My first Labour party conference was back in the early 1990s when as a campaigner for penal reform I was part of a group of free-thinking radicals and lawyers (including a young barrister called Keir Starmer). Our efforts to convince the party that community sentencing was a more effective response to crime than the existing prison system were stymied by political reality: the public was – and is – convinced that locking people up is the automatic response to crime. Watching the same Keir Starmer as Prime Minister 30 years later struggle with prison overcrowding has been a reminder of a broader truth. Institutions can become so deeply embedded in political and public thinking that reform never gains traction.
These days, I am in health rather than criminal justice but in truth the arguments remain strikingly similar. For prisons, read hospitals. While in theory, Government is committed to moving healthcare from our overcrowded, expensive hospitals into the community, in the public’s mind – and that of many doctors – healthcare means hospitals.
In eyecare, millions of people routinely access eye health services in community settings, and advances in technology mean many tests, monitoring appointments and follow-up services can now be delivered safely and effectively outside hospital. Yet policy, funding and public attitudes often continue to treat hospital care as the default. The same institutional assumptions that have frustrated reform in criminal justice are now holding back the shift towards more community-based healthcare.
The Ten-Year Health Plan has trumpeted the intention to move funding from secondary to community care but the decades-long reduction in the proportion of spending that goes on primary rather than secondary care is now down to 8% of NHS spend.
What is striking is that both prisons and hospitals, which occupy such a central role in our thinking, are in their current guises relatively recent inventions. In hospitals, the shift from a primarily religious institution dispensing alms and rudimentary care to a self-consciously clinical, doctor-led medical establishment only took place in the first half of the 18th century and it took the professionalisation of the medical profession and the introduction of basic nursing practices the following century for the hospitals in the modern sense to begin to emerge.
And, while lock-ups and debtors gaols had existed for centuries, it was not until the twin pillars of capital punishment and overseas transportation crumbled away in the early 19th century that prisons began to play a central role in penal policy.
The vast hospital and prison estates that now consume so much of our resources (£140bn on hospitals alone) and so dominate our social policy thinking were born not out of necessity but out of these changes in our conceptual approach to the underlying issues.
The political heft of prisons and hospitals now defies attempts at policy reform. Badenoch’s attack on Labour’s prisoner release programme – concluding that it will mean dangerous criminals will be released to rape and kill again – is politics 101. Hospital openings are political catnip; hospital closures political suicide.
Moreover, the very longevity of these institutions means that we – and they – have somewhat lost sight of what they are there to do. The first flush of idealistic prison-building in Victorian England may have been rooted in some now-unpleasant ideas but at least the architects of the early penal reformatories had rehabilitative ambitions. Similarly, the history of the Borstal movement was an initial triumph of ambition and achievement. The depressingly high reconviction rates among released prisoners have left our gaols aspiring to be little more than expensive, overcrowded warehouses for the mad, the bad and the merely unlucky.
Where the comparison ends is that if the failing nature of our prison system is viewed as an accepted policy truth, the reputation of our NHS hospitals remains politically unquestionable. Yes – there have been repeated individual scandals but the power of the secondary care-dominated hospital establishment, the amazing clinical care that is provided in most hospitals and the dedicated work undertaken by the vast majority of the 1.5 million staff who work there, have largely insulated the institution as a whole from serious criticism.
Until now. Because in reality policy-makers are right to question the centrality of the hospital model to our conception of effective healthcare. Hospitals may be the best way of providing medical intervention in acute cases, where operations or immediate intervention may be required at any moment. However, the services offered in hospitals can often easily be provided in a community setting. Advances in technology now mean that medical interventions may not need to be so invasive and hospital stays can be kept to a minimum while recovery is effectively monitored remotely after discharge; in eyecare, for example, post-cataract and glaucoma monitoring is just as effective outside hospitals as in them. And for patients, advances in our standards of living over the past two centuries mean that it is no longer the case that the institutional care, routine and diet provided in hospital are better for us than can be provided in our own homes. Anyone who has spent much time in a hospital lately can attest that, like prisons, one of its key roles is simply to warehouse those in need.
While campaigners like myself back in the 90’s were putting the case for prison reform, there was a wilder fringe of lawyers and academics who were arguing not for reform but abolition; indeed, their house magazine was called the Abolitionist. There has never been a movement to abolish hospitals. However, three hundred years after the opening of the first clinical hospitals in the UK, it must be time to take a hard look at whether we should continue to build our healthcare system around the centrality of the hospital model.
What the best parts of our best hospitals do is groundbreaking; we must protect that at all costs. But we should not allow our admiration for those successes to prevent us asking radical questions about whether the hospital model more generally is still fit for purpose. Above all, we need to be willing to be radical in our approach: as the failure of successive governmental aspirations to move healthcare out of hospital into the community can attest, the power of institutions is sufficiently strong to resist attempts at tinkering – despite all the evidence to the contrary.
