KEIR STARMER’S announcement in January this year of a “deal between NHS and the independent sector to cut NHS waiting lists” was accompanied by Donald Trump’s declaration that any trade agreement between Britain and the US would be dependent on Britain opening its NHS to US companies.

A coincidence? Health and Social Care Secretary Wes Streeting’s only comment was that the NHS “does not feature in any current trade negotiations with the US.”

Labour’s 2023 NHS manifesto promised to double the number of district nurses in order to expand “hospital at home” services. In power, Labour has been actively promoting initiatives aimed at providing hospital-level care in patients’ homes, freeing hospital beds, reducing unnecessary A&E admissions and promoting community-based care.

But “hospital at home” (HaH) is not a new idea. In 1939 my mum Freda Sandels moved to London from Chipping Norton, a town with a radical history.

Aged 18, she got a job as an almoners’ clerk in the then London County Council Public Health Department, later qualifying as an almoner (a social service worker in a hospital) herself at London’s Whittington Hospital.

This was before the formation of the NHS in 1948, prior to which many “welfare” services in England and Wales — including healthcare — were delivered either by charitable bodies or under the Poor Law system.

Almoners, literally, provided “alms” for those in need. Sandels had already had experience of the system as a child, when members of her family were admitted to (and died in) the sick ward of her local workhouse.

As an almoner, her job included visiting a patient’s family to assess their needs: if a couple had two children and five kitchen chairs, they were required to sell one of the chairs before they were eligible for assistance.

If a homeless person was treated in hospital she had to ship them out the next morning to a neighbouring borough.

Radicalised by the experience she joined the Communist Party (and met my dad), studied for her London University Extra-Mural Diploma in Social Studies and subsequently — within the NHS — became head medical social worker at Barnet General Hospital.

As a medical social worker, Sandels became interested in the history of British medicine and the way that the NHS had been introduced as a “two-tier” system whereby “primary” care takes place in the community and “secondary” specialist provision is confined to hospitals.

This division in British medicine — with GPs independently contracted to the NHS and hence not accountable to local health authorities — is now taken for granted in Britain but was by no means inevitable.

The division leaves a gap. It is assumed that any specialist treatment that individuals — “patients” — living at home can be adequately met through attendance as a hospital out-patient while their basic support is the responsibility of their family, possibly helped by local authority social services provision.

But in Sandels’ own words: “This concept does not fit well with reality. Many patients at home suffer unnecessarily and are denied recovery prospects because they do not have access to specialist treatment and hospital-held resources.

“Equally, many hospitalised patients could be more effectively cared for at home, given the availability there of specialist treatment … traditionally available to them only in hospitals.”

In 1972 Sandels was awarded a British Council fellowship to make the first of several visits to study the French health service, in particular its Hospitalisation a Domicile (HaD) schemes in Bayonne, Bordeaux, Grenoble and Paris.

Her articles urging practical action to set up similar services within the NHS led to radio and television broadcasts and requests to speak at meetings, seminars and conferences which secured considerable interest from health administrators, doctors and nurses, academics and patient representatives.

In 1977 together with Brunel University she received a grant from the Nuffield Foundation to make a more systematic study of the French HaD. This led to several publications and to a major grant from the Sainsbury Family Charitable Trusts to establish an HaH scheme in Britain.

Several health authorities applied to host it and Peterborough was chosen with a pilot scheme running between April 1978 and March 1981 which continues today and has led to many similar initiatives throughout Britain.

Sandels’ book, Hospital At Home: The Alternative to General Hospital Admission, was published in 1984 by Macmillan. It had taken a while to write and its publication coincided with the tightening of Margaret Thatcher’s attack on public services.

Reactions ranged from those who saw HaH as a way of “saving money” to others who warned of the dangers such a scheme would offer to privatisation.

The 1973 National Health Service Reorganisation Act — just one of a huge number of “reforms” of the NHS — transferred responsibility for community support of the sick (and other disadvantaged people) from health authorities to local authority social service departments.

This had already led to a change in the Peterborough scheme from one which, employing medical social workers, genuinely bridged the gap between primary and secondary care to one which was GP-led.

And in 2008, Tony Blair’s Health and Social Care Act changed the rules, allowing larger businesses to buy up practices in England in an effort to drive competition and innovation.

Today US healthcare companies are deeply embedded in the NHS. The US Centene corporation already owns 70 GP surgeries in Britain through its subsidiary Operose Health — now sold to the HCRG (previously Virgin) Care Group.

NHS England was set up by the Tories following the 2012 Health and Social Care Act so they could declare that bed shortages and longer waiting lists for treatment were “not our problem.”

The Act abolished the NHS’s foundational guarantee of universal care and transferred healthcare from the government to this new and supposedly “independent” body, NHS England, replacing primary care trusts with clinical commissioning groups and then, in July 2022, with so-called integrated care boards couched in the language of “consumer choice” but allowing the private sector to be represented.

Today there is a pressing need for proper healthcare beyond existing GP and community health services, for those who wish and would benefit from it, in their own homes. Labour declares that its Mission to Build an NHS Fit for the Future will ensure “that more people get care at home in their community.”

But is Hospital At Home the answer? It could certainly relieve the pressure on hospital beds. And — provided essential medical input both from hospital specialists and from GPs is “on tap” and free, together with the necessary appliances, dedicated trained nursing and care staff and support to otherwise invisible family carers to make sure that nothing “falls through the cracks” — it will be welcomed by many, especially the elderly and vulnerable.

But by itself, it won’t solve the crisis in the NHS. And under the present government, it is likely to involve means testing and to provide yet another opportunity for private profit — at our expense.

Hospital at Home can be downloaded free from www.tinyurl.com/hahclarke.