Julie Bailey, of campaign group Cure the NHS. Photo: Getty
Show Hide image

If the NHS is to improve, we have to realise sometimes things have to close

Closing important services for financial reasons is stupid. But closing expensive things we don’t need so that we can spend the money on new things that we do isn’t.

The National Health Service runs on three things: public money, staff good will and jargon. Of these three, only the latter never seems in danger of exhaustion.

The NHS is festooned with jargon. Swimming in it. NICE, QIPP, QUALY, AfC; PCTs, CCGs, F1s, and F2s. I spent two years writing for the weekly trade newspaper GP, during which I became something of an expert in the nGMS contract for GPs, plus of course MPIG and QOF. (Obviously one can’t truly understand the nGMS contract without understanding MPIG.) Getting to grips with that remains one of the most intellectually challenging things I’ve ever done, yet it’s been of no use whatsoever in the wider world. It’s the public policy equivalent of learning Klingon.

There is, however, one bit of NHS jargon that more of us probably should understand. “Reconfiguration” means, in essence, changing where patients have to go to get different bits of healthcare. And the reason it’s worth getting your head round is that it lies at the root of so much of so many of the rows about changes to NHS services.

That includes, one suspects, this week’s row about clause 119 of the of the care bill, which would allow administrators appointed by the health secretary to chop bits off hospitals, without bothering with the trifling matter of public consultation. Jeremy Hunt’s motivations for wanting such power may indeed be exactly as sinister as everyone seems to expect. Then again, it’s just plausible that the clause is simply a recognition of the fact that, at present, reconfiguration is simultaneously a) vital, and b) damn near impossible because no one ever wants to close anything. Hunt’s latest wheeze may be nothing more dodgy than an attempt to fix a dysfunctional system.

To explain why, we need to explain why reconfiguration is necessary in the first place. Demand for healthcare is rising, thanks to an ageing population, but it’s also changing: where once healthcare was something people received in short sharp bursts when sick, it’ll increasingly be something that a significant chunk of the population need access to all the time.

Hospitals aren’t really set up to cope with this ongoing, low-level care, which most people would much rather have closer to their home anyway. They’re also expensive (big buildings, big overheads). And, as medicine has become more specialised, a consensus has developed that you’re better off being treated in a big hospital full of experts rather than a small one without any. If you’re admitted to your local district general with a suspected case of Elledge’s Disease on a Friday, but the consultant who specialises in it only visits on a Wednesday, then that’s five days in which you’re going to have to make do with the care of junior doctors and nurses who know relatively little about the disease. All that time, you’re stuck in a hospital bed, and costing the NHS money. (Oh, and you might die. Nasty condition, Elledge’s disease.)

So – for a long time everyone’s wanted to make the health service less dependent on the traditional model of a hospital in every town. Instead of the bog standard district general that does everything, as much healthcare as possible would be provided by smaller community centres (polyclinics, extended GP practices, that sort of thing). Meanwhile, the hardcore stuff would be handled by a smaller number of really big hospitals, and networks of centres that specialise in specific conditions (stroke, cancer, and so on). All this should save money. It’d be more convenient. And it could also, though this bit’s more contentious, provide better care.

But reconfiguration brings its own problems, too. While this brave new world would see a lot of patients treated closer to their homes, some, especially those from rural areas, would have to travel further. That probably means longer life-or-death dashes in ambulances with sirens blaring; at the very least, it means fewer visits from friends and family.

More than that, though, it means closing hospitals, or at least bits of them, and that is bloody hard to do. There’s nothing that excites a local newspaper as much as a campaign to save the local A&E department; nor is there anything more likely to turn a loyal front bencher into a shouty rebel. (Don’t believe me? Here’s William Hague protesting against NHS cuts in his constituency.)

So while policy wonks and politicians generally support reconfiguration in the abstract, once you start talking about closing specific things, and people realise they’re going to lose doctors/services/jobs/votes, it tends to evaporate. And, to the layperson, defending an NHS facility from closure because it’s a vital public service, and doing so for sentimental or political reasons, tend to look exactly the same.

The problem is, if the NHS can’t reduce the money it spends on expensive district generals, it won’t be able to afford all the shiny new stuff that’s meant to replace them. Closing important services for financial reasons is stupid. But closing expensive things we don’t need so that we can spend the money on new things that we do isn’t. I’m not pretending it’s easy to know which is which; but if the health service is to improve we need to at least be open to the possibility that redundant services exist.

As time goes on the demands on the health service are going to change, and to do some things better it’ll need to stop doing other things badly. Reconfiguration matters, and it means that your local A&E might have to close. Shouldn’t we have an honest conversation about that?

