Greater Manchester shows that if local areas can build strong relationships between partners around an ambitious local reform plan, they can make very real progress. By Harry Quilter-Pinner
Simon Stevens recently argued that the growth of new Accountable Care Organisations will “effectively end the purchaser provider split”. At the same time it is an open secret that Sustainability and Transformation Plans are an attempt to circumvent the silos created by the 2012 Health and Social Care Act.
Together these trends suggest that the reform agenda set out in the Five Year Forward View are in fact aiming to undo the two most significant bits of NHS legislation since the 1970s.
This is no great travesty. There is plenty of evidence that the purchaser-provider split has been ineffective, with the best commissioners working in close partnership with providers, and the worst wasting large amounts of money on poor care.
Likewise, no one will mourn the death of Andrew Lansley’s reforms, which are widely regarded as one of the main obstacles to delivering integrated care, and one of the biggest debacles in the history of the NHS.
The greatest act of devolution
However, it raises a fundamental question: can these two crucial parts of the national architecture within the NHS be undone without new legislation? IPPR has been investigating the most serious attempt to answer this question – Greater Manchester’s experiment in health “devolution”.
Local government is now involved in decision making in a way entirely lacking in most STP areas, and, partly as a result of this, the reform agenda is progressing at pace
When it was announced in 2015, Simon Stevens said that it was ”the greatest act of devolution… in the history of the NHS.” However, the reality, is that whilst local leaders have received some new powers over commissioning and budget allocation, they still sit within the straitjacket of national legislation; have no new powers over regulation, workforce or revenue raising; and remain ultimately accountable to the secretary of state for health.
That said, it has become increasingly clear to IPPR that the continuity which exists on paper belies the degree of change which is now happening on the ground. One local health leader in Greater Manchester recognised this: ”both nothing has changed, and everything has changed”.
Perhaps most importantly, local government is now involved in decision making in a way entirely lacking in most STP areas, and, partly as a result of this, the reform agenda is progressing at pace.
Take Tameside and Glossop as an example. Local leaders have come together and essentially created a single commissioning function between health, social care and public health worth nearly £500 million. However, in their own words, this has been “difficult and convoluted” and “could have been made much easier if the legislation was more conducive to place-based solutions”.
Against all odds
In other areas of Greater Manchester such as Salford, leaders are progressing with plans to create ACOs against all the odds.
At some point the government will have to face up to the fact that the national legislation in its current form is not fit for purpose
This suggests that whilst the legislation is not an absolute barrier to change, it is making it harder to achieve change and is slowing it down at a time when we can little afford to drag our feet. Furthermore, as local areas such as Greater Manchester push forward with reform, there will be a growing gap between the system that the legislation describes, and the one that exists on the ground.
This will make it near impossible for people on the outside to work out who is accountable and where decisions are taking place.
All of this has led IPPR to conclude that Greater Manchester, and other devo health areas (with London likely to follow suit in the near future), require a ”devo-health+” deal to enable them to complete the transition that has begun.
This would ultimately include making the mayor and the Combined Authority accountable for the NHS; giving local areas a combined financial control total for both providers and commissioners, alongside their share of the sustainability and transformation fund; as well as considering further fiscal devolution to give local areas real autonomy from central government.
However, this conclusion – that national legislation is a barrier to integration and progress on the government’s reform strategy – also has implications for the rest of the country and in particular for STPs.
Notably, Greater Manchester shows that if local areas can build strong relationships between partners around an ambitious local reform plan, they can make very real progress. At some point the government will have to face up to the fact that the national legislation in its current form is not fit for purpose.
Harry Quilter-Pinner is a research fellow at IPPR, the UK progressive think tank. He is co-author of Devo-Health: Where Next?