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.

Pexel
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This week, a top tip to save on washing powder (just don’t stand too near the window)

I write this, at 3.04pm on a sticky Thursday afternoon, in the state in which Adam, before his shame, strolled in the Garden of Eden.

Well, in the end I didn’t have to go to Ikea (see last week’s column). I got out of it on the grounds that I was obviously on the verge of a tantrum, always distressing to witness in a man in his early-to-mid-fifties, and because I am going to Switzerland.

“Why Switzerland?” I hear you ask. For the usual reason: because someone is paying for me. I don’t think I’m going to be earning any money there, but at least I’ll be getting a flight to Zurich and a scenic train ride to Bellinzona, which I learn is virtually in Italy, and has three castles that, according to one website, are considered to be “amongst the finest examples of medieval fortification in Switzerland”.

I’m not sure what I’m meant to be doing there. It’s all about a literary festival generally devoted to literature in translation, and specifically this year to London-based writers. The organiser, who rejoices in the first name of Nausikaa, says that all I have to do is “attend a short meeting . . . and be part of the festival”. Does this mean I can go off on a stroll around an Alp and when someone asks me what I’m doing, I can say “Oh, I’m part of the festival”? Or do I have to stay within the fortifications, wearing a lanyard or something?

It’s all rather worrying, if I think about it too hard, but then I can plausibly claim to be from London and, moreover, it’ll give me a couple of days in which to shake off my creditors, who are making the city a bit hot for me at the moment.

And gosh, as I write, the city is hot. When I worked at British Telecom in the late Eighties, there was a rudimentary interoffice communication system on which people could relay one-line messages from their own computer terminal to another’s, or everyone else’s at once. (This was cutting-edge tech at the time.) The snag with this – or the opportunity, if you will – was that if you were not at your desk and someone mischievous, such as Gideon from Accounts (he didn’t work in Accounts; I’m protecting his true identity), walked past he would pause briefly to type in the message “I’m naked” on your machine and fire it off to everyone in the building.

For some reason, the news that either Geoff, the senior team leader, or Helen, the unloved HR manager, was working in the nude – even if we knew, deep down, that they weren’t, and that this was another one of Gideon’s jeux d’esprit – never failed to break the monotony.

It always amused us, though we were once treated to a terrifying mise en abîme moment when a message, again pertaining to personal nudity, came from Gideon’s very own terminal, and, for one awful moment, for it was a very warm day, about 200 white-collar employees of BT’s Ebury Bridge Road direct marketing division suddenly entertained the appalling possibility, and the vision it summoned, that Gideon had indeed removed every stitch of his clothing, and fired off his status quo update while genuinely in the nip. He was, after all, entirely capable of it. (We still meet up from time to time, we BT stalwarts, and Gideon is largely unchanged, except that he’s now a history lecturer.)

I digress in this fashion in order to build up to the declaration – whose veracity you can judge for yourselves – that as I write this, at 3.04pm on a sticky Thursday afternoon, I, too, am in the state in which Adam, before his shame, strolled in the Garden of Eden.

There are practical reasons for this. For one thing, it is punishingly hot, and I am beginning, even after a morning shower, to smell like a tin of oxtail soup (to borrow an unforgettable phrase first coined by Julie Burchill). I am also anxious not to transfer any of this odour to any of my clothes, for I will be needing them in Switzerland, and I am running low on washing powder, as well as money to buy more washing powder.

For another thing, I am fairly sure that I am alone in the Hovel. I am not certain. To be certain, I would have to call out my housemate’s name, and that would only be the beginning of our problems. “Yes, I’m here,” she would reply from her room. “Why?” “Um . . .” You see?

So here I lie on my bed, laptop in lap, every window as wide open as can be, and looking for all the world like a hog roast with glasses.

If I step too near the window I could get arrested. At least they don’t mind that kind of thing in Switzerland: they strip off at the drop of a hat. Oh no, wait, that’s Germany.

Nicholas Lezard is a literary critic for the Guardian and also writes for the Independent. He writes the Down and Out in London column for the New Statesman.

This article first appeared in the 22 September 2016 issue of the New Statesman, The New Times