Emily Crawford argues that health reforms should be at the heart of the government’s devolution plans, not an add on

Thinking about current healthcare reforms, centred on sustainability and transformation plans, the parable of the river comes to mind. That is the story where you are standing on the riverbank; suddenly a person comes floating by, drowning, calling for help.

You dive in to rescue them, pulling them out of the water only for another to float by calling for help, and then another, and another. It is a natural response to head upstream to find out what is causing all these people to fall into a dangerous river.

But the current approach to reform is more focused on fishing out acute trusts that are drowning out of the river than it is on looking upstream to prevent these issues.

High quality care

And who could blame Simon Stevens and the NHS leadership for that? With funding flat lining, A&E targets being missed, hospitals in debt, and the ever growing population of the aged and the ill, the demands of ensuring high quality care today is indeed an urgent priority.

‘Current healthcare reforms ­­are rather insular and inward looking’

Yet current healthcare reforms ­­– with the STP process at its heart and operational shifts via vanguards – are rather insular and inward looking and fail touch the upstream in any substantive way.

Six years ago, the Marmot review gave us the startling statistic that only 20 per cent of health is attributable to clinical care within the formal health system. The remaining 80 per cent was linked to physical environment, lifestyle choices and social networks.

Levers for change

Local government holds many of the levers to improving health and wellbeing, with responsibilities for the built environment, housing, schools, early years and family support, community services and public health.

The Five Year Forward View places great emphasis on prevention, early intervention and wider determinants of health.

Such an approach presumes strong collaboration and joint strategic commissioning between health and local government on mutual priorities.

‘Health has not been central to the devolution project’

However, when I asked Mr Stevens about the relationship between the STP process and the dynamic devolution deals agenda that is rapidly handing down new powers and investment to local leaders, his reply was that “there isn’t one”, because so far “health has been an add-on to devo deals”.

He is right. To date, health has not been central to the devolution project – that has been primarily focused on rebalancing economic growth. But it should be.

Greater Manchester’s strategy is to show that improving health is a fundamental part of improving growth, both in terms of increasing the reach of the potential labour market and reducing demand on public services.

Parallel tracks

It seems odd that two transformational agendas – devolution deals and STPs – should be progressing on parallel tracks, taking little heed of each other.

At its most practical level, the STP footprint decision making process, determining the shape and scale of 44 local health economies, was undertaken in isolation from the devolution deal combined authority boundaries.

‘Carving up England is an unavoidably messy business’

When we talk about place based transformation, boundaries matter. Being coterminous is a huge benefit for simplifying governance, finance and operational structures.

Carving up England into units of governance is an unavoidably messy business. The fact that STP footprints cross over some local authority boundaries and were determined without any reference to the devolution footprints is indicative of the narrow approach to reform and absence of action on getting upstream on the wider determinants of health.

Dams in demand

The current difficulties facing hospitals and GPs working at the sharp end of increasing demand lie upstream, in the lifestyle decisions, the social isolation and the unemployment that so often present later down the line in ill health.

Healthcare reform is a difficult task – both in complexity and scale. It is a big ask for that programme to actively, substantially and productively engage in the parallel agenda of devolution to combined authorities.

That is the task, however, if NHS leaders are to move upstream. Health leaders need to work with local government leaders and build essential dams in demand by tackling the wider determinants of health and stemming the flow that leads to drowning trusts.

Emily Crawford is principal research consultant at ResPublica