Devolution – silver bullet or Swiss cheese?

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In recent months, health has found itself caught up in government’s latest big idea – devolution. Adjectives such as ‘historic’ and ‘ground-breaking’ have been used by some to describe the deals signed so far, while others have suggested they herald the start of a ‘two-tier’ or ‘Swiss-cheese’ health service. But what does devolution really mean for the NHS?

Our new briefing explores the latest developments, charting the devolution journey from its origins to the current day, as well as setting out some of the key questions that still require resolution.

What stood out most clearly to us when we looked at this issue in detail was the difference between rhetoric and reality. While the implications of the Cities and Local Government Devolution Bill for health are potentially far-reaching – creating the ability for local authorities to be given responsibility for a huge array of NHS commissioning functions – the reality (as we understand it) is that health’s ‘devolution revolution’ is to be delivered largely within existing legislation. This makes it closer to delegation than it is to devolution.

This is perhaps not surprising. Legislation has become a bit of a dirty word since the Lansley reforms, and the current government seems to recognise that any hint of another structural reorganisation should be avoided at all costs. Still, it seems slightly bizarre that a Bill with the potential to change the face of the NHS as we know it is provoking little wider scrutiny in comparison to the listening exercises, petitions and even raps inspired by the Health and Social Care Act 2012.

But just because this is not strictly devolution does not mean it is ‘business as usual’. When we speak to people involved in the devolution projects in Greater Manchester and Cornwall, it is clear that the possibility of greater self-determination is generating a level of dynamism approximating to a social movement. NHS and local authority leaders are coming together to think about how services can be transformed for the benefit of their populations, and in doing so are sweeping away long-standing barriers to change. All of this suggests that policy goals that previously seemed unobtainable might be within touching distance. Genuine integration across health and social care services and a greater focus on population health are just some of the prizes on offer if areas can make this work.

We do have concerns, of course. By adopting a process of delegation rather than full devolution, areas like Greater Manchester and Cornwall are being forced to innovate at the edges of existing legal boundaries. This begs many questions about how it will all work in practice. Who would ultimately stand behind provider deficits? How will regulatory oversight work? How different might local areas end up looking from one another?

Our biggest concern is that this becomes such a focus that people are distracted from the central challenges facing the NHS today – finances and future sustainability. Devolution will not be a quick fix to those challenges – savings strategies often result in improved outcomes rather than lower costs, take time to deliver and require significant upfront investment – and we don’t have a lot of time to spare.

Our final concern (less fashionable, but important all the same) relates to the legislative issue. Legislation is by no means the most effective lever for change, particularly where commitment on the ground is lacking, but there is also a risk that change not properly accounted for within legislation can easily be unravelled, even where the local commitment to get things done exists in abundance. The challenge now is for areas to take advantage of the current levels of political support in a way that means they are able to deliver tangible change for their communities that becomes impossible to go back on.


John Kapp

Comment date
19 November 2015
Very well researched and argued paper. My perception is that we now have the worst of all worlds. Abdication by the centre, and failure to pick up the leadership by local councillors. My investigations have shown that there is a power vaccuum over the health budget, which in Brighton and Hove is £350 mpa (£1 m per day, which is equal to the next 2 biggest spenders (Socail Care and Education) put together. The Clinical Commissioning Group are headless, with no-one to lead them (No, not NHS England, nor Dept of Health) The Health and Wellbeing Board are set up to lead them, but the councillors don't want to take responsibility for leading them (who would?) so deny that it is their job. I have got the chair (cllr Daniel Yates) to get a legal opinion on whether he holds this budget, which is expected by the end of this month. Their terms of reference make it clear that the CCG is accountable to the HWB. More on papers on section 9 of
Best wishes Yours, 01273 417997--------------------------------------------

David Oliver

visiting fellow,
The King's Fund
Comment date
18 November 2015
Dear Helen

Great blog and good to have you working at the fund. I don't have your expertise in this policy area but i am just thinking out loud about whether devolution of powers to localities and local government is likely to deliver all the benefits some people suppose it might.

I understand the attraction of local services designed by local leaders around local needs and also the good examples of this from other countries such as Sweden, New Zealand and the Netherlands.

However, i would suggest the recent track record of devolving service leadership or at least strategic direction/accountability from traditional NHS structures or from Whitehall is mixed

1. The Beter Care Fund has had a very mixed track record in delivering what it was intended to or in how well it has been administered?

2. Has moving public health to local government really delivered anticipated benefits and have Health and Wellbeing boards been any more effective than traditional NHS departments of public health?

3. Does commissioning of social care services from cash strapped local government suggest any greater competency at commissioning and quality assuring services than the NHS?

4. Does the lack of ringfence for local government mean (as we have seen with further social care an public health budget cuts) actually jeopardise the viability of traditional health services

5. By analogy, did those localities in "transforming community services" policy who gave the contract to community services to private providers, mental health trusts or social enterprises do any better on the whole than ones who gave the contract to the local acute provider? SOme of the best examples of joined up care across the acute/primary/community interface i have seen have been in "vertically integrated" organisations where the big bad acute was given the contract despite ideological hostility.

6. When it comes to devolution of service leadership to nations rather than cities or regions as in Scotland, NI and Wales, they have certainly been able to move away from purchaser provider split, commissioning and apparatus that surrounds it and keep proportionately more acute beds per 1000. And Scotland has arguably led the way with some of the national quality improvement initiatives. However, the proof positive that its not all about organograms, pooled budgets or organisations is that the health systems in the devolved nations share all the same wicked problems or pressurised urgent care, too much responsive mode, not enough proactive/anticipatory, still silo working and different language and values and incentives in different organisations, still too much fragementation

In general (as the fund has said in other documents like "making integration happen at scale and pace" a focus on structural solutions tends to overpromise when its more about adequately funded and staffed services and genuine collaboration, dialogue with the person truly at the centre of thinking.

This may be Un PC to day but i think sometimes we have a "democratic surfeit" - i would much rather in general entrust the running of public services to so called "unaccountable technocrats" (i.e. professionals steeped in running and working in those services and with the right training and technical knowledge) than local politiicans often in post for a short time, always at risk of falling out with colleagues in neighbouring authorities and with a whole range of political imperatives going beyond health and care. Several big northern cities actually voted against having a metropolitan mayor but it now seems they will get one whether they like it or not.

Devo Manc for instance requires cross conurbation, cross council collaboration on an epic scale - we arent talking one metropolitan authority like the old GMC with one CCG and one community health provider - far from it. And even pre Devo Manc the "healthier together" plans are still cause of much local dispute with some providers inevitably winners and losers and locals unhappy about outcomes.

The track record of local politicians and MPs opposing sometimes much needed closures of small local hospitals/community facilities makes me wonder how much appetite there is for major reconfiguration among local councillors

Finally, just an observation, the government seem quite selective about what they wish to devolve or centralise. Education is the obvious parallel. The government in England is hostile to local authority maintained schools and by forcing more schools to become academies, by creating free schools even in areas where they are not needed (and all desptie recent evaluations suggesting that neither perform any better or worse on average than LA schools) they are effectively disempowering local government when it comes to education but trying to empower it when it comes to health. The for the police elected crime commissioners (often with little background or expertise in policing) which has been an experiment yet to yield notable results.

I would suggest the service at the moment needs stability not yet more Lansley-esque entropy. And that the biggest concern about devolution is that when the money runs out, as it will central government will simply wash its hands and say "we gave you control of your own budget, now you sort it out"


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