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
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The DUP scored £1bn for just ten votes – so why be optimistic about our EU deal?

By March 2019, we’re supposed to have renegotiated 40 years of laws and treaties with 27 ­countries.

If Theresa May’s government negotiates with the European Union as well as it negotiated with the Democratic Unionist Party, it’s time to cross your fingers and desperately hope you have a secret ­Italian grandfather. After all, you’ll be wanting another passport when all this is over.

The Northern Irish party has played an absolute blinder, securing not only £1bn in extra funding for the region, but ensuring that the cash is handed over even if the power-sharing agreement or its Westminster confidence-and-supply arrangement fails.

At one point during the negotiations, the DUP turned their phones off for 36 hours. (Who in Westminster knew it was physically possible for a human being to do this?) Soon after, needling briefings emerged in the media that they were also talking to Labour and the Lib Dems. In the end, they’ve secured a deal where they support the government and get the Short money available only to opposition parties. I’m surprised Arlene Foster didn’t ask for a few of the nicer chairs in Downing Street on her way out.

How did this happen? When I talked to Sam McBride of the Belfast News Letter for a BBC radio programme days before the pact was announced, he pointed out that the DUP are far more used to this kind of rough and tumble than the Conservatives. Northern Irish politics is defined by deal-making, and the DUP need no reminder of what can happen to minnows in a multiparty system if they don’t convince their voters of their effectiveness.

On 8 June, the DUP and Sinn Fein squeezed out Northern Ireland’s smaller parties, such as the SDLP and the Alliance, from the region’s Westminster seats. (McBride also speculated on the possibility of trouble ahead for Sinn Fein, which ran its campaign on the premise that “abstentionism works”. What happens if an unpopular Commons vote passes that could have been defeated by its seven MPs?)

The DUP’s involvement in passing government bills, and the price the party has extracted for doing so, are truly transformative to British politics – not least for the public discussion about austerity. That turns out to be, as we suspected all along, a political rather than an economic choice. As such, it becomes much harder to defend.

Even worse for the government, southern Europe is no longer a basket case it can point to when it wants to scare us away from borrowing more. The structural problems of the eurozone haven’t gone away, but they have receded to the point where domestic voters won’t see them as a cautionary tale.

It is notable that the Conservatives barely bothered to defend their economic record during the election campaign, preferring to focus on Jeremy Corbyn’s spending plans. In doing so, they forgot that many of those who voted Leave last year – and who were confidently expected to “come home” to the Conservatives – did so because they wanted £350m a week for the NHS. The Tories dropped the Cameron-era argument of a “long-term economic plan” that necessitated short-term sacrifices. They assumed that austerity was the New Normal.

However, the £1bn the government has just found down the back of the sofa debunks that, and makes Conservative spending decisions for the rest of the parliament fraught. With such a slim majority, even a small backbench rebellion – certainly no bigger than the one that was brewing over tax-credit cuts until George Osborne relen­ted – could derail the Budget.

One of the worst points of Theresa May’s election campaign was on the BBC ­Question Time special, when she struggled to tell a nurse why her pay had risen so little since 2009. “There isn’t a magic money tree that we can shake that suddenly provides for everything that people want,” the Prime Minister admonished. Except, of course, there is a magic money tree, and May has just given it a damn good shake and scrumped all the cash-apples that fell from it.

That short-term gain will store up long-term pain, if the opposition parties are canny enough to exploit it. In the 2015 election, the claim that the SNP would demand bungs from Ed Miliband to prop up his government was a powerful argument to voters in England and Wales that they should vote Conservative. Why should their hospitals and schools be left to moulder while the streets of Paisley were paved in gold?

The attack also worked because it was a proxy for concerns about Miliband’s weakness as a leader. Well, it’s hard to think of a prime minister in a weaker position than May is right now. The next election campaign will make brutal use of this.

Northern Ireland might deserve a greater wodge of redistribution than the Barnett formula already delivers – it has lower life expectancy, wages and productivity than the British average – but the squalid way the money has been delivered will haunt the Tories. It also endangers one of the Conservatives’ crucial offers to their base: that they are the custodians of “sound money” and “living within our means”.

Labour, however, has not yet quite calibrated its response to the DUP’s new-found influence. Its early attacks focused on the party’s social conservatism, pointing out that it is resolutely anti-abortion and has repeatedly blocked the extension of equal marriage through “petitions of concern” at Stormont.

This tub-thumping might have fired up Labour’s socially progressive supporters in the rest of the UK, but it alienated some in Northern Ireland who resent their politicians being seen as fundamentalist yokels. (Only they get to call the DUP that: not Londoners who, until three weeks ago, thought Arlene Foster was the judge who got sacked from Strictly Come Dancing.)

And remember: all this was to get just ten MPs onside. By March 2019, we’re supposed to have renegotiated 40 years of legislation and treaties with 27 other European ­countries. Ha. Hahaha. Hahaha.

Helen Lewis is deputy editor of the New Statesman. She has presented BBC Radio 4’s Week in Westminster and is a regular panellist on BBC1’s Sunday Politics.

This article first appeared in the 29 June 2017 issue of the New Statesman, The Brexit plague

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