The announcement that Greater Manchester is to receive a large-scale devolution of health and social care powers has been taken to be a significant development for the sector. There are plenty of gaps to fill in the plans over the next 12-18 months, but the scale and pace of changes proposed so far leave the health and social care sector with some important reflections.
Why devolve? Normative conclusions from positive propositions
Within the world of policy makers, thinktanks and political reformers, a familiar argument goes like this: England is one of the most centralised states in Europe. Therefore we should devolve spending decisions to a more local level. Both of these statements may be valid, but the logic is flawed. Hume articulated nearly 300 years ago that one cannot derive “ought” from “is”. Descriptive statements about “what is” do not automatically correspond with what “should be”.
Arguments from local democracy, economic development and health reformers can do better than this, and they have done. However, when considering devolution of health policy the respective merits of individual changes must be properly considered, rather than a blanket assumption that decentralisation must always be inherently a good thing.
What do we mean by "devolution"?
Certain words become in vogue during certain periods. ‘Devolution’ has been very much so since the Scottish referendum. Often these words can become over-used, and it’s difficult to work out just what is being proposed. Since 2010 the Department of Local Government and Communities have embarked on a policy of ‘localism’, which in many councils’ experience has meant taking on a huge amount of additional risk without additional funding coming with it. The Health and Social Care Act 2012 devolved a number of commissioning responsibilities and strategic decision making to local areas, but has hardly been met with widespread celebration.
The Manchester deal has been described as being in line with the spirit of subsidiarity, where powers are devolved to the lowest, most local level possible. One of the first developments for Greater Manchester will be to establish a new Greater Manchester Partnership Board, which could be seen as a new tier of local administration. How might look to people in Bury if the Greater Manchester Combined Authority end up sucking power upwards away from local councils and local people? Perhaps the personalisation agenda and the increasing role of communities in promoting health are the most interesting and revolutionary ‘devolution’ items that are happening in health and social care.
What's new and unique in the Manchester deal?
For the Manchester deal, it’s currently difficult to work out what is major new change, and what is riding on the wave of current policy. The transfer of responsibilities for primary care and specialised services commissioning from national to local is already in motion across the country. NHS England has indicated it will implement long term budget allocations across all commissioning streams over the next 3-4 years. Any area of the country can develop new models of care should it wish, and there has been some testing of local freedoms with regard to payment systems and quality frameworks. This is all emerging national policy, open to local discretion. There certainly seem to be some new and unique items in the Manchester deal; the issue of local discretion over regulation seems the most interesting at first glance. The devil will be in the detail, but for the moment the announcement seems more like one of evolution rather than revolution.
If Greater Manchester, then Leeds?
Inevitably, attention will turn to what other English cities are doing on this agenda. Leeds will be looking at developments over the Pennines with interest. There are some unique aspects to Greater Manchester which have made them the most likely candidates to jump first. They have had over 10 years of co-working across the region under the Greater Manchester Combined Authority. The region has a ‘Healthier Together’ transformation programme across health and social care. Greater Manchester is one of the pilot sites for the government’s Community Budgets programme and they are a key part of the Combined Authority’s 3-5 year programme to transform public services.
Greater Manchester also has a quite unique health and social care economy in which a vast majority of commissioning and provider spend is self-contained within the region. Leeds and West Yorkshire have more transient boundaries and contain large specialist centres, so Manchester’s economic anomaly is not replicated. However, the overall aim for more integrated services is not necessarily a causal consequence of devolution. Leeds is the only city recognised by government as an Integration Pioneer, and partners in the city are building on the success of its Neighbourhood Teams to examine potential for new models of care and better care for patients.
We should end by returning to the ‘Why devolve?’ question. So much health reform is dominated by an infatuation with where political power should sit, hence the many restructures and top-down re-disorganisations. Discussions about devolution could centre on this. Leeds has a vision for a high quality, sustainable health and social care system, where people who are the poorest improve their health the fastest. This will be delivered by designing high quality services which are integrated across health and social care and are coordinated around the needs of people. If large-scale ‘devolution’ can help with this, then so be it.