Essential insight into NHS matters in the North West of England, with a particular focus on the devolution project in Greater Manchester. By Lawrence Dunhill

Tied up in legal knots

National leaders might be pretending the Health and Social Care Act never happened, but unfortunately for some it’s still the law – which means it’s still creating problems for local NHS organisations.

Take those in Lancashire and Cumbria, where there is an urgent need to get on with implementing the Five Year Forward View.

Setting up “accountable care systems” – for Morecambe Bay and the rest of Cumbria – is seen as critical to ensuring the sustainability of services in what are two of the most deeply troubled corners of the NHS.

So it’s pretty worrying that the CCG chiefs in both areas believe the plans cannot happen quickly under the current legislation. And it seems pretty clear that national leaders are reluctant to even start thinking about changing the Health Act 2012.

The issue is the commissioner-provider split – which would be at least partly broken down by the ACS model – as this was finally entrenched in law under the 2012 act (after 20 years of being used in practice, but with some legal uncertainty).

Now local leaders, understandably, will want to get all the legal stuff clarified before they start making big changes to their health systems. But without any imminent prospect of legislative change, this leaves them with little option but to muddle through.

If you consider what’s happened (with remarkable pace) in Greater Manchester in recent months, maybe that is possible.

We are about to see Salford Royal Foundation Trust merge many of its operations with Pennine Acute Hospitals Trust, while avoiding a lengthy legal process that would have come with a formal merger.

I’ve been told of a few possible workarounds for the ACS model, in which it could effectively perform some of the commissioning roles without them being formally transferred, so let’s hope these can prove effective.

One would involve an ACS supporting a CCG to “fulfil its functions”, in a similar way to commissioning support units, without the duties being formally transferred.

Another could bring a more flexible approach to defining what is classed as commissioning, automatically enabling some functions to be defined as provider functions and transferred.

The message from NHS England and NHS Improvement seems to be don’t get caught up in the legislation, focus on getting all the relevant leaders in the room to agree on what you want to do. Then a way can be found to do it, working around the Health Act.

Liverpool picked ahead of Manchester

As was predicted, the national review of heart surgery units in England led to a straight choice between Liverpool and Manchester. In the end Liverpool got the nod, which means Central Manchester University Hospitals Foundation Trust will lose its surgical service for adults with congenital heart disease.

It did seem a stretch to imagine moving children’s surgery from Alder Hey and adult surgery from Liverpool Heart and Chest Hospital, in order to create a collocated unit in Manchester (imagine the furore of ceasing a service at Alder Hey). Moving in the other direction probably involves less upheaval, as it will involve moving far fewer procedures.

NHS England, which announced the decision in a strongly worded statement last week, warned Central Manchester it would take “enforcement action” if it did not cease carrying out some procedures.

While University Hospitals of Leicester Trust and Royal Brompton and Harefield FT – also set to lose heart surgery units – have vowed to challenge the decision, Central Manchester seems resigned to it.

After making the point that its service was “excellent” and it was “disappointed” with the decision, Central Manchester said its priority would be “to work closely with colleagues in both NHS England and Liverpool to make the transition as safe and smooth as possible for our patients and their families”.

North by North West takes an in-depth weekly look at one of the NHS’s most challenged and innovative regions. There will be a particular focus on the devolution experiment in Greater Manchester, but my scope will also include Merseyside, Lancashire, Cheshire and Cumbria.

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