If devolution is the answer, what is the question?
Health policy is notoriously prone to fads and fashions.
Health policy is notoriously prone to fads and fashions. It was Ted Marmor who warned against the ‘persistent pursuit of panaceas’ that are promoted enthusiastically as policy solutions, only to be quietly dropped when they fail to live up to expectations. Arguably, the latest fashionable policy idea for both the NHS and local government is that of regional devolution. Manchester is out there in front with DevoManc, and the city regions jostling to be next in line for devolution of power to run health and social care appear to have been pipped at the post by rural Cornwall which is soon to be running DevoCorn.
The English NHS is one of the most centrally run health systems in the world, with ministers prone to micro-managing the performance of health care organisations, and local managers and boards routinely looking upwards for guidance and approval. This makes it all the more fascinating that NHS England and the Treasury have done a deal with Greater Manchester to try out a very different way of running local health and care services. However, before we get too carried away, we should take some time to examine existing research evidence. At a recent public debate hosted by Leeds Beckett University we did just this, asking: if devolution is the answer, what is the question?
The first question that devolution will be trying to answer is how to commission health and social care in a more locally appropriate manner, at a time when resources are scarce and decisions about funding priorities likely to be tough and contested. Joint commissioning has been extensively researched and evidence suggests that arrangements typically spend too much time on processes, structures and relationships, with precious little attention paid to agreeing clear desired outcomes and how these will be measured. Research into health commissioning likewise reveals a tendency to focus on service design and stakeholder involvement, with funders struggling to take difficult decisions about stopping one service and putting in place another. If regional devolution is to buck this trend, it will need to have robust arrangements for enacting its funding priorities, along with political cover at a local and national level.
A second purpose for regional devolution will be the search for the holy grail of integrated care, something that eludes countries across the OECD. Local government and the NHS are bedevilled by poor coordination of services offered to frail older people, children and vulnerable families, and those living with mental health problems, and the separate funding, governance and provider arrangements in England are often blamed for this. Research evidence is however somewhat equivocal in the area of integrated care: efforts to improve care coordination seem to improve user and carer experience, but struggle to save money, and may in fact unearth additional demand. It is important to note that in Northern Ireland, where health and social care have been run jointly for decades, similar problems of disintegrated care are often found.
The third reason for devolution is likely to be a whole-hearted attempt to refocus health and social care on prevention of frailty and ill-health, rather than being forever caught up in sorting out service provision for those already struggling with complex health conditions. Perhaps this is where a devolved approach has something rather different to offer, drawing together the resources and expertise of public health, regional development, housing, education, and NHS care into a single process of planning, priority setting and commissioning. Indeed, there is learning to be gained from Wales, where different health and care funding priorities have been adopted, focused more strongly on prevention, public health and social care. Boldness will however be needed here by any devolved English region, for investment in public health and prevention will entail cuts to services elsewhere. Local government is well-used to making such unpopular decisions and meeting its financial targets, but the NHS has a tradition of baulking difficult choices and living with over-spends that get bailed out by national politicians running scared of the voters.
Alongside all of this is the spectre of that most uncomfortable of facts - that research has shown unequivocally that structural reorganisation rarely achieves its intended goals, and distracts from the tough business of getting on with changing services. The most profound challenge to Manchester and Cornwall is to demonstrate that by working in a new joint arrangement across health and local government, different and more accountable decisions can be made about service provision, whilst avoiding unnecessary and distracting changes to management arrangements and organisational structures.
If devolution to regions is to really enable a properly accountable and bold ‘NHS Local’ in place of the centralised approach we have had since 1948, there will be need for absolute clarity as to its purpose, and how local people, politicians and professionals can measure success. Perhaps the most difficult question to ponder is whether DevoManc and DevoCorn will prove to be radical new organisations that enable preventative and holistic care, or the latest in a line of policy fads.