Health and social care devolution: the Greater Manchester experiment

Devolution: the development of the idea

England is one of the most centralised European states, with public services such as healthcare, education, criminal justice, transportation, and economic development largely delivered or controlled by central government.7 England’s 353 local authorities have a more limited role than municipalities in many other countries. Their budget is mostly provided by central government (only 25% is raised through local property taxes), which also closely oversees their performance. But it was not always like this. British local authorities were once powerhouses. Many decades ago they ran most public services, took a leading role in economic development, and established many local public utilities, and their political leaders were often senior public figures with national standing.8 However, successive national governments have stripped local authorities of their independence.

There have been two major initiatives to reverse this trend towards centralisation—the devolution of powers to new democratic structures in Scotland, Wales, and Northern Ireland in 1999, which has transformed UK governance,9 and the attempt to establish regional government in some areas of England in 2004, proposals that were rejected by the electorate in the north east and then abandoned.10 Four factors have led to the current enthusiasm for devolution:

• Devolution to Scotland and Wales and the recent Scottish independence referendum have sparked a wider debate about English governance11

• The centralised and London-centric nature of England’s political economy is increasingly seen as limiting economic growth outside London, leading to socioeconomic disadvantage for other cities and regions12 13 while London itself has benefited from the greater freedoms granted to the London mayor and the Greater London Authority14

• At a time of unprecedented constraints on public spending, the centralised, functionally fragmented model of public services is asserted to be inherently inefficient15

• Transfer of public health responsibilities to local authorities and the creation of health and wellbeing boards have developed capacity and networks and perhaps increased local government’s appetite for engaging with the healthcare system.

The government has responded by offering English regions devolution deals in which they can secure greater powers in return for some democratic reforms. Greater Manchester has had over two decades of stable leadership and close political cooperation between the 10 local authorities (box 1), making it well placed to secure an initial agreement on devolution over transport, planning, and housing. The agreement to devolve control of health and social care was a late and dramatic extension of the already ambitious devolution deal. Other devolution deals in Cornwall, Yorkshire, Birmingham, and London are in train, though most do not include health and social care, perhaps because of its scale and complexity.16

Of course, seen from an international perspective, plans for devolution of health and social care in England look rather less radical. Local and regional governments have a large role in the healthcare system in Sweden, Norway, Spain, Italy, and Germany, for example, though in the context of different political structures and traditions.17 Such devolution arrangements are normally spelt out in detail through primary legislation that defines the extent and scope of devolved powers (as has been done with devolution to Scotland, Wales, and Northern Ireland). Within England, no such legislative settlement is in prospect, and all the existing accountabilities and structures are to remain in place. Some would describe this as delegation rather than devolution because the transfer of powers being offered to Greater Manchester has no legal force and, unusually, involves delegation to a coalition of public bodies rather than to a single statutory authority.

What will devolution achieve and how?

The ambitious rhetoric about health and social care devolution in Greater Manchester is unambiguous in stating two main aims: to secure the greatest health improvement for the 2.6 million population and to reduce the health inequalities within Greater Manchester and between Greater Manchester and the rest of England. But it is not clear how this is to be done or how devolution will help to bring it about. The strategic plan for Greater Manchester, published in December 2015,18 sets out four high level reform themes: upgraded population health prevention, transformed community based care and support, standardised acute and specialist care, and standardised clinical support and back office services. It also describes new collective leadership and governance arrangements.

We have reviewed the published reports, papers, documents, and presentations from Greater Manchester leaders and identified what we think are the three intended mechanisms of action: subsidiarity and governance; integration around places and people; and efficiency and effectiveness.

Subsidiarity and local governance—At its simplest, this is the idea that decisions about Greater Manchester should be taken in and with Greater Manchester, rather than at a national level. But in fact it also means greater coordination and collaboration in decision making across the conurbation. The idea is to establish agreed mechanisms for making collective decisions that will stick and be clear about what decisions can be taken at, for example, a local authority or CCG level, and what needs a higher level of decision making. The new governance arrangements are designed to promote consensus based decision making on difficult issues such as resource allocation or service reconfiguration, making it more difficult for any organisation to defect. However, because all the existing accountabilities, regulatory arrangements, and performance management metrics remain, there is substantial potential for conflict between the collective purpose and the targets of individual organisations—local authorities, NHS trusts, etc.

