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.

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The Brexit ministers who just realised reducing immigration is a problem for them

Turns out there's a teeny tiny hiccup with reducing immigration...

On 27 December 2015, the then-backbencher MP David Davis declared he was "voting out" in the forthcoming EU referendum. Among his reasons was the "disastrous migration crisis". 

Fast forward 14 months. Now the minister responsible for Brexit, Davis has been spotted in the Latvian capital of Riga, with a slightly different message

He admitted it was not plausible that Brits would immediately take jobs in the kind of low-paid sectors like agriculture and social care currently staffed by migrant workers. 

Immigration restrictions "will take years" to be phased in, he added. 

Davis is only the latest minister in the Brexit government to realise that immigration might be down to more than some pesky EU bureaucrats. Here's when the penny dropped for the others: 

Andrea "Seasonal Labour"  Leadsom

During the EU referendum campaign, Brexit charmer-in-chief Andrea Leadsom told The Guardian that immigration from EU countries could “overwhelm” Britain, and that her constituents complained about not hearing English spoken on the street. 

But speaking to farmers in 2017 as Environment secretary, Leadsom said she knew “how important seasonal labour from the EU is, to the everyday running of your businesses”. She said she was committed to making sure farmers “have the right people with the right skills”. 

Sajid “Bob the Builder” Javid 

The Communities secretary Sajid Javid backed the Remain campaign like his mentor George Osborne, but when he was offered a job in the Brexit government, he took it.

Javid has criticised immigrants who don’t integrate, but it seems there is one group he doesn’t have any qualms about - the construction workers who build the homes that fall under his remit.

As early as September, Javid was telling the FT he wouldn’t let any pesky UK border red tape get between him and foreign workers needed to meet his housebuilding targets.

Philip “Citizen of the World” Hammond

So if you can’t kick out builders, what about that perennially unpopular group of workers, bankers? Not so fast, says Philip Hammond.

Just three months after Brexit, he said the government would use immigration controls “in a sensible way that will facilitate the movement of highly-skilled people between financial institutions and businesses”. 

As a Chancellor who personally backed Remain, Hammond is painfully aware of the repercussions if the City decamps to the Continent. 

Greg “Brightest and Best” Clark

The Business, Energy and Industrial Strategy secretary backed Remain, and has kept his head down since winning the meaty new industrial brief. 

Nevertheless, he seems willing to weigh in on the immigration cap debate, at least on behalf of international students. Asked whether the post-study work visa pilot should continue, Clark said the government wanted to attract the brightest and best.

He continued:

"We have visa arrangements in place so that people can work in graduate jobs after that, and it is important that they should be able to do so."

Jeremy "The Doctor" Hunt 

The Health secretary kept his job in the turmoil of the summer, and used his conference speech to toe the party line with a pledge that the NHS would rely on less foreign medical staff in future.

The problem is, Hunt has alienated junior doctors by imposing an unpopular contract, and even those wannabe medics that do sign up will have to undergo half a decade of studying first.

Asked about where he plans to find NHS workers in Parliament, Hunt declared: “No one from either side of the Brexit debate has ever said there will be no immigration post-Brexit.” He also remained “confident” that the UK would be able to negotiate a deal that allowed the 127,000 EU citizens working for the NHS to stay. 

So it turns out we might need agriculture and construction workers, plus students, medics and even bankers after all. It's a good thing the government already has a Brexit plan sorted out...
 

Julia Rampen is the editor of The Staggers, The New Statesman's online rolling politics blog. She was previously deputy editor at Mirror Money Online and has worked as a financial journalist for several trade magazines.