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

Photo: Getty Images
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The Fire Brigades Union reaffiliates to Labour - what does it mean?

Any union rejoining Labour will be welcomed by most in the party - but the impact on the party's internal politics will be smaller than you think.

The Fire Brigades Union (FBU) has voted to reaffiliate to the Labour party, in what is seen as a boost to Jeremy Corbyn. What does it mean for Labour’s internal politics?

Firstly, technically, the FBU has never affliated before as they are notionally part of the civil service - however, following the firefighters' strike in 2004, they decisively broke with Labour.

The main impact will be felt on the floor of Labour party conference. Although the FBU’s membership – at around 38,000 – is too small to have a material effect on the outcome of votes themselves, it will change the tenor of the motions put before party conference.

The FBU’s leadership is not only to the left of most unions in the Trades Union Congress (TUC), it is more inclined to bring motions relating to foreign affairs than other unions with similar politics (it is more internationalist in focus than, say, the PCS, another union that may affiliate due to Corbyn’s leadership). Motions on Israel/Palestine, the nuclear deterrent, and other issues, will find more support from FBU delegates than it has from other affiliated trade unions.

In terms of the balance of power between the affiliated unions themselves, the FBU’s re-entry into Labour politics is unlikely to be much of a gamechanger. Trade union positions, elected by trade union delegates at conference, are unlikely to be moved leftwards by the reaffiliation of the FBU. Unite, the GMB, Unison and Usdaw are all large enough to all-but-guarantee themselves a seat around the NEC. Community, a small centrist union, has already lost its place on the NEC in favour of the bakers’ union, which is more aligned to Tom Watson than Jeremy Corbyn.

Matt Wrack, the FBU’s General Secretary, will be a genuine ally to Corbyn and John McDonnell. Len McCluskey and Dave Prentis were both bounced into endorsing Corbyn by their executives and did so less than wholeheartedly. Tim Roache, the newly-elected General Secretary of the GMB, has publicly supported Corbyn but is seen as a more moderate voice at the TUC. Only Dave Ward of the Communication Workers’ Union, who lent staff and resources to both Corbyn’s campaign team and to the parliamentary staff of Corbyn and McDonnell, is truly on side.

The impact of reaffiliation may be felt more keenly in local parties. The FBU’s membership looks small in real terms compared Unite and Unison have memberships of over a million, while the GMB and Usdaw are around the half-a-million mark, but is much more impressive when you consider that there are just 48,000 firefighters in Britain. This may make them more likely to participate in internal elections than other affiliated trade unionists, just 60,000 of whom voted in the Labour leadership election in 2015. However, it is worth noting that it is statistically unlikely most firefighters are Corbynites - those that are will mostly have already joined themselves. The affiliation, while a morale boost for many in the Labour party, is unlikely to prove as significant to the direction of the party as the outcome of Unison’s general secretary election or the struggle for power at the top of Unite in 2018. 

Stephen Bush is editor of the Staggers, the New Statesman’s political blog.