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Is it time to get rid of hospitals? How care can be moved into the home

There is a growing realisation that hospitals are an impediment to getting care where we want it: in our own homes.

My father had a stroke and was ill for more than four years before he died. During that time, he went into hospital five or six times. He always came out worse than when he went in.

Other than initially, when he was admitted to hospital after the stroke, he probably never needed to be there at all. When he developed his final pneumonia and we wanted to stop his antibiotics, we had to fight to let him stay at home to die, because the district nurse was worried that, without a “terminal diagnosis”, we might all be accused of killing him. As his GP, who supported us, said ruefully: “Dr Shipman has a lot to answer for.”

A few months after my father died, I spent a year as the cabinet member for adult social care and health at Camden Council in London. I was dealing with millions of pounds’ worth of cuts to social care for the elderly, and, despite our best efforts, there just wasn’t enough money to provide care at home. My public health budget was cut by 6 per cent, even though I had been told that “prevention” was the new byword.

At the same time, nearby hospitals were building new units, expanding their services and running up huge debts. The deficit for University College Hospital at the end of 2016 was £32.5m.

This is happening all over the UK, not just in London. Only 9 per cent of the total health budget in England is spent on GPs and that figure is falling as GP numbers drop. Data released last year by the King’s Fund showed that district nursing numbers had fallen by 28 per cent in the past five years to just under 6,000; the think tank also found that the wider community-nurse workforce has shrunk by 8 per cent to 36,600.

Gary Porter, the Tory councillor who chairs the Local Government Association, said in February that adult social-care services face a £1.2bn funding gap by 2020.

Hospitals may complain about crowded accident and emergency departments and bed-blocking, but they still control almost the entire health budget. Their buccaneering chief executives have the ear of government and their overspending is indulged. As budgets shrink, it is more cost-effective for hospitals to absorb community services because the expertise and space for new clinics is already on site.

In my view, we have been brainwashed into thinking about the NHS almost entirely through the medium of hospitals. Television shows heroic, if exhausted, doctors and nurses in such programmes as 24 Hours in A&E, One Born Every Minute and Hospital.

I have become increasingly cross about this enormous power imbalance in the NHS, which supports hospitals but has not helped the growing population of needy and elderly patients. What if we moved significant resources and brought hospital-level care into homes for the likes of my father? What if we got rid of hospitals altogether?

I am not proposing to abolish all hospitals, of course. People need specialist inpatient care, whether it’s for heart surgery, stroke treatment, or hip replacements. But these are not needed by that many of us.

Bringing services out of hospital is not a novel idea. It is what the King’s Fund has been advocating for some time.

The new Sustainability and Transformation Plans (STPs), the government’s latest attempt at NHS reorganisation, advocate this, too. According to a recent BBC analysis, under these plans, hospital services will be scaled back across a third of England. Yet if this is to be done, it must be done well: not as a stealth cut, but as a new vision.

One problem with the current approach is that it is predicated on moving billions of pounds from the NHS. The early signs that huge sums will be transferred from hospitals to the community are not good, though there may be better integration at the community level. People could end up with worse care at home, or none whatsoever, and more overcrowded hospitals. This would be the worst of all worlds. A successful transition would require duplication of services, at least for a while. As the medical director of one STP outside London told me: “Getting funding out of acutes and into the community is difficult and may need double running.”

In such a system, you would need investment in clinics with doctors and nurses, within easy reach of everyone, open 365 days a year, 24 hours a day, to take people out of accident and emergency departments. In the Netherlands, 160 clinics have been built to do just that.

There is a growing realisation that hospitals are an impediment to getting care where we want it: in our own homes. It’s time to accept that most of them need to go. 

This article first appeared in the 02 March 2017 issue of the New Statesman, The far right rises again

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Andy Burnham and Sadiq Khan are both slippery self-mythologisers – so why do we rate one more than the other?

Their obsessions with their childhoods have both become punchlines; but one of these jokes, it feels to me, is told with a lot more affection than the other.

Andy Burnham is a man whose policies and opinions seem to owe more to political expediency than they do to belief. He bangs on to the point of tedium about his own class, background and interests. As a result he’s widely seen as an unprincipled flip-flopper.

