Devolution revolution

Meeting the health challenges of the 21st century may actually be achieved in Greater Manchester. What does that mean for the rest of the country?

The devolution of health to Greater Manchester was one of the more surprising and arguably the most innovative aspects of the Devo Manc deal. We at ResPublica were the first to recommend health devolution as a policy to follow in our Devo Max – Devo Manc report published in September of last year where we argued for the fullest possible devolution of area-based public spend to the Manchester City region. The fundamental argument for the devolution of health spend to competent authorities is, and remains, that only devolution can deliver the type of structural, institutional and cultural change that could create a health service designed for the problems of the 21st century rather than the 19th century.

And this failure to modernise our health service offer is the fundamental problem that I believe devolution has the potential to solve. Currently our health services are designed for a world of illness and disease that is no longer present. Our health system was designed in the 1940s to treat problems that derived from the 1880s. In 1948 when the modern NHS system was created, a 65-year-old would have had a life expectancy at birth of 44 years for men and 48 years for women.¹ No surprise then that the system was designed with this pattern of mortality and disease in mind. GPs would handle simple problems and large district hospitals would deal with the acute cases where people where either struck down by infectious epidemics, industrial disease or accidents and unfortunately patients usually died within six months of infection or diagnosis.

Today’s population
The NHS was understandably therefore founded on an acute care model, catering to the diseases and problems of the last century with an additional accident and emergency function to cope with industrialisation. Today however, life expectancy is 79 years for men and 83 years for women and it is growing each and every year. The population today ages slowly, lives with chronic disease, and its attendant co-morbidities, and need decades not months of attendant care. As a recent research paper pointed out: “Men aged 65 today have a seven-in-10 chance of needing some care before they die; women aged 65 nearly a nine-in-10 chance.”²
The disease profile of the population has dramatically changed: an estimated two-thirds of those who have reached pensionable age have at least two chronic conditions, and we are approaching a situation where people live 20 plus years after retirement. With such demographic changes the nature and intensity of our health demands has shifted by several orders of magnitude and for some conditions is set to rise exponentially. Obesity, diabetes, dementia, cancer, arthritis and mental health (especially depression) are driving the cost and demand pressures on the system to breaking point: around 15 million or 25% of the population in England suffer from long-term conditions and they account for around 70% of total NHS spend in England. In addition they account for 50% of all GP appointments, 64% of hospital outpatient appointments and 70% of all inpatient bed days. To put it simply 30% of the English population due to chronic conditions account for 70% of NHS England’s spend.

Out of touch
As is almost universally acknowledged by politicians and administrators, the current NHS system is not designed for this state of affairs and it is not coping well. All the money is hard wired into the hospitals and the acute service – very little of the overall spend (probably less than 2%) makes its way out to effective early intervention and community care. The current system is siloed, fragmented and has become a referral system that deals (often very badly) with symptoms rather than causes. The NHS as it currently is struggles to reform itself, institutionally nobody really is in charge, each part of the system is autonomous has its own rules and governance and can in effect declare independence from the rest. It is virtually impossible to realign the system without complete institutional redesign and that is, for me at least, the hope and promise of full place-based devolution of health services.

What devolution can bring
Devolution thus has a double or even a treble promise. First and most importantly it offers redesign and repurposing, the possibility of a 21st century health system focused around chronic rather than acute conditions and the manifestly better health outcomes that will result. Secondly, it will be far more cost effective, potential savings though yet to be quantified would if rolled out across England be in the order of billions. Thirdly, it offers the promise of expanding health into areas never before recognised as having decisive consequences for health and well-being. In this sense what is good for Greater Manchester is good for the country as a whole.

Greater Manchester
For Manchester what is on offer after April 2016 is the chance to manage some £6 billion of health expenditure, and commission and plan across the 10 Greater Manchester councils, 12 clinical commissioning groups (CCGs) and the NHS and foundation trusts a new integrated health service together with NHS England for Greater Manchester’s 2.8 million people. The aim is to turn round a situation where the city region’s residents have some of the worst health outcomes in the country to parity with the best. The focus is on early intervention, commissioning across primary and secondary care to force money out of acute into the chronic and by solving problems at source and preventing untreated demand escalating to hospital admission and intervention. Since so many of the chronic conditions derive from lifestyle and damaging patterns of eating or lack of exercise they can only be tackled in the community with behaviour change and advice and teaching offered early in the diagnosis. With diabetes for example it is helped by drugs but diet and exercise are vital for stabilisation. In terms of the third promise of new health interventions, it is now accepted by the Greater Manchester Combined Authority that employment is a heath indicator and a health outcome – so integrating welfare to work for example with mental health services is finally structurally possible. Other opportunities for intervention spring to mind, such as linking enforcement of home insulation in the private rented sector to doctors flagging to the councils where a parent desperately needs a warm home for themselves and their children.

A hopeful success
Manchester has been a vanguard region in this regard, it has created new shadow institutions to drive both strategy and implementation and the whole scheme will go live in April 2016. The challenges are mostly practical, they are ones of ensuring divergent institutions and command and control practices are allied to new reporting outcomes and matrices and creating the reward and incentives to collaborate. Interestingly, few challenge the conceptual arguments for devolution, the problems and the prizes are simply too great. If Manchester succeeds and the evidence mounts then this pattern will roll out everywhere, if it struggles and fails it is hard to know how we can redesign the NHS such that it is fit for purpose. If it succeeds and I suspect it will – then we will finally chart the pathway to a service that can meet the health challenge of the 21st century.

Phillip Blond, director of ResPublica.

References
1 Smith I.R and Smith S.K Away from the past and to a sustainable future. 2015. hsj.co.uk/Journals/2015/06/29/x/e/i/Away-from-the-past-and-to-a-sustainable-future.pdf (accessed 22 September 2015)
2 Forder, J. and Fernández, J-L. Analysing the Costs and Benefits of Social Care Funding Arrangements in England: technical report . 2012. eprints.lse.ac.uk/24977/1/Analysing_the_costs_and_benefits_of_social_care_funding_arrangements_in_England.pdf (accessed 22 September 2015).