Labour recognises that it could end up closing hospitals too

The party's plan to integrate health and social care makes sense fiscally and clinically but the politics could be more difficult to navigate.

Up to a point, the politics of the NHS are easy for Labour. No one doubts the strength of feeling towards the health service in the party that built it. By contrast, many voters suspect the Tories wish it harm, which is why an oath of allegiance to the NHS was a central part of David Cameron’s attempt to “decontaminate” his party’s brand in opposition.

Specifically, the Conservative leader pledged to protect health spending and avoid “top-down reorganisations.” By 2015 the NHS will be suffering from a funding crisis, exacerbated by a vast reorganisation that smells enough like privatisation by stealth to cause the Conservatives bountiful political harm.

The "safety first" option for Labour is to watch this grizzly spectacle unfold, and march against it under a “Save our NHS” banner. This will certainly be a feature of the 2015 campaign. But it is to the credit of Labour’s shadow health team – Andy Burnham and Liz Kendall – that they are thinking a bit deeper about how their party might run the health service if it actually formed a government.

The NHS is heading towards a financial crunch, driven by the rising cost of treatment and an ageing population, regardless of the immediate fiscal challenge facing the Treasury. In other words, even if George Osborne’s economic plans were working (and they’re not), even if growth and revenues returned to pre-crisis levels, even if every household in Britain urged the government to tax them some more out of sheer love for the NHS, it would need structural reforms to make it financially sustainable. (Of course, the Tories say that is their motive too but they struggle to convince.)

Part of Labour’s answer is the integration of social care with the NHS. Currently the two services rub along in disjointed fashion, with little coordination and no consistency. As a result, the health service ends up picking up the tab for failings in social care services. Hospitals fill up with elderly patients suffering from chronic, long-term conditions, which is neither a good way to look after people nor an efficient use of finite resources. The theory is that integrating the two services could save billions over time by spending smaller sums on the kinds of early interventions that limit hospital admissions and help elderly patients lead healthier, happier lives.

This in turn is part of a more profound transition to what Burnham and Kendall call “whole person care" – re-orienting treatment and NHS institutions to consider the conditions that lead to ill health in the first place. It means concentrating on interventions that protect society (considering, for example, diet, exercise, stress); empowering and encouraging people to look after their own health. (Advocates of this approach often cite diabetes as a classic case of something that will cost the NHS a whole lot more if dealt with only once it is manifest than if investment were put into helping people change their lifestyles.)

Ed Miliband has today announced the creation of a commission to examine how it might be done. Part of the remit is to achieve the integration with a minimum of disruption to existing structures (i.e. not necessitating another great upheaval) and without a great up-front spending commitment. That won't be easy.

A commission to look at ways to implement an idea may not sound like a bold stride towards manifesto clarity but in the context of Labour’s softly-softly approach to policy it is genuine progress. It is a step towards a broader expression of budget priorities – which areas or departments will be favoured and which will suffer if Labour finds itself governing in austerity. The question of when and how to signal those priorities, or indeed whether it needs to be done at all, is one of the thorniest debates that goes on in the shadow cabinet. Ed Balls is said to be reluctant to permit any announcement that might contain the seeds of a fiscal obligation for the future. Shadow ministers who want to develop their portfolios complain that without some fiscal guidelines they can’t credibly develop plans for government. That leaves the front bench stuck in the realm of stating warm but vague intentions or just whingeing about coalition policy.

For people who have followed Labour’s cautious steps towards an NHS policy, Miliband’s announcement today is hardly new. Burnham made a speech on ‘whole person care’ in January. Kendall has been delicately but consistently making the case that Labour cannot sit back and defend the pre-2010 status quo since joining the front bench. Finally, it seems, they have persuaded Miliband to put his personal authority behind their approach. (It is a rule of Westminster politics that no-one believes something will actually happen until they hear it from the leader’s mouth.)

There is a catch. The “whole person care” idea makes sense fiscally over the long term as a way to save money. It makes sense clinically as a way to achieve better outcomes and modernise the way the health service treats patients. It makes sense as political strategy, addressing the concerns of people who fear they will be abandoned in retirement or worry about how they will care for elderly patients. But it scatters a bunch of tactical land mines in the form of hospital closures.

Pretty much any time politicians look hard at NHS reforms they come to the view that the classic jack-of-all-trades district general hospital is a tired and inefficient model for delivering effective care to communities. But whenever anyone tries to rationalise the system and change the structures, they discover it means wards or whole hospitals closing, leading to demonstrations, petitions, town hall meetings and, usually, political retreat.

“Whole person care” is no exception. It implies a re-allocation of resources to treat people at home and a strategy to encourage patients with chronic conditions to get more treatment at clinics and GP surgeries. It recognises what consultants and healthcare experts have been privately complaining about for years: that many hospitals wards are effectively emergency housing for geriatric patients, which is bad for them and a poor use of resources. But a better use of resources might mean, gulp, fewer wards.

Given his predilection for caution on the topic of public sector reform, Ed Miliband went pretty far today in terms of recognising the existence of an NHS budget challenge. He said:

“The NHS will always be a priority for expenditure under a Labour government, but we must make every pound we spend go further at a time when our NHS faces the risk of being overwhelmed by a crisis in funding because of care needs by the end of this decade.

