The example of DevoManc

DevoManc is a key part of what was George Osborne’s Northern Powerhouse strategy that included giving directly elected mayors considerable powers. In November 2014, the Chancellor of the Exchequer and the Greater Manchester Combined Authority or GMCA (comprised of 10 Councils and led by the first directly elected Mayor outside of London) signed an agreement. This was to devolve powers over transport, housing, planning and policing from central government to the GMCA, together with £22 billion of public funding.

While the initial scope of Devo Manc did not include health, just a few weeks before the 2015 general election, George Osborne and Simon Stevens (head of NHS England) announced a ‘memorandum of understanding’ (MoU) between all Local Authority members of the Association of Greater Manchester Authorities and all Greater Manchester CCGs. The deal was a secretive, top-down arrangement that appeared without warning: there was no consultation with the public, MPs, trades unions or local GPs, and the roles of private sector and third sector providers remain to be determined.

The stated aim given in the MoU is to “ensure the greatest and fastest improvement to the health and wellbeing of the citizens of Greater Manchester (GM)” through creating

“a more integrated approach to the use of existing health and care resources – around £6 billion in 2015/16 – as well as transformational changes in the way in which services are delivered across Greater Manchester”.

It’s also been claimed that ‘reform’ for the region’s health and social care system (which is facing a £2 billion shortfall by 2020) is necessary if it’s to become financially sustainable. (By October 2015 the cost of transforming the system was already over £12 million, spent on legal advice, public consultations and public relations and included £4.6 million spent on external consultants – see http://www.manchestereveningnews.co.uk/news/health/shake-up-nhs-services-greater-10341665).

The MoU sets out plans for the full devolution of funding and decision making for health and social care within GM. Its objectives clearly mirror those of NHS England’s Five Year Forward View (FYFV) which, the MoU notes, include setting up new models of care for delivering the NHS in future: GM has committed to becoming a test bed or trailblazer for these.

And alongside new models of care, around 20% of Manchester’s 3 million people who have been identified as at risk of long-term ill health and hospitalisation will be offered a personalised care package, apparently “directly targeted at each person’s lifestyle and underlying conditions”, with the aim of preventing 60,000 hospital admissions each year (http://www.reform.uk/publication/letting-go-how-english-devolution-can-help-solve-the-nhs-care-and-cash-crisis/).

Devolution will give GM control of the whole health and social care system, including:

  • acute care including specialised services,
  • primary care including management of GP contracts,
  • community services,
  • mental health services,
  • social care,
  • public health,
  • health education, and
  • research and development.

The process will require changes to

  • governance and regulation,
  • resources and finance,
  • capital and estate (“a radical approach will be taken to optimising the use of NHS and social care estates” p.viii)
  • workforce,
  • communication and engagement, and
  • information sharing and systems (such as digital integration across GM).

It means a massive change in the way that funding and commissioning are organised, with the pooling of different streams of funding from NHS England, CCGs, and Local Authorities, Public Health England and mental health and social care services into one pot, and diverting funding directly to new models of care, as described in the FYFV.

To achieve all this, Devo Manc is setting up

  • a new board to set strategy and priorities – the Greater Manchester Strategic Health and Social Care Partnership Board (GMSHSCB). Members will include regional representatives from local councils and the NHS, plus the chief officer of NHS England and a senior figure from the Department of Health.
  • a new organisation to commission services across GM – the Greater Manchester Joint Commissioning Board, made up of representatives from NHS England, 10 Local Authorities, and 12 CCGs, and
  • a new body to provide overall strategic direction and oversight – the Health and Social Care Devolution Programme Board, which will include the chief officer of NHS England.

Membership of these bodies shows that, although Devo Manc is said to be about devolving control of health and social care services to Greater Manchester, it looks like NHS England will still have considerable influence on all the main decision-making bodies.

The speed at which Devo Manc has been set up means that many things are still unclear. For example, how much freedom will GM have to depart from national policies, and what would such freedom mean for a national NHS? Who will be accountable for the £6 billion budget for health and social care – the Mayor or the GMSHSCB? How does competition fit with all this and who will be ensuring safe standards of care: what roles will national regulatory bodies like NHS Improvement and the CQC play in a decentralised system?

What Devo Manc will mean for patients

In theory, greater integration of services such as healthcare, public health and social care should bring benefits. However, current proposals raise serious concerns. For example, civil society groups based in Manchester, such as Greater Manchester Keep Our NHS Public and Save Our NHS, have raised the following concerns about what Devo Manc will mean for patients:

  • cuts to services (the devolved £6 billion budget is not enough to provide an acceptable level of healthcare for those living in Greater Manchester and will lead to cuts and closures now and down the line);
  • reconfiguration of services, leading to cuts (four or five of GM’s current hospitals will become specialist centres. The rest will be downgraded with the removal of emergency surgery, less capital investment, less service provision, and reduced opportunity for professional training);
  • longer traveling times (e.g. the average ambulance journey will increase by about one third, from 12 minutes to 17 minutes);
  • longer waiting times (even if the hospital you are using is local to you, it will be busier because it is now covering a massive area);
  • fewer staff per patient (cuts will mean demands for ‘increased productivity’, with more patients to each nurse and gaps filled by lower-paid, lower qualified staff.

Other concerns about Devo Manc

More indirect consequences for patients may arise from

  • loss of public ownership (Devo Manc will be a guinea pig for increased privatisation through a redesign of services using ‘new care models’ akin to US Health Maintenance Organisations);
  • less public accountability (the new body for planning – the GMSHSCB (see above) – will have no elected representatives;
  • loss of training placements and expert teachers (following the closure of services);
  • cuts to pay and conditions for staff and a demoralised workforce (with, for example, the introduction of local pay and an end to national rates negotiated by trades unions);
  • the de-skilling of staff (lower qualified staff will take on work now performed by doctors and nurses, and the expectation of an increase in unpaid labour (volunteers).

(See http://keepournhspublicgmcr.com)

Sources and further information

The Greater Manchester Agreement: Devolution to the GMCA and transition to a directly elected mayor: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/369858/Greater_Manchester_Agreement_i.pdf

 The Greater Manchester Memorandum of Understanding http://www.agma.gov.uk/cms_media/files/mou.pdf

updated Jan 2017

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