George Osbourne, when Chancellor of the Exchequer, pushed for many of the powers of central government to be devolved to local areas. The argument was that devolution would support economic growth, and bring about public service reform and improved local accountability. A number of devolution deals have been negotiated so far (see our page on the example of Manchester), each varying in content and agreed separately. Each deal potentially means significant changes to the investment of public money, and the planning and delivery of public services, including NHS services.
At the same time, NHS England, in order to push through the transformation of the NHS set out in its Five Year Forward View, has created 44 local health economies or ‘footprints’, which may or may not correspond with the boundaries of devolution deals. Each footprint must produce a Sustainability and Transformation Plan (STP) to restructure local services (such as introducing new models of care), integrate health and social care, and ensure financial balance. So far, it seems that in the development of STPs, it is the local CCGs that are the main drivers, and local authorities have minimal input. It seems fair to say, that at the moment, it’s not clear how this process of ‘transformation’ and that of devolution will align.
The Cities and Local Government Devolution Act (2016) gives the Secretary of State for Communities and Local Government the power to hand over the functions and property of any public body to a county council or combined local authorities.
In the case of the NHS, the Act allows ministers to transfer property, rights and liabilities (such as responsibility for debts) from any public authority (such as NHS England, NHS trusts or NHS foundation trusts) to a county council or ‘combined authority’ (two or more local councils).
While the Act allows health powers to be transferred to a combined authority, these powers are limited in that they cannot change the NHS Constitution. In addition, despite the devolution of health, the ultimate responsibility for the NHS remains at the national level. Accountability for the quality and effectiveness of healthcare remains with the Department for Health, provider organisations, clinical commissioning groups and NHS England. Providers of regulated services will continue to be inspected by the Care Quality Commission and meet national registration requirements.
Pros and cons of devolution
One reason put forward for devolving power over health services to local bodies is that they are in the best position to deal with inefficiencies or to address the place-based issues that lead to health inequalities and the causes of ill-health. Some argue that having powers to deal with complex issues like homelessness, mental ill-health, or traffic pollution can have a greater impact on health outcomes than reforming the NHS itself (http://www.ippr.org/files/publications/pdf/devohealth_whatwhy_Aug%202016_spreads.pdf?noredirect=1).
However, devolution and the integration of health and social care that accompanies this raise many concerns. For example,
- The transfer of NHS assets and functions to local authorities is going ahead with very little opportunity for any democratic challenge or debate. There has been no government consultation or royal commission to take opinion or weigh the evidence for integration or devolution. And, for the most part, there has been no consultation with those living in the areas where devolution is being introduced.
- The transfer of functions and assets only requires secondary legislation, which usually receives little scrutiny.
- Clinical Commissioning Groups (CCGs), introduced by the Health and Social Care Act (2012), were supposedly set up to put clinicians at the heart of decision making about the design and purchasing of health services. However, with devolution, some or all of the responsibilities of a CCG could potentially be taken over by a combined authority. This means that while devolution may shift some powers away from Westminster, for the average citizen, decision-making may become more remote.
- It seems especially unwise to bring in massive change at a time when public services are experiencing unprecedented pressures, and local authorities are facing massive spending cuts.
- While central government has the power to respond to pressure and find additional funding to address NHS deficits, local authorities have no option but to limit spending in order to stay within budget. Devolving responsibility for NHS services to local authorities will allow central government to take unpopular measures (like cutting NHS funding) while local authorities take the blame for the consequences.
- Pooling health and social care funding may mean that money earmarked for NHS services can be hived off by cash-strapped local authorities to help sustain other struggling services that they are responsible for, like adult social care: as the Chair of the Local Government Association is reported to have said “we have to get our hands on NHS funding” (https://opendemocracy.net/ournhs/john-lister/london-devolution-its-obvious-to-all-but-gullible-power-grabbing-councillors-this). Although NHS funding is supposed to be ring-fenced, local authorities may be tempted to find ways (such as redefining health and health services) in order to access NHS money.
- Devolving health has been seen as a way of gaining consent for some of the controversial changes set out in NHS England’s Five Year Forward View (FYFV) and speeding up its implementation. For example, setting up new models of care as described in the FYFV (and seen by some to facilitate the privatisation of the NHS) are central to ‘devo-health’.
- Experience so far suggests that devolution is being used as an undemocratic way of dismantling the NHS as a national service, replacing it with a patchwork of localised services, and raising the prospect of a post-code lottery that decides the availability and quality of health services available to us. It is unclear with devolution if national or local government will decide service priorities and whether, for example, a particular hospital or A&E department can be closed.
- New devolved authorities will have powerful new freedoms to decide on finance, the sale of NHS land, and the introduction of health charges.
- Devolved authorities will also have the power to end national agreements on pay and conditions of work for staff.
- The new models of care proposed are similar to those found in the US: devolved and integrated services based on these models and represent a considerable prize for multinational health care providers, particularly if given the scope to both commission and provide services.
- Devolution may bring new and additional structures, making the NHS even more complex as an organisation.
- The process and resources for local scrutiny and accountability are not transparent: taxpayers are currently in the dar about who is spending their money, how that money is allocated and where responsibility lies if the system fails to deliver good value or things go wrong (see http://www.publications.parliament.uk/pa/cm201617/cmselect/cmpubacc/866/86604.htm).
A number of combined authorities (for instance, Cornwall, Gloucestershire, Liverpool and Greater London) have put forward proposals to control their NHS funding, while there is already agreement for the £6 billion budget for NHS and social care services in Greater Manchester to be devolved to a combined group of local councils as part of a broader deal known as DevoManc. The government, NHS and local authorities signed an agreement to devolve control of health and care services to local commissioners and councils in December 2015 (for details see http://www.gponline.com/devolution-deal-london-opens-door-radical-nhs-integration-plans/article/1376953).
As the King’s Fund think tank points out, the kind of proposals seen so far are more akin to delegation rather than devolution, with formal accountability (and the power to make major decisions) remaining with NHS bodies like NHS England. Without new legislation, there is little to stop NHS England (or other national bodies) from taking back control.