The latest proposals on health devolution: solution or provocation?

Health devolution in England is back on the political agenda. Earlier this month, Reform published a significant new report, Close enough to care: a new structure for the English health and care system. While the health media reacted to its headline message to abolish NHS England, that is a distraction from the truly big ideas the report contains.

It starts by following a well-trodden path, setting out what the NHS-dominated model of health policy and practice suffers from, namely: not prioritising prevention, not acting sufficiently on health inequalities, being excessively focused on the short term, and being a poor partner for other sectors, all made worse by over-centralisation.

For Reform, the answer to these problems is not incrementalism and letting integrated care systems (ICSs) bed in to see if they work – but to leap forward to radical change. In short, that means giving control over the NHS to combined authorities – a power transfer ‘down from’ Whitehall, and ‘up from’ local government and ICSs. This, they argue, is the only way to bring the NHS into a world of stronger local democracy, decisions closer to the public who benefit from them, and coherence between the NHS and local decisions over those things that actually determine the population’s health, such as economic, housing and similar policies.

It is to Reform’s credit that this is a genuine attempt to think beyond the current state of affairs and offer a different possible future; and by doing that it forces genuine thought in response. But while the diagnosis of the problem is one that most would agree with, there are three related questions that need to be asked before proceeding with such radical organisational surgery: is surgery needed right now, might the patient recover ? is the proposed treatment ready to deliver? and what unintended side-effects might accompany the treatment?

On the first, the consistent message from leaders across the NHS – and perhaps more importantly given these proposals, local government – is along the lines of ‘please, don’t change the structures again, let us make sense of ICSs and try and make them work’. It is simply too early to know if ICSs are working, and if they will be given the space to be allowed to work. What we do know is that there is lots of ambition from their leaders, to focus on health inequalities, on prevention and on partnership; and this is written into their principles. Shouldn’t they be given time and resources to actually prove their worth? That will take at least a parliamentary term to know.

Second, are combined authorities ready to take on such a huge role? These are new bodies – the first, Greater Manchester was only set up in 2011 and took on the control over its health and social care budget in 2016. No other combined authority comes close to it in terms of maturity or the extent of its role in health. The way combined authorities have developed so far has been by a process of intense local negotiation over scope and powers, and evolving over time . That means they are hugely different in terms of the scope, powers and influence they have and what any NHS role would ‘connect in to’, all hugely complex. Further, many parts of England do not have combined authorities, so would be starting from scratch. Even if this could be worked through, there is a clear risk that adding the responsibility to manage, run and shape NHS services could fundamentally change what combined authorities are; and acute NHS problems such as waiting lists and access could easily dominate their bandwidth, rather than what is hoped for and envisaged. This is not to downplay the importance of combined authorities in terms of their impact on health, in fact our new project with the Centre for Local Economic Strategies is looking just at that.

On the third question, devolving responsibility for health to combined authorities is easy to say on paper, but opens up all sorts of even bigger questions in practice, as the report sets out. These include the report’s proposals how on setting out for the first time a minimum defined benefits package around NHS entitlements and what each combined authority has to offer (moving beyond the NHS Constitution), and how to allocate resources, and then in turn, opening up the possibility of some offering ‘more’ than others, potentially through revenue raising. These are huge changes to the status quo for local government and the NHS. Even if this is all made to work, and is acceptable to the public, the net result could be wider regional inequalities in outcomes, entitlements and services, if some areas make better choices than others, and start with much better legacy endowments in terms of capability, funding or estate. Obviously, that is not to say that there is not already unjustified inequality in health outcomes overall and those related to the NHS, but this may become more explicit and pinned to regional differences than is the case now. That explicitness, and outcome might be a price worth paying, if it comes in return for better outcomes and narrower inequalities within regions. But how much appetite is there really for this among the public, politicians and those leading combined authorities? To be fair, the report’s authors are aware of such risks and propose ways to mitigate them. But each increases the complexity of the proposed reforms, there are a lot of devils in all those details.

So, where do we end up? In short, Reform’s report should be taken seriously, it is an impressive and really thoughtful contribution, and by bringing radical proposals to the table, forces a rethink of widely held beliefs. A new parliament is exactly the time for such big ideas, but this will also be a parliament that inherits a health and care system in a poor state; with a system that is trying to make ICSs ‘work’, for prevention, health inequalities and be a better partner – for combined authorities and others. So while this might not be the right time for such a significant change, this contribution makes it clearer than ever that ICSs really do need to be wired to succeed, on prevention, on health inequalities and partnership, otherwise bigger surgery could be on its way.