The plans in Manchester have arrived on the back of the government’s commitment to greater devolution for the area and a track record of work on initiatives such as total place and community budgets. The recent focus on health and social care owes much to a meeting of minds between Treasury officials and staff at NHS England in the context of the NHS five year forward view. The developing relationship between George Osborne and Simon Stevens, forged during discussions over NHS funding requirements for the Autumn Statement, has also been important.
The potential benefits of the plans are the closer integration of public services and decisions that are better aligned with the needs of the people of Greater Manchester. While the headlines last week focused on health and social care integration, the memorandum of understanding setting out what has been agreed refers to improvements to health and wellbeing as the overarching goal. A much bigger prize is therefore on offer if local authorities and their NHS partners can use their combined resources to go beyond the integration of care to focus on population health.
Devolution to Greater Manchester should enable decisions to be taken much closer to the population being served, with councillors having a bigger influence on future decisions. This raises the prospect of a health care system similar to those in the Nordic countries where regional and local politicians often have a more significant role than their national counterparts in the running of health and care services. The unanswered question is how much freedom public sector leaders will have to depart from national policies in taking greater control of NHS resources. This is one of many important issues that will need to be worked through in 2015/16, which will be the build-up year.
The main risks of the plans are that they will take time and effort away from work to address the growing financial challenges facing local government and the NHS, and that they will result in confused accountabilities. The worst of all outcomes would be further structural changes to the health service that distract public sector leaders from their core task of improving outcomes for the populations they serve. It will be just as important to ensure that governance arrangements help to clarify where responsibility for providing leadership of public services rests, especially as the coalition government’s reforms have left a vacuum in the NHS that needs to be filled.
Greater Manchester has emerged as the trailblazer of devolution in England because of the undoubted capabilities of the ten local authorities involved and the resulting willingness of the Treasury to devolve more responsibility to them. Much will now hinge on the ability of council leaders to hold together when difficult decisions have to be made about the future of public services. The shared concern of these leaders to improve the health and wellbeing of the conurbation’s population may conflict with what is in the best interests of their own areas. Effective governance arrangements will be needed to deal with such conflict and to shape the relationship between local statutory organisations and central government. Changes in legislation are likely to be needed to deal with these issues and to realign accountability for the use of public resources.
With the general election now only two months away, the government’s proposals are a challenge to the Labour Party whose own plans point in a similar direction but without (yet) being as specific. Labour may be tempted to argue that the rest of the country should follow Greater Manchester’s lead but this would be a high-risk strategy when local authorities in many other areas are not as advanced in their joint working or in developing effective partnerships with the NHS. If history teaches us anything, it is that one-size-fits-all solutions rarely work and that allowing room for different approaches in different areas should be welcomed.
Many important questions remain to be answered, including what the role of clinical commissioning groups is in the proposed arrangements and how not to lose the benefits of GPs’ involvement in commissioning. It will also be important to ensure the plans do not result in a further layer of decision-making being superimposed on an already complex system. The implications for providers are equally unclear, particularly around their relationship with national regulators as partnership-working is strengthened in Greater Manchester. Most important of all is to work through what ‘national’ means in a devolved health and care system and the areas in which local variations in services and standards are not permitted.
With financial pressures on public services set to continue, there needs to be clarity on how overspending of NHS budgets will be handled, especially after the build-up year. This includes the scope for local authorities to switch funding from the NHS to other services. The Commission on the Future of Health and Social Care in England showed that the case for a single health and social care budget is compelling but only if sufficient funding is provided. Merging two leaky buckets does not create a watertight solution, as Simon Stevens has observed, and devolution in a time of austerity risks shifting blame for unpopular decisions from Whitehall to town hall in the absence of sustainable funding agreements.