"When the NHS was in crisis in the 1990s, Labour was able to save it by combining reform with unprecedented increases in funding. We know that budgets will be tighter under the next Labour government. But even in these tough times we want the NHS to provide a better service for patients.

"The changes we propose will ensure that – but they do something else too. They will save billions of pounds which can be better spent elsewhere in the NHS."

Buried in that loose expression of good intent is small print so minuscule it is invisible to the naked eye. It says that that a Labour government could end up closing hospitals too.  

Shadow health secretary Andy Burnham with Ed Miliband in 2010. Photograph: Getty Images.

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

ELLIE FOREMAN-PECK FOR NEW STATESMAN
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Craig Oliver, Cameron's attack dog, finally bites

A new book reveals the spiteful after life of Downing Street's unlikely spin doctor.

It must be hard being a spin doctor: always in the shadows but always on-message. The murky control that the role requires might explain why David Cameron’s former director of communications Craig Oliver has rushed out his political memoirs so soon after his boss left Downing Street. Now that he has been freed from the shackles of power, Oliver has chosen to expose the bitterness that lingers among those on the losing side in the EU referendum.

The book, which is aptly titled Unleashing Demons, made headlines with its revelation that Cameron felt “badly let down” by Theresa May during the campaign, and that some in the Remain camp regarded the then home secretary as an “enemy agent”. It makes for gripping reading – yet seems uncharacteristically provocative in style for a man who eschewed the sweary spin doctor stereotype, instead advising Cameron to “be Zen” while Tory civil war raged during the Brexit campaign.

It may be not only politicians who find the book a tough read. Oliver’s visceral account of his side’s defeat on 24 June includes a description of how he staggered in a daze down Whitehall until he retched “harder than I have done in my life. Nothing comes up. I retch again – so hard, it feels as if I’ll turn inside out.”

It’s easy to see why losing hit Oliver – who was knighted in Cameron’s resignation honours list – so hard. Arguably, this was the first time the 47-year-old father-of-three had ever failed at anything. The son of a former police chief constable, he grew up in Scotland, went to a state school and studied English at St Andrews University. He then became a broadcast journalist, holding senior posts at the BBC, ITV and Channel 4.

When the former News of the World editor Andy Coulson resigned as No 10’s communications director in January 2011 because of unceasing references in the press to his alleged involvement in the phone-hacking scandal, Oliver was not the obvious replacement. But he was seen as a scandal-free BBC pen-pusher who exuded calm authority, and that won him the job. The Cameron administration, tainted by its association with the Murdoch media empire, needed somebody uncontroversial who could blend into the background.

It wasn’t just Oliver’s relative blandness that recommended him. At the BBC, he had made his name revamping the corporation’s flagship News at Ten by identifying the news angles that would resonate with Middle England. The Conservatives then put this skill to very good use during their 2015 election campaign. His broadcast expertise also qualified him to sharpen up the then prime minister’s image.

Oliver’s own sense of style, however, was widely ridiculed when he showed up for his first week at Downing Street looking every inch the metropolitan media male with a trendy man bag and expensive Beats by Dre headphones, iPad in hand.

His apparent lack of political affiliation caused a stir at Westminster. Political hacks were perplexed by his anti-spin attitude. His style was the antithesis of the attack-dog mode popularised by Alastair Campbell and Damian McBride in the New Labour years. As Robert Peston told the Daily Mail: “Despite working closely with Oliver for three years, I had no clue about his politics or that he was interested in politics.” Five years on, critics still cast aspersions and question his commitment to the Conservative cause.

Oliver survived despite early wobbles. The most sinister of these was the allegation that in 2012 he tried to prevent the Daily Telegraph publishing a story about expenses claimed by the then culture secretary, Maria Miller, using her links to the Leveson inquiry as leverage – an accusation that Downing Street denied. Nevertheless, he became indispensable to Cameron, one of a handful of trusted advisers always at the prime minister’s side.

Newspapers grumbled about Oliver’s preference for broadcast and social media over print. “He’s made it clear he [Oliver] doesn’t give a s*** about us, so I don’t really give a s*** about him,” a veteran correspondent from a national newspaper told Politico.

Yet that approach was why he was hired. There was the occasional gaffe, including the clumsy shot of a stern-looking Cameron, apparently on the phone to President Obama discussing Putin’s incursion into Ukraine, which was widely mocked on Twitter. But overall, reducing Downing Street’s dependence on print media worked: Scotland voted against independence in 2014 and the Tories won a majority in the 2015 general election.

Then came Brexit, a blow to the whole Cameroon inner circle. In his rush to set the record straight and defend Cameron’s legacy – as well as his own – Oliver has finally broken free of the toned-down, straight-guy persona he perfected in power. His memoir is spiteful and melodramatic, like something straight from the mouth of Malcolm Tucker in The Thick of It. Perhaps, with this vengeful encore to his mild political career, the unlikely spin doctor has finally fulfilled his potential. 

This article first appeared in the 29 September 2016 issue of the New Statesman, May’s new Tories