By James Tout on 26 Feb 2015
Other major cities will soon be demanding their own health devolution plan
Greater Manchester’s town hall politicians were doubtless popping the champagne corks to news that they are to be handed the entire NHS budget for the region.
After all, this first large scale pooled NHS and social care budget, worth £6bn puts real meat on the bones of devolution to England’s cities and regions.
It also further cements Manchester’s title of “second city”, validating a long-running PR effort to steal Birmingham’s crown.
Ostensibly, this is a shrewd pre-election move to show that the government is delivering on David Cameron’s pledge, made on the steps of Downing Street the morning after Scotland’s rejection of independence in September, for greater decentralisation within England, which is currently the poor relation when it comes to power sharing.
If delivered as set out, it would also create a huge pilot project for the hoped for integration of health and social care set out in NHS England boss Simon Stevens’ NHS Five Year Forward View.
The detail of quite how things will work is still sketchy, however. The Greater Manchester Combined Authority, or the GMCA as it has become known, is made up of 10 councils and 12 CCGs, between which health and social care budgets are split at present.
Already, local CCGs and councils have banded together to start integrating care through the Healthier Together campaign.
But the onus will now be on them – and local politicians – to speed up the process in readiness for taking responsibility for health spending from April 2016.
All of this will happen before the scheduled election in 2017 of the first “metro mayor” for the GMCA area, who is also expected to assume overall control over other key areas such as education and transport.
So far, Greater Manchester has managed to present itself as northern England’s beating heart, and its swagger has allowed it to become the golden child of English devolution.
But there are already fears that the process is being rushed through to appease local opinion and that Greater Manchester is not yet ready to manage the new combined budget.
Furthermore, its trailblazer status cannot last long. Other large cities – Birmingham, Leeds, Newcastle or Bristol – will very soon be demanding the same kinds of concessions from central government.
A cynic might say that central government will be more than happy to oblige – especially a re-elected Tory government.
David Cameron and George Osborne are all too aware that with power comes responsibility. And if that responsibility – especially for the hot potato of the NHS – can be shifted on to local leaders in Labour-controlled councils, so much the better.
Passing the buck
Politically, Greater Manchester is virtually a one party state, with most of the 10 local authorities solidly Labour.
In that respect, as in population and the size of its health and care budgets, it’s broadly similar to Wales, where health is already a fully devolved matter.
In recent months, the NHS in Wales, run by Carwyn Jones’ Labour administration in Cardiff, has come in for a barrage of abuse from Mr Cameron and parts of the right wing media.
Wales performs significantly worse than England on everything from accident and emergency waits to ambulance response times, and from referral to treatment to diagnostic tests, a report by the House of Commons Library has shown.
The furore has turned the NHS in Wales into a political football – although perhaps rugby ball would be more apt.
As health is devolved to Manchester and other Labour voting cities, are we not in danger of seeing the same pattern replicated elsewhere?
It is not too far fetched to imagine that once local political leaders get their hands on NHS funding, they may choose to spend it very differently to how the national government might like them to, as has happened in Wales and Scotland.
Now, it may be that having local control over allocation of budgets, tailored to the health and social care needs of different demographics around the country, will work well for different populations – as has arguably happened in Scotland with flagship schemes such as free personal care for the elderly.
However, if things do not turn out rosy, expect the recriminations to start soon.
We can also expect more complaints of a “postcode lottery” for health and care services as different regions set different priorities.
“Once local political leaders get their hands on NHS funding, they may choose to spend it very differently”
In short, the deal with Manchester may turn out to be a Pandora’s box.
We could be on the verge of witnessing a further balkanisation of the NHS by region. Tribal politicians will regard their new fiefdoms as playgrounds in which to experiment, while simultaneously slinging mud at their opponents when divergences start to appear, as they surely will.
You may see this as a worthwhile trade off for gaining control over the cash.
But as the Scottish referendum showed us, the NHS lends itself to being scrapped over. Anyone hoping for “no more games” with the health service can kiss that dream goodbye.
First published in Health Service Journal on 26 February 2015.