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Devo-Health : What and Why? (PDF) Harry Quilter-Pinner August 2016 © IPPR 2016 DEVO— HEALTH WHAT & WHY? Institute for Public Policy Research 4. There are risks involved in health devolution. Rather than simplifying the post-Lansley landscape, devo-health in Manchester SUMMARY has so far just created a new level of bureaucracy; rhetoric appears to be running ahead of reality, given that history shows structural changes rarely deliver in terms of efficiency or heath outcomes; and there are very real concerns that ‘devo-health’ will ultimately lead to finger-pointing between central and local government The purpose of this booklet is to set out the context for IPPR’s research as the next round of public sector cuts hit. on devo-health and the questions which we would like this programme 5. Having said that, the most commonly cited concern – that of work to address. We are also setting out some initial hypotheses we will lose the ‘N’ in the NHS – has been exaggerated. about devo-health which we will look to test as we proceed. Significant variation in the quality of care and the health outcomes achieved already exists across England under our KEY FINDINGS more centralised system. While it is feasible that devo-health 1. At the moment, ‘devo-health’ is more akin to delegation than could make this worse, that seems unlikely, especially as the devolution. In Manchester, the health secretary rather than the newly NHS Mandate and NHS Constitution will remain in place. elected mayor will remain ultimately accountable for health and care. 6. A huge number of unanswered questions remain. How Going forward, this may need to change, with local mayors given much freedom should local areas have to differ from national clearly defined roles in the NHS and the centre stepping away from policy? Should full devolution follow delegation? Is there a role its responsibilities, in order to give local leaders ‘skin in the game’ for fiscal devolution? How can local areas unlock the potential and enable local communities to hold them to account. benefits of devo-health, and what should local areas do with 2. Devo-health has the potential to drive improvements in health their devolved powers? How do we keep the ‘N’ in the NHS from both within and outside of the NHS. Devo-health can while also delivering place-based public services? Will the catalyse reform within the NHS (particularly integration) and funding pressures on the NHS and local government ultimately can drive improvements in the social determinants of health undermine efforts at reform? Our programme will look to address through the creation of place-based public services. The these questions and more over the coming months. latter has particular potential given that health devolution is likely to be part of broader decentralisation deals. 3. The potential benefits of devo-health do not imply that every area in the UK should take on powers over the NHS, ABOUT IPPR but rather that it should be considered as one option in looking IPPR, the Institute for Public Policy Research, is the UK’s leading progressive thinktank. We are an independent to drive reform going forward. There is a better case for charitable organisation with more than 40 staff members, paid interns and visiting fellows. Our main office is in London, with IPPR North, IPPR’s dedicated thinktank for the North of England, operating out of offices in proceeding with devo-health in urban areas with clearly Manchester and Newcastle, and IPPR Scotland, our dedicated thinktank for Scotland, based in Edinburgh. established geographic boundaries and with a strong history The purpose of our work is to conduct and publish the results of research into and promote public education in the of joint working between the NHS and local government. economic, social and political sciences, and in science and technology, including the effect of moral, social, political All future devolution deals should adhere to the decentralisation and scientific factors on public policy and on the living standards of all sections of the community. IPPR, 4th Floor, 14 Buckingham Street, London WC2N 6DF • T: +44 (0)20 7470 6100 • E: [email protected] • www.IPPR.org principles set out in IPPR North’s report Decentralisation decade Registered charity no: 800065 (England and Wales), SC046557 (Scotland) (see Cox et al 2014): they must have a clear purpose; be joined This paper was first published in August 2016. © 2016. The contents and opinions in this paper are the author's only. up across silos; be given time to bed in; have cross-party Download support; and will necessarily be asymmetrical. This document is available to download as a free PDF and in other formats at: http://www.ippr.org/publications/devo-health 1 INTRODUCTION Over the past few decades the one constant in public policy The surprise inclusion of health in the northern discourse has been the desire to decentralise economic, powerhouse initiative has raised a number of public service and democratic power within the UK