The handing of control of more than £6bn of health and social care spending to the Greater Manchester Health & Social Care Partnership is perhaps one of the most exciting developments in this area since the formation of the NHS nearly 70 years ago.
The partnership’s chief officer – Jon Rouse – certainly sees it in that context. Although he stresses the partnership’s powers amount to “delegation” rather than devolution, the former council chief executive says its aims are to put right “what we think was wrong from the start in the NHS” and enable “NHS and local democratic decision making to weave together”.
“Because our governance is headed by the politicians - [Wigan MBC] leader Lord Smith (Lab) is the chair of our partnership board - when we engage with the public about change we have already got that in principle commitment and decision from the locally elected leaders,” he says. “That is a very different environment in which to attempt to transformation.”
Having spent nearly three years at the Department of Health as director general for social care before taking up his current role, Mr Rouse has a unique viewpoint on why, despite all the time and energy poured into trying to work more closely together over recent years, the NHS and local government often struggle to see eye to eye.
He says that with the exception of the eight areas forging ahead by creating accountable care systems, “most” of the sustainability and transformation partnerships still have an approach of “‘we are NHS, we must engage local government’”. “That isn’t what we’re doing in Greater Manchester, we’re allowing local government to lead,” he adds.
“It has to be more than engagement. The engagement is with the pubic and the workforce; the relationship with local government should be one of equals.”
He said if other STPs had not got this message they should look at the fact recent NHS funding for transformation and capital plans went almost exclusively to Greater Manchester and the eight accountable care systems.
“There is a message here about the direction in which government and the NHS national bodies want to see areas travel,” he added.
Asked why so many in the NHS struggle to see local government, particularly local politicians, as equals, Mr Rouse says there are some “very big cultural differences” with the NHS more “hierarchical” and “technocratic” as a result of the “very high safety premium” on its services. Meanwhile, local government is more “tactical”.
“Local government is the more pragmatic of the two cultures, it’s also more advanced on the efficiency and productivity agenda,” he says. “On the other hand the NHS is much more advanced on use and application of business intelligence and evidence to make decisions.”
However, he said in Greater Manchester the maturity of relationships between councils, which have been formally working together as the Association of Greater Manchester Authorities since the 1980s, had been a big factor in the area’s success to date.
“In many other STP areas… it’s much more difficult because that join up isn’t there,” he says.
The recent election of Andy Burnham (Lab) as the first mayor of the Greater Manchester CA has added a new dynamic to politics in the city region. Despite having no official role in the partnership, Mr Burnham’s manifesto set out commitments on the health and care agenda, including plans to introduce a ’national care service’ for the area. This sparked speculation Mr Burnham’s arrival could spell trouble for the partnership.
However, Mr Rouse insists there is no conflict between Mr Burnham’s ambitions and the partnership’s plans.
“Whether the mayor’s got a formal statutory role or not he’s got the democratic legitimacy. This is somebody who won pretty much every ward in GM in all 10 districts,” he says.
The partnership has also committed to work with the mayor on his main manifesto objectives of improving school readiness and access to employment, tackling loneliness and isolation on older age, and reducing homelessness.
“We see ourselves as a major contributor to the mayor achieving those objectives and in return he gives us support in all sorts of ways, but particularly around engagement with the public and workforce and advocacy,” Mr Rouse says.
This focus on the wider social determinants of health is another area in which the work in Greater Manchester differs from many of the other STPs, although Mr Rouse says some of the accountable care systems, particularly Nottinghamshire and South Yorkshire and Bassetlaw, are also doing good work on this agenda.
“I genuinely am impressed by what I’ve seen in those [eight] accountable care systems and to some extent they are performing higher than we are on some elements of their integration programme. We no longer feel like a club of one.”
Having worked for both local and central government Mr Rouse says his current sub-regional role is the one he has “enjoyed the most” because the 2.8 million population of Greater Manchester was a “great size” to work with.
“You’ve got enough flex in the system in terms of the care pathways and the number of organisations in order to do mutual aid, move resource around, rethink services, do consolidation where that makes sense, do devolution to community level where that makes sense.”
Mr Rouse highlights reconfiguration of stroke services and the development of common standards for the assessment treatment and care of young people with ADHD across Greater Manchester as particular successes. The latter he said was not being done anywhere else in the country but was an issue local leaders chose to prioritise.
However, he said in common with most parts of the country urgent and emergency care was still tough to deal with. “That tests the partnership to its limits and we haven’t cracked it yet,” he added.