Letting Go: How English devolution can help solve the NHS care and cash crisis

Abstract

“England’s NHS is advancing towards major decentralisation, beginning in Greater Manchester. The process now seems inevitable given the impetus driving public sector devolution in England. This historic change will transform a centrally-controlled, command system that has underpinned the NHS since 1948. It can help cure the NHS’s twin care and cash crises, namely a failing service model and a lack of affordability. This valuable prize is attainable without losing NHS core values.

The Government has agreed that, from April 2016, Greater Manchester’s entire £6 billion health and social care budget, currently dispersed through more than 30 organisations, local and national, will be consolidated within a single partnership body which will define overall strategy. Executive powers will rest with a new Greater Manchester Joint Commissioning Board. Actual commissioning will be delegated, according to subsidiarity, to the most effective level.

This is much more than a bureaucratic change. Greater Manchester aims to become the UK’s first city to concentrate its assets – medical and non-medical – on improving the health of its citizens. To achieve this goal, it has developed a care model that focusses on maintaining and improving the health of its population through a system-wide approach that rewards keeping people well, independent, at home and out of hospital. Almost 600,000 (up to 20 per cent) of the city’s three million people who have been identified as most at risk of disease progression and hospitalisation will be offered an annualised care package. It will be personalised and directly targeted at the person’s lifestyle and underlying conditions, with their GP as the accountable doctor. The city’s goal is to eliminate at least 60,000 hospital admissions per year.

Greater Manchester anticipates that even after the most rigorous provider efficiency and productivity savings, it will still be left with a recurring annual budget deficit for health and social care of over £500 million by 2017-18. But if the benefits of NHS devolution are realised, the city could save £250 million each year through reduced admissions to hospital and the benefits of health and social care integration.

But effective English devolution would need to go beyond the NHS devolution witnessed in Scotland, Wales and Northern Ireland, where power remains concentrated in Holyrood, Cardiff Bay and Stormont. Effective devolution requires decentralisation of key powers including flexibility within longer than usual budgetary commitments from Whitehall; rights to reconfigure and develop capital assets; new workforce requirements for Health Education England; and more local control over the pricing, contracts and competition for services in order to incentivise a shift into fully integrated and expanded community, primary and social care delivery. Devolution should also see a more flexible regulatory regime than currently administered by national bodies such as Monitor, the Care Quality Commission and the Trust Development Authority, because local health priorities will differ from national ones.

Crucially, devolution in England must not be allowed to take the “National” out of the NHS. We envisage that decentralisation and its local flexibilities should be accompanied by national guarantees on access to a primary care physician and services as well as to specialist diagnosis and treatment, especially for “killer” diseases. This will require a national measurement system, ensuring local compliance and public transparency on performance.

Our conclusion of NHS devolution in England, particularly in the format proposed by Greater Manchester, is one of cautious enthusiasm. For the first time, a large city region has offered a model of healthcare in the UK that focuses on preserving and improving the health of all citizens rather than merely treating them when they are sick. It could provide a step change in health outcomes, particularly for the worst off. If successful in fixing the care model, this innovative approach could help make the NHS more financially sustainable, by controlling the numbers needing expensive acute care.

Nevertheless, we must protect all NHS values. Important principles of fair access, quality and equality of treatment as well as robust financial control have been at the core of NHS success and support since 1948. They must not – and need not – be lost amid the enthusiasm for an exciting vision.”