and more fundamental questions which have not, as yet, been recently within England. Labour, Coalition and Conservative fully answered. How far could health devolution go? governments alike have been part of a growing consensus behind What are the risks and how can they be managed? decentralisation. Its latest incarnation – the northern powerhouse What should local areas do with their new health agenda – could mark a significant further step forward in that powers? What are the implications for central journey. government of devo-health? ‘A true powerhouse requires true power…’ It is these questions and others – being asked at George Osborne, former chancellor of the exchequer both the national and local level – that IPPR’s new programme of research on devo-health will look to In his ‘Northern Powerhouse’ speech (Osborne 2014), the former answer in the coming months. This introductory paper chancellor offered to start a dialogue with local leaders about establishes the context for the IPPR programme, the ‘devolution of powers and budgets’ to be managed by the key questions we wish to address, and some of newly created combined authorities and metro mayors. Greater our initial thinking on a set of foundational questions Manchester became the first new region to take up his offer, gaining raised by the emerging devo-health deals in Greater new powers over transport, housing, planning, policing, skills Manchester and across England. and employment support. The most radical element of Greater Manchester’s deal, however, was the announcement in February We hope you find this and our future contributions to 2015 that the region would also get control over its £6 billion NHS the debate both useful and interesting. budget. Rt Hon Alan Milburn ‘This has the potential to be the greatest act of devolution Former secretary of state for health … in the history of the NHS.’ Simon Stevens, chief executive of the NHS 2 3 ‘It’s the biggest act of devolution in England’s NHS since WHICH AREAS 1948 – and it now means that Greater Manchester will make its own decisions about the health and social care ARE INTERESTED needs of its residents.’ IN DEVO- SIR HOWARD BERNSTEIN, CHIEF EXECUTIVE, MANCHESTER CITY COUNCIL HEALTH? Greater Manchester North East Population: 2.7 million Population: 2 million Deal includes all of health Commission on health and care system. and social care devolution. Greater Manchester is not the only area asking for or considering extra health powers. West Midlands Population: 4.0 million Indeed, if all areas currently asking for Commission on mental Greater London health powers were to receive them, health, may result in Population: 8.6 million then around one-third of England’s devolution ask. Five devolution pilots, population would be covered by some likely to be a pan-London form of devo-health agreement. ask in future. However, as it stands, devo-health is Cornwall still considered an experiment. In the Population: 500,000 short term, the government is likely Devolution of health & to give significant powers to only a social care budgets to small number of urban areas that have facilitating pooling. demonstrated a history of joint working between the NHS and local government, and which have a more developed form ‘Today's agreement is of local democracy. another crucial step in our devolution revolution, and is the start of our handing over valuable Deals mentioning health and social care announced March 2016 healthcare power to local Devolution deal agreed: aspects of health included leaders in London.’ Devolution bid in discussion: aspects of health included GEORGE OSBORNE, CHANCELLOR OF THE EXCHEQUER 4 5 Greater Manchester will receive some more freedoms (see pages 12–13), but through the so-called Warner amendment to WHAT DO the Cities and Devolution Bill (2016) it will be Jeremy Hunt (as health secretary) and not the newly elected mayor who is ultimately WE MEAN BY accountable for health and care in the region. This means there will DEVO-HEALTH? still be a significant degree of national oversight and control. This is reinforced by the retention of existing organisational statutory responsibilities: clinical commissioning groups and foundation trusts will still be accountable to Whitehall rather than to the Greater Manchester combined authority (GMCA). This means that GMCA’s influence will be dependent these bodies voluntarily ceding decision- Devolution is the most complete type of decentralisation, meaning making power to the local level rather than to Whitehall, whose power the transfer of power from a more national to a more local body. over these organisations is based on primary legislation. For example, since devolution to Scotland in 1998, the Scottish government has had complete control over its share of the NHS All this raises significant questions about the degree to which budget and is held to account when it fails to deliver by the Scottish Manchester and other ‘devolved’ regions will really have the power population.
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