Today, Greater Manchester becomes the first region in England to be given new powers in the devolution of health and social care services from national government to regional decision-makers. But what makes this region’s devolution project so exciting is that its ambitions go way beyond the integration of health and social care, says Helen McKenna.

Halfway through the most financially austere decade in its history, with hospital deficits widespread and the dispute over the junior doctors’ contract still unresolved, the NHS could be forgiven for feeling it does not have much to celebrate. Talk of empowering health professionals and setting hospitals free to innovate (motifs of the Lansley reforms) have been swept aside in favour of a return to top-down command and control in a desperate attempt to prevent the Department of Health overspending on its budget.

Bucking the trend

Yet one region appears to be bucking this trend. While the NHS is caught up in negotiations with the national bodies over the complexities of the annual planning round, Greater Manchester is gearing up for what has been described by NHS England’s Chief Executive Simon Stevens as ‘the greatest integration and devolution of care funding since the creation of the NHS in 1948’. From today, health and social care services in Greater Manchester are being overseen locally by a new Health and Social Care Strategic Partnership Board, made up of all NHS organisations and local authorities in the area, as well as other key stakeholders including the voluntary sector and patient groups.

Although what is currently happening in Manchester is technically more a case of delegation than devolution, particularly as formal accountabilities will remain with the national NHS bodies, it is nevertheless a far cry from ‘business as usual’.

For a start, several national budgets (including for some specialised services, public health, pharmacy and secondary dental services) will be delegated from NHS England to Greater Manchester. The region will also take on responsibility for £450m of ‘transformation funding’ over the next five years, with the freedom to invest in initiatives aimed at delivering the clinical and financial sustainability of local health and care services.

Perhaps the most important change, however, will be greater local determination over matters relating to health and care – from 1 April, the principle that “all decisions about Greater Manchester will be taken with Greater Manchester” will apply. While this may not (yet) be full devolution, what it does mean is that Greater Manchester will have a seat at the national table when decisions are being taken which impact on it.

Postcode lottery

While some commentators have expressed concerns that the devolution agenda risks creating a postcode lottery in relation to health access and outcomes, it is important not to overlook the fact that variation is already a feature of the NHS (as documented in the NHS Atlas of Variation series) In fact, mortality rates (adjusted for age) in Greater Manchester are so much higher than the national average that health officials equate them to a jumbo jet full of passengers crashing into the region nearly every month. Considered in this context, it is not surprising that the area has pushed for greater control over its own fate – sticking with the status quo does not appear to be a winning strategy (in terms of health outcomes) for the people of  Manchester.

Here at The King’s Fund we are cautiously optimistic about the changes currently taking place. In exchange for more of a say over its own future, Greater Manchester is promising to deliver changes to health and care services that we and many others have long been calling for. In its final report, the Barker Commission called for an end to the historic division between health and social care, suggesting that local authorities and NHS partners integrate their budgets and create a single commissioning function. The work in Greater Manchester appears to be bringing this vision to life, enabling genuine integration across health and social care.

But what makes Greater Manchester’s devolution project so exciting is the fact that their ambitions go much further than the integration of health and social care to consider public services in the round. This creates the opportunity to look beyond the role of health services in determining health outcomes to the (far more influential) wider social determinants of health – for example, the roles of early years, education, employment and housing. In taking this approach, Greater Manchester has recognised that the current focus on treating rather than preventing ill health limits the gains that can be achieved for communities, and that only by considering all of the elements that influence health can inequalities in health and well being be properly addressed.

• For more analysis of devolution by The King’s Fund, please visit: http://www.kingsfund.org.uk/publications/devolution

• To mark Greater Manchester being handed control of its £6bn health and social care budget, we’re running a series of blogs from leading commentators on what it really means for the region. Read more on Devolution issues.