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Devo Manc: five early lessons for the NHS Devo Manc: five early lessons for the NHS
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Related: The Manchester experiment is not the way to integration
When the chief executive of NHS England, Simon Stevens, describes the deal to devolve £6bn in health and social care spending to Greater Manchester as having “the potential to be the greatest act of devolution there has ever been in the history of the NHS”, we need to sit up and take notice. At a stroke, all those years of piloting and procrastinating around the NHS-social care boundary appear to have been solved by a memorandum of understanding (MoU)When the chief executive of NHS England, Simon Stevens, describes the deal to devolve £6bn in health and social care spending to Greater Manchester as having “the potential to be the greatest act of devolution there has ever been in the history of the NHS”, we need to sit up and take notice. At a stroke, all those years of piloting and procrastinating around the NHS-social care boundary appear to have been solved by a memorandum of understanding (MoU)
But have they? Even at this early stage of “devo Manc”, as it is known, there are five lessons for the rest of England.But have they? Even at this early stage of “devo Manc”, as it is known, there are five lessons for the rest of England.
1 Clarify the national-local settlement1 Clarify the national-local settlement
How much freedom will there be to depart from national policies? We are accustomed to the idea of a national health service with across-the-board rights, standards and targets, but there will be little point to the devolution package if regional discretion is effectively curtailed. If the model spreads across England, can we contemplate the existence of eight versions of the NHS? And it’s about responsibilities as well as powers: taking responsibility for NHS overspends and for sorting out the troubled line between healthcare free at the point of use and means-tested social care. The chancellor, George Osborne, and health secretary Jeremy Hunt would be very happy to devolve these political hot potatoes to pliant and cash-strapped local bodies.How much freedom will there be to depart from national policies? We are accustomed to the idea of a national health service with across-the-board rights, standards and targets, but there will be little point to the devolution package if regional discretion is effectively curtailed. If the model spreads across England, can we contemplate the existence of eight versions of the NHS? And it’s about responsibilities as well as powers: taking responsibility for NHS overspends and for sorting out the troubled line between healthcare free at the point of use and means-tested social care. The chancellor, George Osborne, and health secretary Jeremy Hunt would be very happy to devolve these political hot potatoes to pliant and cash-strapped local bodies.
2 Sort out governance arrangements2 Sort out governance arrangements
We know there is to be a regional strategic health and social care partnership board to oversee developments, alongside a joint commissioning board. Little else is clear. The guiding principle is said to be “subsidiarity”, but exactly what will be left with individual councils and clinical commissioning groups is murky, even though they will retain their existing legal responsibilities. Then there is the issue of who will actually be accountable for the £6bn budget. On the one hand, the Greater Manchester partners say this will be the responsibility of a newly created health and social care chief executive; on the other, Osborne has demanded the creation of an all-powerful elected mayor for Greater Manchester, who may have other ideas.We know there is to be a regional strategic health and social care partnership board to oversee developments, alongside a joint commissioning board. Little else is clear. The guiding principle is said to be “subsidiarity”, but exactly what will be left with individual councils and clinical commissioning groups is murky, even though they will retain their existing legal responsibilities. Then there is the issue of who will actually be accountable for the £6bn budget. On the one hand, the Greater Manchester partners say this will be the responsibility of a newly created health and social care chief executive; on the other, Osborne has demanded the creation of an all-powerful elected mayor for Greater Manchester, who may have other ideas.
3 Ensure providers are signed up3 Ensure providers are signed up
The parties to the agreement are the regional commissioners. The position of providers is less clear, though they have all attached “letters of support”. The MoU baldly states that “during 2015-16 providers will establish an agreed form of arrangements to enable them to provide a collective and positive response to the requirements of the shadow joint commissioning board”. This has all the ingredients of a political minefield, with GPs already complaining of being excluded from decision-making. Ultimately most services are locally delivered by relatively autonomous professionals whose commitment to a new strategic vision needs to be secured.The parties to the agreement are the regional commissioners. The position of providers is less clear, though they have all attached “letters of support”. The MoU baldly states that “during 2015-16 providers will establish an agreed form of arrangements to enable them to provide a collective and positive response to the requirements of the shadow joint commissioning board”. This has all the ingredients of a political minefield, with GPs already complaining of being excluded from decision-making. Ultimately most services are locally delivered by relatively autonomous professionals whose commitment to a new strategic vision needs to be secured.
4 Engage with the people4 Engage with the people
The fact that the programme involves some accretion of power by democratically elected councils at the expense of unaccountable NHS bodies has perhaps served to obscure the issue of democratic governance. Citizens, patients, service users and carers appear to have had no voice in the unfolding arrangements. Indeed already there is a public campaign of protest, with a rally set to take place in central Manchester at the end of this month. After-the-event consultation may be a quick route to decision-making, but is rarely the best.The fact that the programme involves some accretion of power by democratically elected councils at the expense of unaccountable NHS bodies has perhaps served to obscure the issue of democratic governance. Citizens, patients, service users and carers appear to have had no voice in the unfolding arrangements. Indeed already there is a public campaign of protest, with a rally set to take place in central Manchester at the end of this month. After-the-event consultation may be a quick route to decision-making, but is rarely the best.
5 Get the politics right5 Get the politics right
The NHS is inherently political and it is naive to think these changes can be passed off as somehow technocratic. Powers over the NHS didn’t even figure in Osborne’s wider devolution agreement with Greater Manchester as recently as November 2014, yet only a few weeks afterwards the NHS devo Manc bombshell exploded without warning. Although most of the councils involved are Labour-controlled, the local MPs appear to have been kept in the dark.The NHS is inherently political and it is naive to think these changes can be passed off as somehow technocratic. Powers over the NHS didn’t even figure in Osborne’s wider devolution agreement with Greater Manchester as recently as November 2014, yet only a few weeks afterwards the NHS devo Manc bombshell exploded without warning. Although most of the councils involved are Labour-controlled, the local MPs appear to have been kept in the dark.
This situation is even more remarkable given that several of Labour’s frontbench health team – including the shadow health secretary, Andy Burnham – are members for Greater Manchester constituencies. Labour has long been beavering away on a national strategy for locally integrated care and seems to have been taken unawares. Meetings with all 22 of the region’s Labour MPs have now been held to “avoid further potential disagreements”, but a battle between local MPs and regional and local partners is hardly the best way to launch a major new initiative.This situation is even more remarkable given that several of Labour’s frontbench health team – including the shadow health secretary, Andy Burnham – are members for Greater Manchester constituencies. Labour has long been beavering away on a national strategy for locally integrated care and seems to have been taken unawares. Meetings with all 22 of the region’s Labour MPs have now been held to “avoid further potential disagreements”, but a battle between local MPs and regional and local partners is hardly the best way to launch a major new initiative.
Related: Manchester’s plan has implications for the whole NHS
There is no doubting the significance of NHS devo Manc, and it may well be that this sort of “scale and pace” approach can bring greater success than the incrementalism of the past 40 years. Osborne has said the agreement “sets a trail for the rest of the country to follow”. If so it is a route that needs to be tread with the utmost caution. Devolution and integration are wonderful leitmotifs, but are unlikely to be achieved at the stroke of a pen.There is no doubting the significance of NHS devo Manc, and it may well be that this sort of “scale and pace” approach can bring greater success than the incrementalism of the past 40 years. Osborne has said the agreement “sets a trail for the rest of the country to follow”. If so it is a route that needs to be tread with the utmost caution. Devolution and integration are wonderful leitmotifs, but are unlikely to be achieved at the stroke of a pen.