NHS insiders in Greater Manchester have been pleasantly amazed by the speed at which negotiations progressed leading up to today’s historic agreement to devolve and integrate £6bn of health and social care spending for the conurbation.

A corollary of that speed is there remains a long list of difficult questions to be worked through over the coming year before we can see clearly how this deal will work in practice.

Among these are:

But while there is some way to go before we can say what exactly the Manchester devolution deal will look like, there is now greater clarity on what it is not.

As the Greater Manchester Combined Authority’s chair, Lord Smith, said today, this is not a “town hall takeover of Greater Manchester’s NHS budget”.

Structure isn’t everything

As the devolution memorandum of understanding makes clear, what is being proposed here has little in common with the devolution of health budgets to Scotland or Wales.


It instead relies on a combination of NHS England’s existing powers to delegate specialised commissioning and primary care budgets to clinical commissioning groups, and the freedoms of NHS bodies to pool budgets and powers with each other and with councils, using joint commissioning boards and section 75 agreements.

Neither NHS England nor CCGs will lose their statutory accountability for money or service standards, and as the small print notes, there will need to be “agreement as to the precise scope and extent of the commissioning functions that can lawfully be delegated”.

None of this is to imply that the Manchester agreement does not have the scope to transform the way services are commissioned for the conurbation, only that there are some fiendishly complex structural issues to sort out to make it work.

‘The deal is a testament to the past success of NHS and local authorities to work together’

However, structure isn’t everything. At least as important to this deal will be the strength of local relationships. The Manchester deal is both a testament to the past success of NHS and local authority commissioners in the area in working together, and an opportunity for those relationships to attain a new level of maturity.

Watch and see

Across the country, the NHS will now be watching Manchester to see whether bringing local authorities this close to decisions about NHS services can help overcome political resistance to controversial service change, or if Manchester can develop new ways to involve the NHS in the funding or provision of social care.  

In many parts of England, CCGs talk about the desire to put “one pot of money” on the table, and have a mature discussion with providers and local government about how that money can best meet the health and care needs of the population.

Manchester is now in a position to try that approach on an unprecedented scale.

‘Commissioners believe the devolution deal with strengthen their ability to make effective decisions’

But there are ever more demands on that pot of money, and as any marriage guidance counsellor will tell you, financial worries put a strain on even the best relationships. NHS and council leaders will need to keep up the momentum that brought them to this agreement to get through the inevitable difficult times ahead.

It’s worth remembering some recent Manchester history.

The last five years have seen a review of health services across the conurbation, dubbed Healthier Together, which last summer produced options for major restructuring of acute services.

There was broad consensus on the case for change, but some major disagreements once the proposals were revealed.

Commissioners believe the devolution deal will strengthen their ability to make clear and effective decisions to improve services.

A decision on Healthier Together is expected soon after the election. It is possible this will mark the first real test of Manchester’s new arrangements.