English devolution offers great benefits, improving patient outcomes, potentially transforming the care and cash crisis, while protecting NHS core values, says Norman Warner and Jack O’Sullivan

Manchester, backdrop for Engels’ searing critique of Victorian poverty, has been one of England’s sickest cities since the industrial revolution.

Some 200 years of growth, half a century of deindustrialisation and 67 years of the NHS have not moved Mancunians up the health league table.

Jack O'Sullivan

Jack O’Sullivan

Healthcare officials equate excess deaths to a jumbo jet full of passengers crashing in Greater Manchester virtually every month.

This longstanding human tragedy helps explain why a city that has been most let down by healthcare is poised to rescue England’s NHS from its care and cash crisis.

Indeed, the hullaballoo over a “northern powerhouse” distracts from what is arguably a more important aspect of English devolution.

Over recent months, we have had unique access to what we call “Healthopolis” - Britain’s first city region to concentrate its assets, medical and non-medical, comprehensively around its citizens’ health.

Devolution to Greater Manchester of its £6bn health and social care budget from 2016 makes that possible, for the first time.

Welcome to Healthopolis

Greater Manchester’s devolved “Healthopolis” has two strengths.

Norman Warner

Norman Warner

First, it resolves the fragmentation of leadership, commissioning and service delivery that undermines most modern health and social care systems.

Second, it aligns NHS and social care with other resources that build wellbeing, such as housing, transport and job support, all at the same devolved level.

“We want GPs effectively to have two prescription pads,” explained a local NHS manager.

“One for medical prescriptions and one that can refer patients to supports around work, training, housing and exercise that might offer more long term solutions than say, antidepressants.”

‘It resolves the fragmentation of leadership that undermines most modern systems’

This means radical changes for 600,000 Mancunians, the 20 per cent most at risk of disease progression or hospitalisation.

We have been told that one in five Mancunians will be offered unprecedented one to one, intensive primary and community care, using all available tools, to eliminate at least 60,000 acute admissions a year.

As another official explained: “A certain level of obesity can trigger bariatric surgery for thousands of people. But where are the triggers for more intensive primary care that would intervene much earlier, and much more effectively, for the person and the NHS?”

NHS shake up

Providing better care will simultaneously tackle the NHS cash crisis.

Greater Manchester anticipates that even the most rigorous provider efficiency and productivity savings will leave a recurring health and social care budget deficit of £500m a year by 2017-18.

‘Devolution could halve the requirement for extra funding’

But the pay-off from devolution – reducing hospitalisation through new care models, and merging health and social care – could cut that figure by about £250m.

Greater Manchester, like the rest of the NHS, still needs extra funding, say managers. However, devolution could halve the requirement.

Managers know that achieving these changes will shake up the existing NHS dramatically.

They want transitional funding to enhance primary and community care rapidly, enough to cover stranded costs in the acute sector.

They need greater control over primary and acute estate.

As one manager said: “Nobody has the facility or duty to say ‘what shall we do with all of it?’ That has to change if we are to leverage the city’s estate efficiently.”

Time to change

Health Education England will be expected to transform workforce training to develop an army of generalised consultants, nurses and carers required for the new care model.

Payments by results no longer meets need – Greater Manchester wants contracts that include new, system-wide performance indicators and incentives that reward keeping people well, independent, at home, and out of hospital.

‘It would be better to shift the focus of regulators towards improving the effective system operation’

Managers see potential clashes with, for example, the four hour accident and emergency target that requires excellence in part of the system, but not whole system working.

Rules of competition need recasting. One manager said: “We need the freedom to select competition that improves the logic of the system rather than the freedom not to apply competition at all.”

The role of national regulators is also under review. “It would be better to shift the focus of regulators towards improving the effective operation of the system rather than focusing simply on the statutory health of individual organisations,” explained a local health manager.

Published today, Letting Go, the first evaluation of English NHS devolution, taking into account the Greater Manchester pioneers and those who will inevitably follow, details ways, amid so much change, to protect NHS core values.

We recommend:

  • national guarantees on access to primary physicians, specialist diagnoses and treatment;
  • national measurement systems;
  • ways to enforce local compliance to national standards;
  • means to ensure public transparency on performance and to provide robust intervention where there is failure.

This new phase of devolution is much more promising than Scotland, Wales and Northern Ireland.

There, the NHS has not decentralised and, as a result, has largely failed to develop better ways to deliver care, focussing instead on more staff and public entitlements.

English devolution offers greater prizes, improving patient outcomes, potentially transforming the care and cash crisis, while protecting NHS core values.

Norman Warner is a Labour member of the House of Lords and former minister of state for NHS Reform in the Blair Government (2003-2007) and Jack O’Sullivan leads a consultancy on innovation in health and social policy and is a former Harkness Fellow in Health Economics