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Great expectations

Great expectations
22 April 2016

Greater Manchester now has full control of its health and social care budget, but what plans do the region’s leaders have in place. How will other areas plan to take on such a responsibility for its population? 

Greater Manchester now has full control of its health and social care budget, but what plans do the region’s leaders have in place. How will other areas plan to take on such a responsibility for its population? 

Healthcare devolution is arguably one the biggest changes for the health service in England since 1948. Is it another step forward towards achieving, the chief executive of NHS England, Simon Steven’s ambitious vision for a modern health service, or the end of the NHS as we know it?
Manchester, Liverpool, Hampshire, Cornwall and London are all in line for devolution – arguably one of the biggest shake-ups in the history of the NHS. Empowering local decision makers and breaking down the barriers between health and social care are just some of the aspirations for this bold move.
Fans claim that devolution will also help tackle community issues that can often fall between the gaps of an increasingly fragmented and bureaucratic system.
It’s a radical solution, but with the Public Accounts Committee claiming that “there is not yet a convincing plan in place for closing the £22 billion efficiency gap”, it seems doing nothing isn’t an option at all.
As the eyes of the NHS fix on Manchester this spring, we take a look at the past, present and future for devolution, and whether it is the answer.

Grand experiment
Described by the novelist George Orwell in The Road to Wigan Pier as “the belly and guts on the nation,” Greater Manchester (GM) could now be better described as the beating heart of George Osborne’s, chancellor of the exchequer, northern powerhouse. Emerging from its industrial past, the city has been reinvigorated, and is – from April this year – the test-bed for an ambitious plan to devolve responsibility for health and social care to local leaders.
The opportunities for devolution are genuinely transformational, with Manchester the first system given the opportunity to trial them. Since signing an agreement in November 2014, Greater Manchester has had less than 18 months to develop its business plan for integrating health and social care. It has also needed to create a management system and a cooperative culture capable of managing a combined health and social care budget of £6.2 billion and looking after the health of 2.8 million people.
It’s not just Manchester who wants to take control of their own, Cornwall has since become the first rural county to be invited to develop a business plan for devolution – a process that’s due to come to an end this year. In late 2015, Jeremy Hunt, secretary of state for health, announced five pilot projects in London to test the feasibility of devolution, with Liverpool and Hampshire also exploring the possibilities offered with greater freedom from Whitehall.
In total more than 20 organisations have expressed an interest in taking on at least some devolved powers for managing healthcare locally. It remains to be seen how much power Whitehall is willing to relinquish.

A new relationship
“Devolution is part of a natural process,” says an excited Warren Heppolette, strategic director of health and social care reform for Greater Manchester. Cooperative working across the city has a long and successful history. One key milestone in the process was the creation of the Greater Manchester Combined Authorities (GMCA) in 2011, which apparently helped gain Osborne’s support for devolution.
Fundamental to the Devo Manc model is the concept of place-based care. It’s a care model described in GMCA’s glossy promotional material as a “shift from a system, which has too much reactive, expensive and institutional care to one which enables, encourages and promotes health and well-being through place-based, integrated working”.
According to Heppolette, it’s about sharing a more holistic view of health; recognising that the determinants of health and well-being are much broader than have previously been considered. It’s clearly inspired by the ‘new relationship between patients and communities outlined in the Five Year Forward View.
In fact, the Forward View runs throughout Devo Manc, with those involved keen to explain how the boundaries between organisations are often the boundaries to effective care. Only through integration and a shared understanding and will to tackle them that any real impact can be felt.
The organisation has already announced a number of proposals for the area, including – perhaps inevitably – a commitment to providing seven-day primary care across Manchester, as well as making some bold pronouncements like wanting to see 6,000 fewer people with cancer, and increasing support for the 25,000 of people with mental health conditions.

The management challenge involved in devolution is quite staggering. GMCA brings together the region’s 12 clinical commission groups (CCGs), 15 NHS providers, 10 local authorities and NHS England. All will want a say on how healthcare is delivered.
“There are a lot of meetings,” exclaims councillor Sue Murphy, one of the members of the Strategic Partnership Board Executive. There’s also a Strategic Partnership Board, joint commissioning board, local district meetings and potentially a host of others.
It’s easy to imagine a growing bureaucracy, but Murphy is keen to point out that’s not the case. “There’s a small team of staff at GM [Greater Manchester] level, mostly seconded from partner agencies, with an acting chief officer.” The lack of a permanent chief office has been identified as a significant risk, but Murphy is keen to point out it has been addressed. “We’re about to appoint a permanent chief officer, and the rest of the permanent appointments will follow on from that,” she adds.
It’s a potentially confusing system, but one that – at the moment at least – seems to function. Structures and systems are important, but it’s at the local level where the benefits of devolution should be felt most acutely. Thankfully it’s where the decisions are being made too.
The Greater Manchester area has been carved up into 10 localities, each of which has been asked to create five-year plans for health and social care and wider public service reform, which have been developed and agreed between commissioners and providers within each locality.
Decision making at local level is the most effective. These aren’t just words. The intention is to pool up to £2.7 billion of health and social care spending at locality level across GM to make these plans a reality. This money won’t go to shoring up the cash-strapped acute sector, but will genuinely be used to help transform care.
In addition to this, Greater Manchester has been given £450 million in transformation funding by NHS England to help deliver the ambitious plans for the region.
Devolution isn’t a no strings attached offer to take charge, the need to tackle a forecasted £2 billion deficit is at the forefront of the agreement.
When asked how the money will be spent, it’s reassuring to know that there is a process and that all members will have a say. Each of the localities will draw up their own plans and a formal system for requesting funding will be introduced. It’s all part of a well-rehearsed commitment to transparency that is at the heart of devolution.

