The fundamental problem surrounding the current political debate about the future of the NHS is that it is ignoring the fundamental issue: the current pattern of provision.

On the one hand, the Government is proposing building more hospitals and a 15-year plan for more staff – without any suggestion of how it will cough up the money to pay for it all or enact the immigration policies that would welcome new and needed foreign health workers.

On the other, Labour promises new targets for ambulances and diagnoses times, cutting deaths from heart disease and suicide – targets that presumably can be used to manage NHS managers, who too often carry the can for political failure. While they have gone quiet on “salaried GPs”, more helpfully the opposition proposes repayment of health professionals university debts and bans on junk food.

However, the missing narrative remains the need for radical change to the NHS’s patterns of care. Neither party’s proposals have the courage to address that.

There is handwringing on both sides about the comparatively low provision of hospital beds. Yes, Germany and France both have more beds per 1,000 population than the UK, assuming they count beds in the same way as we do. But as a percentage of health care spend, according to the Office for National Statistics, the proportion of UK expenditure on hospital care (41.8%) exceeds Germany (28.9%), France (38.3%) and even European countries with similar numbers of hospital beds per 1,000 population, like the Netherlands (33.7%) and Sweden (38%).

Simply put, we over-hospitalise, partly because we don’t invest in more appropriate – and cheaper – types of care and partly because the one-stop- hospital-shop is pretty convenient for some of our most powerful clinical workers.

What the health of the nation needs most is a radical re-configuration of services to less acute, more appropriate and less expensive care.

The current provision of services does not match current patterns of need, especially among the elderly chronically ill. The political debates give lip service to the need for “integrated care” but ignore the elephant in the room – the all-consuming ever-dominant hospital. This lack of acknowledgement undermines the possibility of service transformation by continuing to entrench both money and power in big acute  hospitals.

Of course we need hospitals, but not nearly as many as we have currently. I say that as someone who has spent two nights in my own local NHS hospital following hip replacement surgery recently. Of course that could not have been done in my home nor (easily) in a community health centre. Some conditions, some services, do need acute hospital facilities.

However, health policy experts estimate that as much as 60% of the NHS’s clinical budget is being spent on the chronic conditions of elderly people and ageing baby boomers which can be cared for in facilities other than hospitals – smart homes, care homes, hostels.

In my own case, my local hospital is located less than a mile from my home, which is great. Within two further miles, however, are two other large acute teaching hospitals that could have provided the same care.

Now, I know friends in rural Scotland, for example, will point out that they have to travel tens of miles to their local hospital. But in our urban areas, we have plenty of hospitals, many of them sited and built before the motor car. Indeed, a  former director of health care in the London region opined that we could close at least a half dozen acute facilities in the metropolis without any significant impact on the population’s health.

Currently, we do not have enough low-level chronic facilities or home care professionals – neither in cities nor in the shires – because the current configuration of the NHS is so dominated by acute hospitals and by the medical professionals who work in them.

Many of the relatively new Integrated Care Boards are trying to come to grips with this, exercising analytically informed commissioning decisions (of considerable volume and money) in a manner that seeks to change patterns of care. But they are being undermined in their efforts, often being forced by their regional supervisors to first meet the expenditures – frequently in excess of prescribed budgets – of local hospitals, led by hospital managers and clinicians who know that whatever they spend will be covered before any shift of funds to non-acute care. It’s that perverse.

Only large-scale commissioning decisions to close hospitals as part of a programme that simultaneously opens and staffs home care, urgent care centres, smart homes and chronic care facilities is capable of providing the fundamental change we – as potential patients – and the NHS require. Of course, standing in the way are not only the acute elephants but also the political dinosaurs who wish to retain a hospital within site of every ballot box.

The current political talk of reform – on all sides of the political spectrum – only protects the status quo. That’s not good enough.

This blog was first published in the Byline Times.