National and Devolved Politics

Manchester health deal ‘closer to delegation than devolution’ as centre retains power

In its current form, ‘devo-health’ in Greater Manchester (GM) is closer to delegation than actual devolution and has so far just created a new level of bureaucracy as opposed to “simplifying the post-Lansley landscape”, new IPPR research has revealed.

The influential think tank defined delegation in its report as when responsibilities for setting policies and delivery are transferred to semi-autonomous entities, but still with a degree of accountability back to central government. It argued this is the case in GM because while it will receive some more freedoms, it will actually be health secretary Jeremy Hunt, and not the newly-elected mayor, who is ultimately accountable for the region’s health and care.

“This means there will still be a significant degree of national oversight and control,” the report added. “This is reinforced by the retention of existing organisational statutory responsibilities: CCGs 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 on these bodies voluntarily ceding decision-making power to the local level rather than to Whitehall, whose power over these organisations is based on primary legislation.”

IPPR said this raised some significant questions about the degree to which GM and other devolved regions will really “have the power and ‘skin in the game’ to steer the ship going forward”.

So far in GM, the think tank claimed rhetoric around health devolution “appears to be running ahead of reality”, given that history shows “structural changes rarely deliver in terms of efficiency or health outcomes”.

“There are very real concerns that ‘devo-health’ will ultimately lead to finger-pointing between central and local government as the next round of public sector cuts hit,” it added.

Its report, which looked at health devolution more generally, did acknowledge that devo-health can “catalyse reform within the NHS (particularly integration) and can drive improvements in the social determinants of health through the creation of place-based public services”. The main channels for this catalysing effect, the think tank said, would be through more empowered local leaders and greater local accountability.

But it outlined a series of risks involved with the process, including the complexity of the landscape involved (geographical, functional and bureaucratic), ongoing public sector cuts, the experience and capabilities of staff, inequality in access and in outcomes, and an overall lack of real devolution – since the Department of Health would retain ultimate accountability.

The IPPR also argued a “huge number” of questions remain unanswered, such as:

1. How much freedom should local areas have to differ from national policy?
2. Should full devolution follow delegation? Is there a role for fiscal devolution?
3. How can local areas unlock the potential benefits of devo-health, and what should local areas do with their devolved powers?
4. How do we keep the ‘N’ in the NHS while also delivering place-based public services?
5. Will the funding pressures on the NHS and local government ultimately undermine efforts at reform?

“It is these questions and others – being asked at both the national and local level – that IPPR’s new programme of research on devo-health will look to answer in the coming months,” former health secretary Alan Milburn said in the introduction to the report, which he added was just an introductory paper to establish the context for devo-health.

Initial conclusions

As part of a series of ‘informed hypotheses’, which the IPPR said it will look to test as its research programme continues, the think tank said devo-health must be part of a larger devolution package if areas are to unlock improvements in the social determinants of health.

“Powers over transport, housing, criminal justice, welfare and employment (alongside existing public health and social care powers) are most likely to be coterminus with health. Funding must then flow across these boundaries,” it said.

Other emerging thoughts included the need for clearly defined leadership roles, greater revenue-raising powers at the local level, and further relinquished central control.

The report follows on the heels of another major piece of health devo work, led by think tank Localis and supported by cross-party political leaders. But whilst that report seemed to back health devolution deals across all areas, the IPPR argued that not every area should take on powers over the NHS.

“There is a better case for proceeding with devo-health in urban areas with clearly established geographic boundaries and with a strong history of joint working between the NHS and local government,” the report added.

However, PSE’s own investigation found in June that health devolution may actually be a more effective solution to place-based health and social care integration than sustainability and transformation plans, with GM councils reporting greater amounts of involvement and enthusiasm towards health work than most other local authorities.

We will be providing continuous coverage of IPPR’s devo-health research as further reports are released.

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