SS DevoManc has now set sail after a six weeks stopover in port during the general election. Dr Lawrence Benson tries to plot its course.
Let’s recap on DevoManc. It’s about the devolution of power and resources from Westminster to the city region of Greater Manchester (GM), including for health and social care. This marks a radical policy departure for England. The prompt for this was perhaps the 2014 referendum in Scotland, as well as George Osborne’s Northern Powerhouse idea.
From April next year, GM will manage resources for health and social care, without being performance managed and controlled by NHS England, the Department of Health and ministers. This is both new and novel, for the English NHS and social care. But the flag that SS DevoManc flies proudly bares only two words: ‘People and Place’. This ship’s passengers are those living in GM
Professor Julian Le Grand reminded us when interviewed in 2002 on BBC Newsnight that “When (Nye) Bevan set up the NHS in 1948 he said the great thing about the new NHS is going to be if a bed pan falls off the bed in Northampton its sound will reverberate throughout the House of Commons. The whole problem since then has been the House of Commons has been deafened by the sound of falling bed pans. It is ridiculous when the Prime Minister has to stand up and defend the action of one particular hospital, one particular occasion, in respect of one patient.” DevoManc addresses this issue directly.
With the general election over – and the Tories in power for five years without the Liberal Democrats – the DevoManc policy is likely to proceed at full pace. Alistair Burt becomes the new health minister in place of the Lib Dems’ Norman Lamb, who was passionately committed to integrated care. Let us see if Burt has the same determination to tackle the systemic problem of poor health and social care integration. With the SNP obliterating the Labour Party in Scotland, devolution is more than ever a government priority, as Prime Minister Cameron stressed in his speech on the steps of 10 Downing Street. DevoManc and the Northern Powerhouse form part of a picture of further devolution across the four UK nations.
I expect Greater Manchester’s politicians, together with George Osborne, health and social care senior managers and NHS England, to refine the design and implementation of DevoManc. After this brief period of uncertainty it may be full steam ahead for the good ship SS DevoManc.
This ship’s journey, though, involves navigating and ploughing through seas where the route is only partially plotted and the icy wind of austerity politics is felt by crew and passengers. Its comfort may be affected by further public service cuts, many falling on local authorities. The NHS is expected to make massive savings for the duration of the new parliament. Brief sunny spells are expected for the NHS (though not social care) from the £8bn promised by the Tories in their manifesto and repeated by Jeremy Hunt after the election.
Greater Manchester is changing its path and direction, which means learning new behaviours and adopting new routines when commissioning integrated health and social care. Policy academics have observed that changing the established path requires huge energy and continued focus by leading participants, in this case Greater Manchester. Systems that change course are often dragged back to their original direction as they can be ‘path dependent’ – so the SS DevoManc may not be able to resist powerful undercurrents. Active support from the Treasury and NHS England is essential, as DevoManc sets a very different course from the remainder of English NHS.
Some of the crew of SS DevoManc may have previously embarked on a similar journey on the SS Health Action Zone – scuppered more than 10 years ago on the orders of government.
The SS DevoManc may now want to radio ahead the captains of other vessels which have previously navigate rough seas using local democratic systems for health and social care. If the captain and crew of the SS DevoManc look outward, they can find many countries which have mature systems of devolved health and social care, using governance structures with local democratic inputs. In distant seas, the SS DevoManc could make contact with the Nordic countries,including Finland and Sweden, that serve as exemplars to this English policy experiment.
The Nordic countries have a long tradition of local public leadership and control over health and social care. In many cases this is commissioned and delivered at the county or even the town / municipality level. As a result, there is a local democratic input to the governance of these organizations that is absent in the English NHS.
If the Captain and crew have a limited budget or not much fuel aboard, they might look across the Irish Sea to Northern Ireland. There they will find decades of integrated structures for health and social care. They could veer due North and engage with the Scots, with 17 years’ experience of national devolution.
The World Health Organisation’s European Health Observatory is a very helpful source to compare health care systems. It is easy to compare and contrast the proposals for DevoManc with those of other health care governance systems internationally by clicking here.