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Devolution – silver bullet or Swiss cheese?


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.