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

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This is the new front in the battle to control women’s bodies

By defining all of us as “pre-pregnant”, women are afforded all the blame – but none of the control.

For several weeks, YouTube has been reminding me to hurry up and have a baby. In a moment of guilt over all the newspapers I read online for free, I turned off my ad-blocking software and now I can’t play a simple death metal album without having to sit through 30 seconds of sensible women with long, soft hair trying to sell me pregnancy tests. I half expect one of them to tap her watch and remind me that I shouldn’t be wasting my best fertile years writing about socialism on the internet.

My partner, meanwhile, gets shown advertisements for useful software; my male housemate is offered tomato sauce, which forms 90 per cent of his diet. At first, I wondered if the gods of Google knew something I didn’t. But I suspect that the algorithm is less imaginative than I have been giving it credit for – indeed, I suspect that what Google thinks it knows about me is that I’m a woman in my late twenties, so, whatever my other interests might be, I ought to be getting myself knocked up some time soon.

The technology is new but the assumptions are ancient. Women are meant to make babies, regardless of the alternative plans we might have. In the 21st century, governments and world health authorities are similarly unimaginative about women’s lives and choices. The US Centres for Disease Control and Prevention (CDC) recently published guidelines suggesting that any woman who “could get pregnant” should refrain from drinking alcohol. The phrase implies that this includes any woman who menstruates and is not on the Pill – which is, in effect, everyone, as the Pill is not a foolproof method of contraception. So all females capable of conceiving should treat themselves and be treated by the health system as “pre-pregnant” – regardless of whether they plan to get pregnant any time soon, or whether they have sex with men in the first place. Boys will be boys, after all, so women ought to take precautions: think of it as rape insurance.

The medical evidence for moderate drinking as a clear threat to pregnancy is not solidly proven, but the CDC claims that it just wants to provide the best information for women “and their partners”. That’s a chilling little addition. Shouldn’t it be enough for women to decide whether they have that second gin? Are their partners supposed to exercise control over what they do and do not drink? How? By ordering them not to go to the pub? By confiscating their money and keeping tabs on where they go?

This is the logic of domestic abuse. With more than 18,000 women murdered by their intimate partners since 2003, domestic violence is a greater threat to life and health in the US than foetal alcohol poisoning – but that appears not to matter to the CDC.

Most people with a working uterus can get pregnant and some of them don’t self-define as women. But the advice being delivered at the highest levels is clearly aimed at women and that, in itself, tells us a great deal about the reasoning behind this sort of social control. It’s all about controlling women’s bodies before, during and after pregnancy. Almost every ideological facet of our societies is geared towards that end – from product placement and public health advice to explicit laws forcing women to carry pregnancies to term and jailing them if they fail to deliver the healthy babies the state requires of them.

Men’s sexual and reproductive health is never subject to this sort of policing. In South America, where the zika virus is suspected of having caused thousands of birth defects, women are being advised not to “get pregnant”. This is couched in language that gives women all of the blame and none of the control. Just like in the US, reproductive warnings are not aimed at men – even though Brazil, El Salvador and the US are extremely religious countries, so you would think that the number of miraculous virgin births would surely have been noticed.

Men are not being advised to avoid impregnating women, because the idea of a state placing restrictions on men’s sexual behaviour, however violent or reckless, is simply outside the framework of political possibility. It is supposed to be women’s responsibility to control whether they get pregnant – but in Brazil and El Salvador, which are among the countries where zika is most rampant, women often don’t get to make any serious choice in that most intimate of matters. Because of endemic rape and sexual violence, combined with some of the strictest abortion laws in the world, women are routinely forced to give birth against their will.

El Salvador is not the only country that locks up women for having miscarriages. The spread of regressive “personhood” laws across the United States has led to many women being threatened with jail for manslaughter when they miscarry – even as attacks on abortion rights make it harder than ever for American women to choose when and how they become pregnant, especially if they are poor.

Imagine that you have a friend in her early twenties whose partner gave her a helpful list of what she should and should not eat, drink and otherwise insert into various highly personal orifices, just in case she happened to get pregnant. Imagine that this partner backed his suggestions up with the threat of physical force. Imagine that he routinely reminded your friend that her potential to create life was more important than the life she was living, denied her access to medical care and threatened to lock her up if she miscarried. You would be telling your friend to get the hell out of that abusive relationship. You would be calling around the local shelters to find her an emergency refuge. But there is no refuge for a woman when the basic apparatus of power in her country is abusive. When society puts social control above women’s autonomy, there is nowhere for them to escape.

Laurie Penny is a contributing editor to the New Statesman. She is the author of five books, most recently Unspeakable Things.

This article first appeared in the 11 February 2016 issue of the New Statesman, The legacy of Europe's worst battle