Sadiq Khan is a man whose policies and opinions seem to owe more to political expediency than they do to belief. He bangs on to the point of tedium about his own class, background and interests. As a result he’s the hugely popular mayor of London, the voice of those who’d be proud to think of themselves as the metropolitan liberal elite, and is even talked of as a possible future leader of the Labour party.

Oh, and also they were both born in 1970. So that’s a thing they have in common, too.

Why it is this approach to politics should have worked so much better for the mayor of London than the would-be mayor of Manchester is something I’ve been trying to work out for a while. There are definite parallels between Burnham’s attempts to present himself as a normal northern bloke who likes normal things like football, and Sadiq’s endless reminders that he’s a sarf London geezer whose dad drove a bus. They’ve both become punchlines; but one of these jokes, it feels to me, is told with a lot more affection than the other.

And yes, Burnham apparent tendency to switch sides, on everything from NHS privatisation to the 2015 welfare vote to the leadership of Jeremy Corbyn, has given him a reputation for slipperiness. But Sadiq’s core campaign pledge was to freeze London transport fares; everyone said it was nonsense, and true to form it was, and you’d be hard pressed to find an observer who thought this an atypical lapse on the mayor’s part. (Khan, too, has switched sides on the matter of Jeremy Corbyn.)

 And yet, he seems to get away with this, in a way that Burnham doesn’t. His low-level duplicity is factored in, and it’s hard to judge him for it because, well, it’s just what he’s like, isn’t it? For a long time, the Tory leadership’s line on London’s last mayor was “Boris is Boris”, meaning, look, we don’t trust him either, but what you gonna do? Well: Sadiq is Sadiq.

Even the names we refer to them by suggest that one of these two guys is viewed very differently from the other. I’ve instinctively slipped into referring to the mayor of London by his first name: he’s always Sadiq, not Khan, just as his predecessors were Boris and Ken. But, despite Eoin Clarke’s brief attempt to promote his 2015 leadership campaign with a twitter feed called “Labour Andy”, Burnham is still Burnham: formal, not familiar. 

I’ve a few theories to explain all this, though I’ve no idea which is correct. For a while I’ve assumed it’s about sincerity. When Sadiq Khan mentions his dad’s bus for the 257th time in a day, he does it with a wink to the audience, making a crack about the fact he won’t stop going on about it. That way, the message gets through to the punters at home who are only half listening, but the bored lobby hacks who’ve heard this routine two dozen times before feel they’re in the joke.

Burnham, it seems to me, lacks this lightness of touch: when he won’t stop banging on about the fact he grew up in the north, it feels uncomfortably like he means it. And to take yourself seriously in politics is sometimes to invite others to make jokes at your expense.

Then again, perhaps the problem is that Burnham isn’t quite sincere enough. Sadiq Khan genuinely is the son of a bus-driving immigrant: he may keep going on about it, but it is at least true. Burnham’s “just a northern lad” narrative is true, too, but excludes some crucial facts: that he went to Cambridge, and was working in Parliament aged 24. Perhaps that shouldn’t change how we interpret his story; but I fear, nonetheless, it does.

Maybe that’s not it, though: maybe I’m just another London media snob. Because Burnham did grow up at the disadvantaged end of the country, a region where, for too many people, chasing opportunities means leaving. The idea London is a city where the son of a bus driver can become mayor flatters our metropolitan self-image; the idea that a northerner who wants to build a career in politics has to head south at the earliest opportunity does the opposite. 

So if we roll our eyes when Burnham talks about the north, perhaps that reflects badly on us, not him: the opposite of northern chippiness is southern snobbery.

There’s one last possibility for why we may rate Sadiq Khan more highly than Andy Burnham: Sadiq Khan won. We can titter a little at the jokes and the fibs but he is, nonetheless, mayor of London. Andy Burnham is just the bloke who lost two Labour leadership campaigns.

At least – for now. In six weeks time, he’s highly likely to the first mayor of Greater Manchester. Slipperiness is not the worst quality in a mayor; and so much of the job will be about banging the drum for the city, and the region, that Burnham’s tendency to wear his northernness on his sleeve will be a positive boon.

Sadiq Khan’s stature has grown because the fact he became London’s mayor seems to say something, about the kind of city London is and the kind we want it to be. Perhaps, after May, Andy Burnham can do the same for the north – and the north can do the same for Andy Burnham.

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.