North by North West: Where is Greater Manchester's transformation?

It would be rash to start making early judgements on Greater Manchester’s devolution project, but there is some cause for concern around one of the key measures of success.

With the help of a £450m transformation fund – a level of investment which other health economies would love to get their hands on – the region has set about trying to reduce demand for acute services, particularly non-electives.

But since the start of the devolution deal in 2016-17, when the five-year transformation funding started kicking in, the trendline has shot up in the wrong direction.

According to official NHS England statistics, Greater Manchester was already starting from a bad position, with a rate of “emergency bed days” well above the national average (although an adjustment is made for deprivation in these figures, the impact is likely to be underestimated). 

But what’s more worrying (and can’t be explained by the deprivation factor) is the sharp spike reported over the course of 2016-17, compared to the more modest national increase.

While no one expected dramatic improvements to be made in year one of devolution, the rate of increase compared to the England-wide figures is surprising.

The boroughs largely driving the increase have been Manchester, Trafford, Wigan, and Salford.

There will be relief that the rate has flatlined in 2017-18, but the flatline obviously still leaves the region stuck on a much higher rate.

Greater Manchester Health and Social Care Partnership has previously cited the four-hour accident and emergency target to be the health economy’s Achilles’ heel. But unless positive progress starts to be shown on emergency bed days, then difficult questions will also start to be asked about the region’s transformation efforts and spending decisions.

Asked about the trend, the devolution team said they had different data which showed a “broadly stable” rate of emergency bed days over the last five years, along with a graph which appears to support this.

The rate shown in the graph is markedly lower, however, so it appears to be measuring something different. The team was unwilling to provide definitions for what was being measured, instead describing the metric as a “work in progress”.

The NHS England data – for which you can see detailed definitions here (page 88) – is used as part of the Clinical Commissioning Group Assessment Framework. Providing the data is accurately reported, it allows useful comparisons between different areas. Emergency bed day rates are deemed to be the one of the most pertinent measures of “transformation” by national leaders.

In one of the more enigmatic replies I’ve seen this year, the devolution team said they were “neither disputing nor not disputing” the official figures.

Assuming the trend is real, this will likely also make for difficult reading by the government and NHS England.

They have given the project significant backing - both political and financial - in the hope that it will help the rest of the NHS find a sustainable path. But if demand keeps soaring, a plan B will be required.