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 is the editor of the New Statesman's sister site CityMetric. He is on Twitter, far too much, as @JonnElledge.

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PMQs review: Theresa May shows again that Brexit means hard Brexit

The Prime Minister's promise of "an end to free movement" is incompatible with single market membership. 

Theresa May, it is commonly said, has told us nothing about Brexit. At today's PMQs, Jeremy Corbyn ran with this line, demanding that May offer "some clarity". In response, as she has before, May stated what has become her defining aim: "an end to free movement". This vow makes a "hard Brexit" (or "chaotic Brexit" as Corbyn called it) all but inevitable. The EU regards the "four freedoms" (goods, capital, services and people) as indivisible and will not grant the UK an exemption. The risk of empowering eurosceptics elsewhere is too great. Only at the cost of leaving the single market will the UK regain control of immigration.

May sought to open up a dividing line by declaring that "the Labour Party wants to continue with free movement" (it has refused to rule out its continuation). "I want to deliver on the will of the British people, he is trying to frustrate the British people," she said. The problem is determining what the people's will is. Though polls show voters want control of free movement, they also show they want to maintain single market membership. It is not only Boris Johnson who is pro-having cake and pro-eating it. 

Corbyn later revealed that he had been "consulting the great philosophers" as to the meaning of Brexit (a possible explanation for the non-mention of Heathrow, Zac Goldsmith's resignation and May's Goldman Sachs speech). "All I can come up with is Baldrick, who says our cunning plan is to have no plan," he quipped. Without missing a beat, May replied: "I'm interested that [he] chose Baldrick, of course the actor playing Baldrick was a member of the Labour Party, as I recall." (Tony Robinson, a Corbyn critic ("crap leader"), later tweeted that he still is one). "We're going to deliver the best possible deal in goods and services and we're going to deliver an end to free movement," May continued. The problem for her is that the latter aim means that the "best possible deal" may be a long way from the best. 

George Eaton is political editor of the New Statesman.