Rural revolution
The current focus in Cornwall, another area vying for autonomy is less advanced than that of Manchester. Currently developing a business plan, the focus at the moment is on bringing the health and social care community together, as Tracey Roose, director of transformation, at NHS Kernow explains: “Local partners in Cornwall and the Isles of Scilly will be collaborating closely in the coming months to agree a long term system-wide transformation plan to join up services further to provide sustainable and seamless high-quality care for patients.”
The local population is currently being asked to become involved in shaping the Cornish plan, with Roose estimating that “2,000 people are expected to share their views via a public survey and community events about how the new five-year health and social care plan should develop”.
Kernow CCG doesn’t have the history of collaborative working that Manchester does, but its arguable whether many others do either. What is slightly concerning is that the area is notorious for a lack of political continuity, with current council chief executive Kate Kennally being the third in the past seven years. The local health system hit the headlines late last year for financial mismanagement, with the CCG placed under legal directions by NHS and ordered to create a recovery plan to deal with its forecast deficit of £14 million.
The greater integration of health and social care could be the pathway to a more sustainable future for Cornwall, but it’s clear there are significant barriers to overcome before NHS England signs off.

Wider world
The capital will soon see five pilot schemes to test devolution. There will be an integrated health and social care pilot in Hackney, the creation of an accountable care organisation in Barking and Dagenham and an interesting attempt to link physical and mental health services in Lewisham.
Hunt, Osborne and Boris Johnson, mayor of London, made the announcement with some fanfare. It’s an enthusiasm shared by those involved. “Devolution is viewed as an integral tool to overcome these challenges and help deliver London’s aspirations at pace and scale,” adds councillor Teresa O’Neill, London councils’ executive member for health.
In fact, progress to date has been modest, with O’Neill describing how “partners involved in each pilot are currently working together on the set-up phase”. Given the publicity and the expectations, it is unsurprising NHS England is keen to see results within 12 months. “During early 2016 all pilots will have completed business plans and new models of working, and negotiated devolution to support delivery,” says O’Neill.
Development is a key word for devolution. It’s clear that one of the biggest challenges NHS England faces with devolution is that there isn’t a one-size fits all approach. Some health and social care systems – and leaders – may not be capable of managing the transformation. “Where devolution is taken forward there will be different forms of it across the country,” an NHS England spokesperson added.
There are local plans being developed in Hampshire and Liverpool, and likely many more behind the scenes, all of which will, in some way, be unique.

All eyes north
It may be more difficult for health systems to wrestle control from Whitehall, believes Helen McKenna, senior policy advisor, King’s Fund. Responding to the criteria for devolution announced by NHS England in September 2015, she believes that “NHS England criteria has set a really high bar,” adding that “our sense is that NHS England isn’t particularly behind the devolution agenda”.
Describing Manchester and Cornwall as “the only meaningful deals” currently on the table, McKenna, adds that she believes NHS England and Simon Stevens are ‘lukewarm’ toward devolution.
It’s easy to be skeptical in the NHS sometimes, but the case for integration has been made so many times it’s widely accepted across the NHS that it needs to happen.
Devolution is one way, but McKenna is keen to point out that a lot of integration can already be achieved within existing systems – it just takes leadership and commitment.
The official line is predictably different. “The impetus for devolution needs to come from local system leaders,” said a spokesperson from NHS England. “We hope that Greater Manchester will be the first of many, and we welcome talks with other local systems that want to do something similar.”
The opportunities for devolution are clear, but one concern many are having is that this revolution could take the national out of the health service. It’s something all involved are keen to address. “There is a really significant principle that the NHS in Manchester was part of the national system. This characterises and defines our relationship going forward,” states Heppolette.
Devolved regions will still receive the same level of scrutiny; with an NHS spokesperson clarifying that “there won’t be any reduction in the level of scrutiny that local services receive from national bodies like Monitor and the Care Quality Commission.”
It’s clear that all eyes will be on Manchester this April. So will it work? “We have a clear stake in everybody’s success, and nobody’s failure,” states Heppolette confidently.

Lawrie Jones, freelance health reporter.

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