“This has the potential to be the greatest act of devolution… in the history of the NHS.”
These were the words of NHS England chief executive Simon Stevens, following the announcement that Greater Manchester was receive its own £6bn annual NHS budget.
However, there is growing evidence that this potential is yet to be realized. New analysis from the Institute for Public Policy Research finds that health ‘devolution’ in Greater Manchester is in fact much closer to delegation, with central government clinging on to control.
The clearest example of this is the Warner Amendment to the Cities and Local Government Devolution Act 2016, which states that it is Jeremy Hunt, as health secretary, rather than the Greater Manchester Combined Authority or Greater Manchester’s directly-elected mayor, who is ultimately accountable for health and care in the region. Furthermore, existing organisational statutory responsibilities have been retained in Manchester, meaning clinical commissioning groups and foundation trusts will still be accountable to Whitehall rather than to local leaders.
Why does this matter? Primarily because real devolution of the health system has the potential to drive significant improvements in health and wellbeing in Manchester. For example, devo-health could act as a catalyst for much-needed reform in the NHS by empowering leaders to make change on the one hand and making them more accountable on the other. However, this will only occur if local leaders feel they have the power, and the responsibility, to shake the system up.
Likewise, the NHS is being ‘devolved’ alongside a range of other public services including transport, welfare, criminal justice and housing policy. This alignment of powers at the local level could allow local leaders to join up public services in order to create a more preventative health system that effectively targets the social determinants of health, such as obesity, smoking, and air pollution.
However, as it stands, the new mayor, who will control many of the other devolved functions, will have a limited role in health, which may well inhibit the pooling of budgets, the joining up of regulation and the creation of a truly place-based healthcare system.
There is no doubt the ‘protections’ aimed at retaining central control of the health service, such as the Warner Amendment, are well intentioned. But there is a significant risk that far from saving the NHS, they will endanger it by giving Whitehall an excuse to cling on to power, and local leaders a reason to sidestep the difficult task of reforming the system.
Devo-health will only deliver if it enables the creation of a radically new health and wellbeing system. Over many years, ministers in Whitehall have been unable to achieve this, so why not give newly elected mayors a go?
Harry Quilter-Pinner, researcher, IPPR