Julie Bailey, of campaign group Cure the NHS. Photo: Getty
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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
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What the tragic case of Charlie Gard tells us about the modern world

People now believe medical science can perform miracles, and many search for them online.

If Charlie Gard had been born 40 years ago, there would have been no doubt about what would, and should, happen. Doctors treating a baby with a rare genetic condition that causes the body’s organs to shut down would have told his parents “nothing more can be done for him”. Charlie – deaf, epileptic, his muscles wasted, his brain probably damaged – would have died peacefully and unremarked. If an experimental US treatment had given such children an estimated 10 per cent chance of survival, his parents would not have known about it. Even if they had, they would have sorrowfully deferred to British doctors.

Now people believe that medical science can perform miracles and, through the internet, search the world for them. Yet they do not trust the knowledge and judgement of the medical profession. They rally public support and engage lawyers to challenge the doctors, as Charlie’s parents unsuccessfully did in the hope of being allowed to take their child for experimental treatment in America, despite warnings that it would be ineffective and distressing for him. This is a strange situation, the result of medical progress, social media, globalisation and the decline of deference. It causes much heartache to everybody involved but, like Charlie’s death, it is probably unavoidable.

Mogg days

A few weeks ago, Jacob Rees-Mogg was a 50-1 outsider for the Tory leadership. Now, as I write, he is third or fourth favourite, quoted by the bookmakers at between 6-1 and 10-1. For a few days, he was the second favourite, ahead of both Boris Johnson and Philip Hammond and behind only David Davis, the clear front-runner. Perhaps Davis organised rich friends – of which I am sure he has a few – to flood the market with bets on Rees-Mogg to frighten Tory MPs into rallying behind him.

But do not write off the man dubbed “the honourable member for the early 20th century” – generously, in my view, since he looks and behaves as though he has stepped off an 18th-century country estate and he actually lives on a 17th-century one. Rees-Mogg, a hard Brexiteer, would be an appropriate leader if we left the EU with no deal. Having excused ourselves from the world’s largest and most cohesive trading bloc, our best prospect for earning our living would be as a giant 18th-century theme park. Who better than Rees-Mogg to front it?

The royal revenue stream

Princess Diana is the gift that keeps on giving. TV companies produce documentaries on the anniversaries of her death and marriage. New tapes, photos and letters are unearthed. Anyone who cut her hair, cleaned her windows or sold her a frock can make a bob or two from “my memories of Diana”. Most important, Diana guarantees the future of the royal family for at least another half-century. In an ITV documentary, Prince William spoke movingly and sincerely (as did his brother, Harry) about losing a mother. Even the most hard-hearted republicans must now hesitate to deprive him also of a throne.

Strictly newsreading

I am a BBC fan. I regard the requirement, imposed by the Tories, that the corporation publishes the names and salary bands of employees paid more than £150,000 a year as an attempt to exploit “the politics of envy” of which Labour is normally accused. But I wonder if the corporation could help itself by offering even more transparency than the government demands.

It could, for example, explain exactly why Gary Lineker (£1.75m-£1.79m), Jeremy Vine (£700,000-£749,999) and Huw Edwards (£550,000-£599,999) are so handsomely paid. Do they possess skills, esoteric knowledge or magnetic attraction to viewers and listeners unavailable to other mortals and particularly to their women colleagues who are apparently unworthy of such lavish remuneration? Were they wooed by rival broadcasters? If so, which rivals and how much did they offer? Have BBC women received lower offers or no offers at all? The BBC could go further. It could invite a dozen unknowns to try doing the jobs of top presenters and commentators, turn the results into a programme, and invite viewers or listeners to decide if the novices should replace established names and, if so, at what salaries. We elect the people who make our laws and the couples who go into the final stages of Strictly Come Dancing. Why shouldn’t we elect our newsreaders and, come to that, Strictly’s presenters?

Mail order

A tabloid newspaper, founded in 1896 and now with its headquarters in Kensington High Street, west London, obsessed with the Islamist terror threat, convinced that it speaks for Middle England. An editor, in the chair for a quarter-of-a-century, who makes such liberal use of the C-word that his editorial conferences are known as “the vagina monologues” and whose voice is comparable to that of “a maddened bull elephant”. Sound familiar?

Two weeks ago, I wrote about Splash!, a newly published satirical novel about a tabloid newspaper from the long-serving Daily Mail columnist Stephen Glover. Now I have had early sight of The Beast, due out in September, also a satirical novel about a tabloid paper, written by Alexander Starritt who briefly worked on the Mail after leaving Oxford University. Like Glover, he pays homage to Evelyn Waugh’s classic Scoop, where the main characters worked for the Daily Beast, but there the similarities end. Glover has written what is essentially a defence of tabloid journalism. Starritt offers a fierce, blackly comic critique, though he cannot, in the end, quite avoid casting the editor Paul Dacre – sorry, Charles Brython – as a heroic, if monstrous, figure.

How many other journalists or ex-journalists are writing satirical novels about the Mail? And why the presumed public interest? Newspapers, with fewer readers than ever, are supposed to be dying. Fiction publishers seem to disagree. 

Peter Wilby was editor of the Independent on Sunday from 1995 to 1996 and of the New Statesman from 1998 to 2005. He writes the weekly First Thoughts column for the NS.

This article first appeared in the 27 July 2017 issue of the New Statesman, Summer double issue