Devo Manc – Don’t Panic

Devolution NHS reorganisation

It’s a wow moment in NHS history.  It’s the latest ‘this is the end of the NHS’ moment.  Headline grabbing proposals for Manchester (somewhere up North) are either a brave experiment or a pending disaster.

An unholy alliance of Tory Central and Labour Local government has not only dared to suggest that some decisions about health services could be taken locally by those we elect; they have actually set out to try this dangerous idea out for real.

The loathing between local authorities and health service is as old as the NHS.  The battle to stop any kind of democratic accountability for health services (or at least the exciting ones like acute care) was lost in the original settlement.  Just how real the shift will be in Manchester is a bit vague but the intention is brave enough.

At the heart of this experiment is actually the very important issue about accountability.  The old NHS was based on the principle that a Secretary of State (who was at least indirectly elected) was accountable for everything including dropped bed pans in Wales.  This long standing fiction was diluted a bit during the reforms of the 1990’s and then recently replaced altogether by the new market settlement post the Lansley changes so that nobody at all is accountable for anything.

Local government is good at accountability.  When any decision is taken you get notice of the intention to decide in advance; you get to see all the relevant documents; you see the actual decision being made (or at least recorded) in public and so you know who has taken it.  Local authorities do have occasional ‘commercial confidential’ moments but by and large there is no doubt about who has decided what and the reasons they have relied on.  The elected decision makers have to work alongside the appointed professional officers who can and do intervene and can and do make their views heard.

The NHS is abysmal at accountability.  Nobody has any real idea who is actually responsible for what, although despite this apparent advantage the NHS is almost incapable of making tough decisions – at the first sign of organised and vocal opposition decisions are mysteriously avoided for as long as possible.

The long and troubled history of contested change and of pointless redisorganisation in the NHS is not due to the battle between public and private sector at all, it’s about protecting the NHS from effective management and so from democracy and accountability.  The NHS wants to remain as an island separated from the rest of the public services; it wants to remain as a federation of vested interests compromising only to mutual benefit, it does not want to be integrated into the public service mire.  It does not even want to be internally integrated, the various tribes want to retain their independence to ensure the disconnected and incoherent system which appears when viewed by the long suffering patients.

So Super Manc is a real threat to the NHS as a separate empire. Which is a good thing as just about everyone agrees that integration would nice.

You can have integration of services without integrated structures (possibly anyway).  But there has to be some financial, structural or organisational change to overcome the years of disintegration – dating back from long before the market ideas made it far worse. There are some big issues around how funding for health care is allocated efficiently, around variations in quality for no apparent reason, of disintegration to support the outdated medical model of care and of the refusal to accept the value of shared decision making and viewing patients and communities as resources.  These issues need resolving so we can move forwards to a modern care system although many prefer to go back to the insular NHS in its golden age sometime in the 1970’s.  The old separate monolithic NHS can’t deliver what is needed, and increasingly impatiently expected, in the current day world.

So we should all welcome what is being tried in Manchester.  Let’s encourage them to try new ideas; they can’t destroy the NHS on their own.  We should all get behind the idea that we have a National NHS so long as entitlement and standards, staff terms and conditions and major priorities are defined nationally.  But we should then acknowledge that there are always local variations and it is pointless assuming that top down national imposition is better than allowing local variations as regards what priorities are set and how funding is allocated locally. And do the national bodies like the CQC, Monitor and all really achieve more than could be done by local means of oversight?

How we deliver the services people need and how we organise provision can be determined locally and can be determined by looking locally at all the many services which contribute to our health and wellbeing.  These decisions made locally should be made by people we elect, that is the role of our democratic structures – to make the hard decisions on our behalf.  Luckily we already have all the structures in place to make this possible as it does for education, housing, environmental health, transport and everything else apart from health.

It is genuinely hard to believe that so many are actually saying they prefer key decisions about health services to be made (or avoided) by unknown, unelected and  unaccountable bureaucrats rather than those we elect.

The risks that this is just a ploy to pass deficits to local authorities or a back door into privatisation and outsourcing which has been the regrettable norm for local authorities are real enough so safeguards and vigilance are necessary but surely these can be addressed; and could it really be any worse than now?

A rational discussion about the role of the whole public sector in wellbeing, and so about accountability and local decision making would be valuable but we have not had one for the last 65 years.