Greater Manchester has announced its plans for health and social care devolution and its oversight of providers. Joy Furnival examines health and social care oversight functions across the UK and asks what Greater Manchester can learn from these.
Devolution and integration of health and social care in Greater Manchester (GM) is the first of its kind in England. GM is a conurbation with a population of almost 2.7 million, which is a million more than Northern Ireland’s, and a health and social care budget of approximately £6bn, which is similar to Wales.
The devolution arrangements are consistent with the goals outlined in the Five Year Forward View from NHS England, aiming to support the transformation of care in GM to reduce health inequalities and improve health outcomes and wellbeing for all GM residents. Initially, it was suggested that GM would develop its own oversight and regulatory system to support these plans, liberating GM from national requirements. However, the finalised devolution agreement indicated that GM oversight will be in addition to existing national regulation.
Whilst these plans are described as ‘breathtakingly’ radical in England, it is less so elsewhere in the UK. Wales, Northern Ireland and Scotland have been using integrated health boards since their devolution. (Northern Ireland has health and social care trusts). Across the three devolved nations there are a variety of approaches for regulation, oversight and scrutiny to ensure patient and public safety and the delivery of health and wellbeing.
In England there are three main regulators, each with its own purpose. Monitor, the sector regulator of NHS foundation trusts (covering two thirds of all healthcare trusts), is responsible for protecting and promoting the interests of healthcare users by promoting provision of efficient and effective healthcare services whilst maintaining or improving their quality. It also authorises and regulates foundation trusts. For non-foundation trusts, the Trust Development Authority (TDA) takes on a similar role for promoting efficient and effective services and ensures organisations are developing to become foundation trusts. The third national body is the Care Quality Commission (CQC), which regulates the quality and safety of care delivered by NHS trusts and foundation trusts, primary care and adult social care.
Across the devolved nations the oversight arrangements, superficially, are surprisingly similar. There are still many complex scrutiny and oversight bodies and devolution does not seem to have simplified this very much.
In Wales, care quality in health boards is scrutinised by Healthcare Inspectorate Wales and the Care and Social Services Inspectorate, with performance and delivery reviewed by the Welsh Assembly Delivery Unit. Similar functions are undertaken in Northern Ireland by the Regulation and Quality Improvement Authority (RQIA), covering health and social care, and in Scotland by Healthcare Improvement Scotland (HIS) and the [social] Care Inspectorate, both with a respective performance and delivery bodies.
Despite integrated health boards in Wales, Northern Ireland and Scotland, there remain separate bodies for scrutiny of health and social care quality, performance and finances, with some joint working. They face familiar challenges, linked to resourcing, consistency of approaches and partnership working – however, new approaches to oversight and scrutiny are emerging.
In Scotland, for example, there is recognition that integration between health and social care is changing the way services are delivered and thus how they need to be reviewed. Consequently, new – and lengthy, each takes 24 weeks – joint inspections for older people are now being completed in tandem with the Care Inspectorate and Healthcare Improvement Scotland. Whilst it is early days for this approach, it demonstrates the commitment to, and the complexity of, scrutinising health and social care services and offers insight as to ways that integrated services could be examined in GM across care pathways.
But what of this transformation and improvement? Won’t all these new powers and bodies and oversight in GM, just be new structures on top of old structures?
There is a risk that it will create more complexity and increase duplication of oversight, whilst fragmenting scrutiny expertise and reducing the consistency of approach needed to ensure patient safety. The Memorandum of Understanding between GM, NHS England and the Treasury – whilst revealing much of the ‘why change’ – reveals little of ‘how’ the new working arrangements will ensure programmes are implemented and evidence-based, new ways of working will be adopted to ensure the best health and wellbeing outcomes and consistently safe care.
GM could look to Scottish devolution. HIS has multiple roles, to both scrutinise through review and inspection against standards and also to provide evidence for best practice and to ensure improvements. It does this through traditional scrutiny activities such as inspections and reviews, but also, more radically, alongside the Scottish Quality Strategy. The Scottish healthcare regulator leads the Scottish Patient Safety Programme and is a key partner in the Scottish Quality Improvement hub, building skills, capability and support for staff and patients, to ensure staff and institutions know ‘how’ to deliver improvements, as well as the ‘what’ and ‘why’. This blends improvement science, evidence and scrutiny approaches for care oversight.
The prospect of further oversight in an already crowded and complex landscape seems almost like an additional burden for GM. However, new forms of oversight will be needed – nationally or regionally – to understand and hold accountable the complex ways in which GM plans to integrate care and work with partners to deliver its aims and health and well-being outcomes.
GM will need innovative solutions for future regulation, oversight and improvement in this area and existing devolution of health care offers learning as to how that may be enacted to ensure the benefits of devolution and health and social care integration are delivered for all the 2.7 million people who live in GM.