Professor Bob Hudson, Centre for Public Policy and Health, School of Medicine, Pharmacy and Health, University of Durham
If there is one thing the NHS needs like a hole in the head it’s another organisational restructuring. David Cameron famously called for “no more pointless reorganisations, no more restructuring at the expense of the people who work in the system” in his 2007 speech to the Royal College of Nursing but then allowed his first Health Secretary, Andrew Lansley, to bring in the biggest – and most controversial – restructuring since the inception of the NHS in 1948. Lansley’s successor, Jeremy Hunt, was then brought in to steady the ship, and the service has since then been attempting to make the 2012 Act structures work as best it can.
Remarkably there is now a further restructuring in prospect spearheaded not by the Health Secretary but the Chancellor of the Exchequer. The starting point is George Osborne’s surprise decision earlier this year to devolve the £6b NHS budget of Greater Manchester to a combined authority of the constituent local councils. The Chancellor said this deal had ‘set a trail for the rest of the country to follow’ and, in responding to his recent deadline for devolution bids, several combined local authorities have taken him at his word – Cornwall, Gloucestershire, Liverpool and London, amongst others, have all tabled bids to control their NHS funding. Analysis by Felicity Dorman for the Health Foundation suggests that in total eleven areas have included greater control of health in their bid but these vary enormously: most want greater integration of health and social care but others are more striking – London wants control of its deficit regime, Cumbria wants to buy out its PFI and Surrey, West Sussex and East Surrey want a cross-sector transformation fund.
This potentially amounts to an administrative restructuring of the NHS that makes Andy Burnham’s pre-election proposal for stronger Health and Wellbeing Boards look decidedly tame – one in which healthcare begins to return to its pre-NHS roots in local government. The Cities and Local Government Devolution Bill currently wending its way through Parliament would, for example, give the Secretary of State for Communities and Local Government the power to transfer the functions and properties of other public bodies to combined local authorities, and as things stand there is no exemption for NHS bodies from this clause. Oddly, despite the potential importance of the Devolution Bill for the NHS, the legislation makes no reference to health and social care or to the Health and Social Care Act 2012, other than Clause 19 which simply requires that the Health Secretary ‘must continue to be able to fulfil his statutory duties conferred by existing legislation notwithstanding any transfer of functions’.
It is time to start asking some serious questions about this silent administrative revolution:
What is the Purpose? Apart from some rather general ideas about the potential efficiencies to be gained from integrated care and ‘service transformation’, no clear reason for these changes has been expressed or debated. This is a major omission and as HSMC’s Director, Judith Smith, has asked in a previous blog – ‘if devolution is the answer, what is the question?’ .
Where are the Providers? Even in the case of Greater Manchester the initial deal appears to have been a secretive top-down arrangement between regional commissioners, national NHS agencies and the Treasury. GP leaders in Manchester, by contrast, have described the announcement of the devolved NHS budget as ‘a total shock’, whilst third sector and independent providers of social care have been reduced to sending an open letter to the Interim Mayor (signed by 29 of the third sector leaders) pleading for involvement in the unfolding discussions.
Where are the Citizens? In principle it would be reasonable to assume that devolution is something to do with empowering citizens of regions and localities, but democratic governance has been signally absent in the debate. Decisions are being made by directly unaccountable combined authorities, usually in conjunction with unaccountable business leaders running Local Enterprise Partnerships.The public will be mystified (if indeed they are even aware) by the multiplicity of bodies running their affairs. In due course greater control will be in the hands of a single directly elected mayor and while this will certainly help to pinpoint responsibility there are dangers in this heroic leadership model of governance. Already there is a wave of resistance to the devolution deal in Greater Manchester from a range of activist groups, trade unions, MPs and the third sector. We therefore need to ask what sort of devolution deal is it that seems to have no seat at the table for its citizens.
Where is the Money? It is far from clear who will hold the purse strings in a regionally devolved NHS, how overspends will be addressed and how the boundary between free healthcare and means-tested social care will be negotiated. For example, can people be assured that the local government model of contracting out and charging will not now be extended into NHS treatment and services? If there is one budget, where does one service model end and another begin? Unless an expensive decision is taken to make the higher need bands of social care free at the point of use – as proposed by the Barker Commission - there may well be confusion and resentment on the part of users and patients.
Since there is unlikely to be any additional funding, the danger here is that the Chancellor and Health Secretary will be only too happy to lay responsibility for rationing at the door of the devolved authorities. Unlike Scotland, devolved regional healthcare in England will not be accompanied by any new fiscal powers – the Greater Manchester deal relies largely on council tax and central government grants. There will be concern that the ‘N’ is being removed from the NHS to be replaced by a balkanised healthcare system with a more pronounced postcode lottery than currently exists with local CCG decision-making – indeed where local CCGs (and hence clinical expertise) fit in to regional devolution is far from evident.
Devolution to English regions is a clever political tactic – nobody is really against it, the rest of the UK already has it in varying degrees, Labour has been left flat-footed and regional political elites are keen to grab whatever powers and responsibilities are on offer. It may well, in principle, be a reasonable idea to regionalise the NHS under local government control – there are arguments for and against. The problem we have is that this debate is not taking place. The NHS and local government is being transformed at pace and scale, yet most people have no awareness of this, have had no consultation and even less involvement. Andrew Lansley’s NHS Bill was famously ‘paused’ in order to undertake a ‘listening exercise’, reflect further and gather fresh evidence. Maybe it’s time to do the same with the Cities and Local Government Devolution Bill?