Devolving health and social care decisions to local politicians and professionals adds further complexity to an already complex system – and does not guarantee that the correct or popular decisions will be taken – argue Julia Segar, Anna Coleman and Kath Checkland.

‘Keep Wythenshawe Special’ is a campaign led by clinicians from Wythenshawe Hospital. A protest march, a judicial challenge and an ongoing campaign supported by local MPs, are responses to a decision to site some specialist services at Stepping Hill Hospital, rather than at Wythenshawe.

This decision is part of the Healthier Together programme which seeks to rationalise hospital care across Greater Manchester (GM) ensuring equality of provision across the conurbation. Hospitals are to work together, forming networks and sharing consultant expertise.

To this end, hospitals across GM have been placed in four groups and within those groups ‘specialist’ and ‘local’ hospitals have been identified. This decision, that so dismayed Wythenshawe Hospital clinicians, came after lengthy deliberation including an extensive public consultation. The decision makers were representatives of GM’s 12 Clinical Commissioning Groups (CCGs).

Local decisions by local people?

Why should this protest be seen as anything other than a local grumble? In fact, it has great significance in light of the devolution of health and social care that is one part of the Devo Manc initiative rolling out on 1st April.

Healthier Together predates ‘Devo Manc’, but is also seen as a crucial part of health and social care devolution. A common mantra of those working to achieve devolution is that decisions affecting the people of GM, should be made in GM, by GM people.

Health ‘Devo’ enthusiasts argue that sharing local expertise and co-operation across GM, as embodied in the initiative, will enable joined up services and pooling of budgets resulting in efficiencies.

There is already a strong and positive history of GM practitioners successfully working together across both health and social care. This positive track record coupled with a sense of being ‘Greater Manchester’ people, is buoying up the proponents of health and care devolution. However, there are also obvious challenges and tensions to be faced in the immediate future.

Lines of accountability

The Keep Wythenshawe Special campaigners have argued that there has been a lack of accountability in the Healthier Together decision-making process. Leaving aside the particular case of Wythenshawe Hospital, we would argue that the lines of accountability within the new structures and organisations for Greater Manchester’s health and social care devolution are complex and blurred.

Even without devolution, health and social care organisation is downright complicated. The reforms brought about by the Health and Social Care Act 2012 caused a huge upheaval. Organisations like Primary Care Trusts which planned and commissioned hospital care were dismantled and new organisations, CCGs, were created. Responsibility for many aspects of local public health moved from NHS organisations into local authorities; and new national level organisations, NHS England and Public Health England were formed.

In the few years since these reforms were instituted, further re-organisations and shifts in responsibilities have taken place. Clinicians, managers and public health professionals have been moved into, out of and between organisations and the speed of these changes has been breath taking.

Further complications

All over the UK the dust is still settling on the 2012 reforms, but in GM a whole new tier of organisational structure has also been formed to deliver health and social care ‘devo’. Across Greater Manchester there are 12 CCGs, 10 local authorities, 14 hospital trusts, 1 ambulance trust, and 1 NHS England team. The Greater Manchester Health and Social Care Strategic Partnership Board has been formed with representatives from all these organisations. Under this umbrella sit two new partnership groups: a Joint Commissioning Board which brings together all local commissioners of health and social care services and a Federation Board which brings together all the major health and social care providers.

How these structures will operate in practice is not yet clear; what is clear is that an extremely complicated system has received a further dose of complication.

The issues of accountability are particularly complicated. For example, CCGs are accountable for aspects of their performance to NHS England, but they are also membership organisations and so their governing body is accountable to their member GP practices. In addition, most CCGs declare on their websites that they are accountable to their patients, and they remain subject to the dictates of a variety of regulatory bodies, such as NHS Improvement.

Co-operation and competition

Greater Manchester’s CCGs, along with their partners, have now taken on a commitment to look beyond the interests of their own members and patients and take a broader view. Likewise, hospital trusts are being called upon to undertake more co-operative work. This runs counter to the imperative for hospital trusts to compete with one another and for commissioners to seek the best way to spend their resources by choosing between providers. Local authorities have a very different management structure, with locally elected political leaders adding yet more different ways of thinking about what it means to be accountable.

Taking all this together, it is far from clear how the different incentives, objectives and regulatory pressures experienced by individuals and their organisations can be reconciled in order to deal with difficult and contentious decisions.

Thus we return to ‘Keep Wythenshawe Special’. The Wythenshawe clinicians feel that their hospital has been downgraded and their unsuccessful legal challenge was brought against the 12 Greater Manchester CCGs with whom the Trust now sits on the GM Strategic Partnership Board. This example illustrates some of the in-built tensions in the system.

Organisations accustomed to viewing one another as competitors must now become more closely allied and local accountabilities will have to be weighed against the responsibility under ‘Devo’ to consider the wider needs of the GM population.

• These issues are further explored in a special Devolution issue of the journal Representation which brings together expert analysis from academics and practitioners in the field. Subjects explored will range from the role of the Mayor to transport and from housing to health, as well as the complexity of relationships within the new GM health and social care structures.

• In the run up to 1 April, when Greater Manchester is handed control of its £6bn health and social care budget, we are running a series of blogs from leading commentators on what it really means for the region. Read more on Devolution issues.