Complex governance questions remain over Manchester devolution plan

A joint statement from the government, NHS England, and the conurbation’s local authorities and NHS organisations this morning confirmed that they hoped “a full agreement will be reached shortly around partnership working in Greater Manchester on health and social care”.

A draft memorandum of understanding on the plans sets out intentions to work towards “full devolution” of commissioning powers for primary care and all “relevant” specialised services by 1 April 2016. These services are currently commissioned by NHS England.

The document states that NHS England is working with Greater Manchester “to prepare for the full devolution of relevant NHS funding to Greater Manchester”.

The intention is that this will make possible both the acceleration of health and social care integration and the commissioning of services on a conurbation-wide scale.

Setting out the principles for this devolution, the document notes that Greater Manchester commissioners may seek to set standards for primary care and specialised services that are “above current national standards and specifications”.

It says that over the coming year “full due diligence and clear proposals will be completed” to outline “the risks and benefits of [Greater Manchester] level commissioning of primary medical services”. This will aim to identify the benefits of devolution against those already available under NHS England’s existing plans to delegate primary care commissioning powers to some CCGs.

On specialised commissioning, the document says the work will prioritise areas where Greater Manchester is currently non-compliant with national specifications, such as specialist cancer surgery.

However, there is significant work to do to establish the accountability and governance arrangements that can make the ambitious proposals a reality.

HSJ understands that under the current legislative framework, NHS England can devolve some, but not all, of its statutory responsibility for primary care and specialised commissioning to CCGs. However, this would have to be devolved to individual CCGs. Those CCGs would then have to institute a further set of governance arrangements to pool responsibility with each other and with local authorities to allow some services to be commissioned on a Greater Manchester-wide scale.

This is further complicated by the fact that – as the draft agreement indicates – some services would still be commissioned at a locality level.

The memorandum of understanding states: “The principle of subsidiarity means that unless the funds are better managed at a [Greater Manchester] level, resources are held at a locality level. Parties recognise the benefit of collaborative work and decision making at both locality and [Greater Manchester] level.”

It is not yet clear which services would be commissioned at a locality level, and which will be commissioned across all of Greater Manchester under the proposed deal.