Jonn Elledge edits the New Statesman's sister site CityMetric, and writes for the NS about subjects including politics, history and Daniel Hannan. You can find him on Twitter or Facebook.

Photo: Getty
Show Hide image

What will the 2017 local elections tell us about the general election?

In her timing of the election, Theresa May is taking a leaf out of Margaret Thatcher's book. 

Local elections are, on the whole, a much better guide to the next general election than anything the polls might do.

In 2012, Kevin Cunningham, then working in Labour’s targeting and analysis team, surprised his colleagues by announcing that they had lost the 2015 election. Despite gaining 823 councillors and taking control of 32 more local authorities, Cunningham explained to colleagues, they hadn’t made anything like the gains necessary for that point in the parliament. Labour duly went on to lose, in defiance of the polls, in 2015.

Matt Singh, the founder of NumberCruncherPolitics, famously called the polling failure wrong, in part because Labour under Ed Miliband had underperformed their supposed poll share in local elections and parliamentary by-elections throughout the parliament.

The pattern in parliamentary by-elections and local elections under Jeremy Corbyn before the European referendum all pointed the same way – a result that was not catastrophically but slightly worse than that secured by Ed Miliband in 2015. Since the referendum, thanks to the popularity of Theresa May, the Conservative poll lead has soared but more importantly, their performance in contests around the country has improved, too.

As regular readers will know, I was under the impression that Labour’s position in the polls had deteriorated during the coup against Corbyn, but much to my surprise, Labour’s vote share remained essentially stagnant during that period. The picture instead has been one of steady deterioration, which has accelerated since the calling of the snap election. So far, voters buy Theresa May’s message that a large majority will help her get a good Brexit deal. (Spoiler alert: it won’t.)

If the polls are correct, assuming a 2020 election, what we would expect at the local elections would be for Labour to lose around 100 councillors, largely to the benefit of the Liberal Democrats, and the Conservatives to pick up around 100 seats too, largely to the detriment of Ukip.

But having the local elections just five weeks before the general elections changes things. Basically, what tends to happen in local elections is that the governing party takes a kicking in off-years, when voters treat the contests as a chance to stick two fingers up to the boost. But they do better when local elections are held on the same day as the general election, as voters tend to vote for their preferred governing party and then vote the same way in the elections on the same day.

The Conservatives’ 2015 performance is a handy example of this. David Cameron’s Tories gained 541 councillors that night. In 2014, they lost 236, in 2013 they lost 335, and in 2012 they lost 405. In 2011, an usually good year for the governing party, they actually gained 86, an early warning sign that Miliband was not on course to win, but one obscured because of the massive losses the Liberal Democrats sustained in 2011.

The pattern holds true for Labour governments, too. In 2010, Labour gained 417 councillors, having lost 291 and 331 in Gordon Brown’s first two council elections at the helm. In 2005, with an electoral map which, like this year’s was largely unfavourable to Labour, Tony Blair’s party only lost 114 councillors, in contrast to the losses of 464 councillors (2004), 831 councillors (2003) and 334 councillors (2002).  This holds true all the way back to 1979, the earliest meaningful comparison point thanks to changes to local authorities’ sizes and electorates, where Labour (the governing party) gained council seats after years of losing them.

So here’s the question: what happens when local elections are held in the same year but not the same day as local elections? Do people treat them as an opportunity to kick the government? Or do they vote “down-ticket” as they do when they’re held on the same day?

Before looking at the figures, I expected that they would be inclined to give them a miss. But actually, only the whole, these tend to be higher turnout affairs. In 1983 and 1987, although a general election had not been yet called, speculation that Margaret Thatcher would do so soon was high. In 1987, Labour prepared advertisements and a slogan for a May election. In both contests, voters behaved much more like a general election, not a local election.

The pattern – much to my surprise – holds for 1992, too, when the Conservatives went to the country in April 1992, a month before local elections. The Conservatives gained 303 seats in May 1992.

What does this mean for the coming elections? Well, basically, a good rule of thumb for predicting general elections is to look at local election results, and assume that the government will do a bit better and the opposition parties will do significantly worse.

(To give you an idea: two years into the last parliament, Labour’s projected national vote share after the local elections was 38 per cent. They got 31 per cent. In 1985, Labour’s projected national vote share based on the local elections was 39 per cent, they got 30 per cent. In 2007, the Conservatives projected share of the vote was 40 per cent – they got 36 per cent, a smaller fall, but probably because by 2010 Gordon Brown was more unpopular even than Tony Blair had been by 2007.)

In this instance, however, the evidence suggests that the Tories will do only slightly better and Labour and the Liberal Democrats only slightly worse in June than their local election performances in May. Adjust your sense of  what “a good night” for the various parties is accordingly. 

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to British politics.

0800 7318496