A potted history of devolution and centralisation in England

I recently read a Briefing by The Kings Fund regarding Devolution and what it means for Health & Social Care in England.

The inclusion of health and social care in the so - called ‘Devo Manc’ agreement announced

in November last year therefore came as a surprise to many. Along with powers over housing, skills and transport, the landmark deal between the Treasury and Greater Manchester paves the way for the councils and NHS in Greater Manchester to take control of the region’s £6 billion health and social care budget.

I particularly enjoyed the point on Measurable Outcomes, leading from the Greater Manchester Agreement.  A strategic sustainability plan (see below) was agreed as one of the deliverables in the memorandum of understanding, which will set out the expected outcomes for the Greater Manchester deal. The figure below shows some of the early outcomes agreed.

 

The Edith Ellen sees a range of potential benefits arising from the devolution agenda – in particular, the opportunity to achieve greater integration of services, between health and social care but also with public health and other areas under local government control, so that areas can begin to focus more broadly on improving the health of the populations they serve. However, possibly because of the pace with which this agenda is moving, there are a number of outstanding questions that will need to be resolved, largely focused on resolving the tension between local and national arrangements, and the extent to which the ‘national’ in the NHS will be preserved. 

A key point to make at the outset is that what we are currently witnessing is not devolution. The models adopted in the deals so far appear to be closer to ‘delegation’ than the formal ‘devolution’ outlined in the Cities and Local Government Devolution Bill. 

In exchange for a greater say over their own futures, areas such as Greater Manchester and Cornwall are promising to deliver changes to health and care services that we and many others have long been calling for. In its final report, the Commission on the Future of Health and Social Care in England (2014) called for an end to the historic division between health and social care, suggesting that local authorities and NHS partners integrate their budgets and create a single commissioning function. The work in Greater Manchester and Cornwall is bringing this vision to life, enabling genuine integration across health and social care. Local partners in Greater Manchester and Cornwall have also committed to look beyond the fragmentation within the NHS and social care system to the broader health of local populations and the impact of the wider determinants of health by combining their resources to enable place - based approaches. In doing so, they have recognised that the current focus on treating rather than preventing ill health limits the health gains that can be achieved for communities, and that only by considering all of the elements that influence health (eg, housing, education, employment, etc) can inequalities in health and wellbeing be properly addressed. It is important to note that many of these prizes are not dependent on ‘devolution’.  Genuine devolution, as enabled through the Cities and Local Government Devolution Bill, would see health functions transferred to local or combined authorities via parliamentary orders, potentially resulting in very significant change to the NHS.

However, there are currently no plans to use the Bill’s powers in this way. Instead, the deals that have been agreed in Cornwall and Greater Manchester are more akin to ‘delegation’ than ‘devolution’. The promises of integration and a greater focus on population health are to be delivered largely within existing legislation, with formal accountabilities remaining with NHS bodies.