Integration around place and people—The current system is seen as highly fragmented and vertically siloed, with complex governance arrangements and limited capacity to set strategic direction and act collectively at both local and national level. No-one seems to be in charge, and services and organisations follow their own agendas. As a result, transitions of care and care pathways across organisations do not work well. People find themselves interacting with a bewildering array of different and disconnected services, and there is little sense of geographical identity and service coherence or direction. Devolution, it is argued, will bring integration in governance, planning, and delivery of services. Integration seems to imply a strong focus on designing and implementing local care organisations to bring health and social care together, with common care pathways and ways of working across Greater Manchester using shared systems, resources, and back office functions. In the longer term, it might mean that the existing organisational structures of NHS trusts, NHS foundation trusts, and CCGs look increasingly outmoded.

Efficiency and effectiveness—Fragmentation produces waste, inefficiency, and poor effectiveness, and it is thought that devolution can produce savings by eliminating duplication and unnecessary service provision. Equally, it is suggested that current services are demand-led and demand-inducing, leading to spiralling levels of activity and cost, particularly in unplanned or urgent care; better service planning will lead to earlier intervention, better prevention, and more ordered care processes, especially for chronic disease and multimorbidity. The advocates of devolution emphasise that this is about much more than health and social care, and that changing those services means addressing worklessness, skills and training, schools, young people’s services, crime and offending behaviours, and more. They have a wider and more ambitious definition of health and wellbeing and argue that people have to take greater responsibility for their health. They estimate that without change, the continuing pressures of demand and existing barriers to efficiency and effectiveness will create a £2bn a year funding gap for Greater Manchester’s health and social care by 2020.4

What might stop it working?

The table sets out six of the main problems that devolution is setting out to address, the mechanisms by which stakeholders think devolution will help, and the intended effects. It also highlights, in the final column, what we think are some of the critical obstacles to success.

For example, there is widespread consensus that Manchester has an outdated, hospital- centric model of acute care, and major service reconfiguration is needed. Some change has been achieved over recent years in areas such as paediatrics, maternity, and emergency surgery, but it has been painfully slow. Devolution envisages both more radical and faster change, achieved through collective action and collaboration across the health economy. But can collective agreement be reached and sustained, and will the vested interests in the status quo really prove any more persuadable of the case for change? Will the new governance structures clear logjams and resolve dissent more effectively than past arrangements?

More radically, devolution advocates envisage closer working and greater integration across health, social care, and other public services. They point, for example, to the way that mental health problems cross criminal justice, housing, employment, health, and social care boundaries. The consequence of this might be to move resources from health services to other public services that have greater potential to improve mental health. Would healthcare providers and other stakeholders be willing to accept changes that disadvantage them in the interests of the greater good?

Lessons for elsewhere

The problems faced by Greater Manchester are being played out in health and social care systems across the rest of the United Kingdom, so it seems likely that the Greater Manchester experiment should hold some lessons for other areas. But devolution gives primacy to place and context, and the efforts to transfer learning need to take this into account. The mechanisms that work (or do not work) in Greater Manchester may do so because of its specific history, geography, context, and actors. This might reinforce the established tendency for local authorities and NHS organisations to be resistant to learning from and adopting innovations from elsewhere. Evaluating the effect of devolution is important, but it is not going to be easy, both because of the sheer number of concurrent initiatives and changes that are likely to confound empirical comparisons of most kinds and because of the unbounded, inherently ambiguous and fluid nature of the devolution project.19

The devolution proposals have already had a galvanising effect on the health and care system in Greater Manchester. Although there is a fierce debate about the benefits and disbenefits of this devolution deal and some distrust of central government devolving responsibility at a time of financial austerity, there is a widespread view that Greater Manchester should take greater charge of its own destiny. Yet our analysis suggests that devolution (or delegation) is a problematic and contested concept. The practical purposes and realities of devolution will become clearer over the coming months, especially as hard decisions and difficult choices are faced.

Senior leaders in both local government and the health and social care system have shown considerable courage in taking on the responsibilities and challenges of devolution, and have a track record of successful collaboration on which to build. Not for the first time in its history, people are watching Greater Manchester pioneering public and social policy changes, and where it leads, others may follow.