do with the health reforms contained in besieged legislation currently causing tumult in parliament.

In technical terms, that might just about be true. The Health and Social Care Bill isn't on the statute books so it cannot directly have led to changes on the ground to which Hague is opposed. But politically the two cannot be separated. Partly, it just looks ridiculous. People conflate 'reform' and 'cuts' (the Sun's copy certainly does) and generally blame the government for everything bad that happens in the NHS so will wonder whose side the Foreign Secretary thinks he's on.

But the Hague conundrum also points to a more subtle, long-term problem. There is something approaching consensus in health policy circles that, eventually, for the sake of cost efficiency and coordination of care, specialist services need to be concentrated in centres of excellence, while routine procedures can be done more locally. What this means in practice is that the medium-sized district general hospital is an endangered species. There will be clinics, often based around GP practices, for the small stuff, and then fancy regional centres for the high-tech, complicated stuff. This dynamic appears to be what is behind the removal of certain services from Hague's constituency. Routine baby deliveries will stay; inpatient paediatric care is moving off 22 miles away to Middlesborough.

The problem with this trajectory - although it might make commercial and clinical sense on paper - is that it makes for atrocious politics. It always means stories of sick patients being forced to travel miles by taxi or ambulance when what they really want is just to stay local. Every constituency has an old-fashioned general hospital and every MP feels obliged to stand by it on the barricades. (Remember Hazel Blears getting into much the same pickle?)

Lansley's reforms are going to replicate this situation in constituencies up and down the country. The new GP-led commissioning structures and enhanced competition to provide care will, it is guaranteed, accelerate the process of 'rationalisation' away from general hospitals. That is partly the point of the reforms, albeit not one the government boasts about. Local surgeries will pick off the work that doesn't need in-patient beds, while specialist hospitals will be the obvious suppliers of more complex procedures. Plenty of Tory and Lib Dem MPs are worried about the dilemma this will create for them. It is a courageous politician indeed who turns up at a local town hall meeting to say 'actually,in the interests of overall NHS efficiency and in support of government policy, I'm here to defend the closure of our casualty/maternity ward.'

Hague isn't planning on doing it. The rest will follow his lead. This is just one of many reasons why Andrew Lansley's reforms are a political disaster. He can't seem to sell them to the public and no one else with a seat to defend containing a cherished local hospital is going to dare do it for him.

Rafael Behr is political columnist at the Guardian and former political editor of the New Statesman

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Why Theresa May won't exclude students from the net migration target

The Prime Minister believes the public would view the move as "a fix". 

In a letter to David Cameron shortly after the last general election, Philip Hammond demanded that students be excluded from the net migration target. The then foreign secretary, who was backed by George Osborne and Sajid Javid, wrote: "From a foreign policy point of view, Britain's role as a world class destination for international students is a highly significant element of our soft power offer. It's an issue that's consistently raised with me by our foreign counterparts." Universities and businesses have long argued that it is economically harmful to limit student numbers. But David Cameron, supported by Theresa May, refused to relent. 

Appearing before the Treasury select committee yesterday, Hammond reignited the issue. "As we approach the challenge of getting net migration figures down, it is in my view essential that we look at how we do this in a way that protects the vital interests of our economy," he said. He added that "It's not whether politicians think one thing or another, it's what the public believe and I think it would be useful to explore that quesrtion." A YouGov poll published earlier this year found that 57 per cent of the public support excluding students from the "tens of thousands" target.

Amber Rudd, the Home Secretary, has also pressured May to do so. But the Prime Minister not only rejected the proposal - she demanded a stricter regime. Rudd later announced in her conference speech that there would be "tougher rules for students on lower quality courses". 

The economic case for reform is that students aid growth. The political case is that it would make the net migration target (which has been missed for six years) easier to meet (long-term immigration for study was 164,000 in the most recent period). But in May's view, excluding students from the target would be regarded by the public as a "fix" and would harm the drive to reduce numbers. If an exemption is made for one group, others will inevitably demand similar treatment. 

Universities complain that their lobbying power has been reduced by the decision to transfer ministerial responsibility from the business department to education. Bill Rammell, the former higher education minister and the vice-chancellor of Bedfordshire, said in July: “We shouldn’t assume that Theresa May as prime minister will have the same restrictive view on overseas students that Theresa May the home secretary had”. Some Tory MPs hoped that the net migration target would be abolished altogether in a "Nixon goes to China" moment.

But rather than retreating, May has doubled-down. The Prime Minister regards permanently reduced migration as essential to her vision of a more ordered society. She believes the economic benefits of high immigration are both too negligible and too narrow. 

Her ambition is a forbidding one. Net migration has not been in the "tens of thousands" since 1997: when the EU had just 15 member states and the term "BRICS" had not even been coined. But as prime minister, May is determined to achieve what she could not as home secretary. 

George Eaton is political editor of the New Statesman.