NHS devolution in Greater Manchester turns one on Saturday, but it is not a birthday many will mark. When the Fabian Society questioned Mancunians for a new report, Local and National, they knew almost nothing about the initiative. Health devolution, it would seem, is happening behind closed doors, decentralisation without democracy.
That seems rather odd to those familiar with the mantras of localism. Devolution is meant to be about bringing power to the people by passing responsibilities to places where there is local transparency, scrutiny and public participation. That is the point of the new metro mayors being introduced in May.
So far, the experiment in Greater Manchester has a different rationale, and the new mayor will only be involved on the margins. It is an attempt to rewire local and regional health economies, by allowing local agencies to work out for themselves how to integrate and reconfigure. This is leading to Greater Manchester councils and the NHS establishing joint commissioning and joint bodies to deliver social care and community healthcare, and embarking on a major reorganisation of hospitals.
The powers and money devolved to the region are important, but so too is the political energy the buzz of devolution has brought to the local public sector. Local leaders are also seeking to align health decisions with their other responsibilities, to ensure each public service promotes good health. This is likely to be where the new mayor comes in, to knock heads together when the temptation is for different agencies to pursue their own paths.
So far this is a purely technocratic, private process. In the 12 months since Greater Manchester was handed new powers, NHS managers, council officials and elected members have been hard at work. But to residents, health devolution is invisible and local MPs and voluntary sector leaders are starting to grumble.
That’s a shame, because the Mancunians we brought together in discussion groups were pretty positive about their city region gaining NHS powers. Many of them saw it as “a coup for Greater Manchester” and all firmly believed that decisions about the city should be made there. They felt that local decision makers understood their communities better and would be easier to hold to account than “some faceless bureaucrat down south”.
But they were concerned about lack of transparency. They understood that experts needed to run complex services like the NHS, but they wanted to be better informed. While they didn’t think residents should call all the shots, one said it mattered that “local people are represented, not just local councils”. She wanted “local people somehow representing different parts of Greater Manchester, or different illnesses … people who’ve got really good local connections, and the skills to have some influence”.
This scepticism about councils was widely shared and will be a significant challenge to the development of health devolution, which is as much about councils getting involved as passing powers down from the centre. Some of the people we spoke to appreciated that councils should be involved in joining up services and preventing ill health. But many felt that councillors did not understand the health service and were poor at communicating with constituents.
They were even more doubtful about whether the new Greater Manchester mayor should influence NHS decisions, although the conversations took place many months before the post comes into being.
The endorsement for devolution we heard in Greater Manchester is not universal. When we spoke to a similar group in Newcastle, they were much more sceptical about the ability of local leaders to do better than national decision makers. They worried about what would happen if the money ran out and said they would rather “wait and see” than follow in Greater Manchester’s footsteps.
But across the country most people think the NHS would do better with more local power. In a Fabian Society/You Gov poll of adults in England, conducted in the autumn, 46% agreed with the statement “if healthcare was managed locally, services in my community would be better”, while only 18% preferred the alternative statement “healthcare is best when national leaders and organisations are in control”. This is the first evidence that there is latent appetite for health localism nationwide.
However, we also found it will only be possible to secure public support for NHS devolution if it happens in a way that avoids the dreaded “postcode lottery”. In the discussions in Greater Manchester and Newcastle, participants refused to accept inequality in standards or entitlements: “Everybody should be entitled to the same level of care, and the same services, regardless.”
And the results from our England-wide survey were just as emphatic. Just 17% preferred the statement “different communities have different needs so healthcare should be different in different places” while 71% chose the alternative, “healthcare should be the same across the country so nobody loses out”.
Localists have been warned. The public is ready to hear arguments that devolution and integration can improve local care. But without guarantees of national consistency, NHS devolution will fail the test of public opinion.
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DevoManc anniversary gives little cause for celebration | Andrew Harrop
