DevoManc’s control of health is at the centre of the government’s localism policy – but the policy is a sham, argues David Walker.
Lack of attention
Since the ‘historic day’ a year ago when the health secretary stood alongside the chancellor in signing the Greater Manchester health devolution deal, Jeremy Hunt has not – it’s fair to say – spent much time or attention on the project. Nor, it would appear (and more to the point) has the chief executive of NHS England, Simon Stevens.
It’s not that Stevens is uninterested in devolution or, better put, ways of organising the NHS at sub-regional level to secure better integration. Where elected local government fits is not unimportant, but less pressing than inserting acute hospitals into new geographies of care – except ‘inserting’ is too active a verb.
Who holds the purse strings?
Aside from finance, health administration is a mess of competing jurisdictions. On the ground, health services regulator Monitor (shortly to become part of NHS Improvement) is perceived by many providers as the main mover and shaper, through the ‘sustainability and transformation plans’ it is insisting they draft, with or without any local government participation.
Perhaps Greater Manchester councils have more profile than in other urban areas but the NHS still holds the purse strings. Greater collaboration must not be mistaken for some general movement towards devolving social policy.
For health, substitute education. The government proposes to change the criteria by which the centre allocates money to schools. “The funding shake-up will remove local authorities from the process, with cash going directly to heads.”
Cameron era ‘localism’
Education secretary Nicky Morgan would doubtless be able to claim cutting councils out is consistent with Cameron era ‘localism’. Heads and governors and parents are, she might say, more authentically local than councillors and officers.
If challenged about Cameron’s preference for chains of academy schools, she could respond that no chain is (yet) as big as a metropolitan district or shire county in the number of schools it runs, let alone a city region such as Greater Manchester.
The truth is, however, that Nicky Morgan doesn’t appear to feel herself under any obligation to defend the inconsistency of the Cameron approach to devolution within England. Whatever George Osborne says, despite the moves within the NHS, sincere commitment to move power away from ministers, especially financial power, is notably absent.
Even as voiced by the government’s policy intellectuals such as Michael Gove or Oliver Letwin, its ‘localism’ is a farrago. For Gove, the justice minister, accountability takes the form of prison governors competing with one another in leagues constructed by his department. Meanwhile Letwin airily (in a recent appearance before the Lords Constitution committee) talks of local governments: the deliberate plural encompasses police and crime commissioners as well as mayors and councillors, who can be safely left to fight it out amongst themselves.
Control and conspiracy theories
“Precise configurations and neatness” are less important than people having a sense of control, Letwin said. But ‘control’ is the antithesis of much of the government’s health and welfare policy. Andrew Lansley wanted, through the 2012 Health and Social Care Act, to abolish ‘control’ and substitute clinician competition. Control of a major component of infrastructure – housing and planning – has been removed from local government. New social policies – for apprenticeship for example – have been reserved for the corporate sector.
Some, conspiracy-minded people say the contradictions are far from accidental. They take their text from Letwin’s pronouncements over the years in favour of breaking down the state by sowing confusion in bureaucratic ranks and rendering accountability incoherent; they cite younger Tory philosophers such as Nick Boles, the skills minister, who lauded ‘chaos’ in public services as a means of clearing the ground.
Government is rarely so single-minded; it’s more a chapter of accidents – especially when departmental autonomy in Whitehall is more marked than ever.
Take the intervention by the chief inspector of schools, Sir Michael Wilshaw, criticising northern councils for failing to improve schools, without addressing the serial reductions in local authority involvement in school management and finance over the past decades – or the willed disjuncture between schooling, apprenticeship and vocational training that has recently been widening.
The Northern Powerhouse will ‘splutter and die’ if young people in Manchester and Liverpool lack skills to sustain it, Wilshaw said. “I am calling on local politicians, be they mayors, council leaders or cabinet members, to stand up and be counted, to shoulder responsibility for their local schools, to challenge and support them regardless of whether they are academies or not.”
Where’s the accountability?
Localism, he appears to be saying, means taking responsibility for services run by others, while finance is moved away from local government and (so successive studies by the National Audit Office and others have explained) accountability disappears into a Sargasso Sea somewhere between schools, academy chains, the Schools Funding Agency and Parliament.
In his pronouncement, Wilshaw displayed the true face of Cameron localism. It’s a tic, an opportunity for speeches; it does have political and philosophical content, but when it’s unpacked, there is little affirmation of belief in multi-purpose elected authorities, whether regional or citywide.
And for all the DevoManc chatter, those ‘purposes’ don’t include health.