An MPU-Unite Statement
SUMMARY
What follows is an analysis of why we feel ‘DevoManc’ is the wrong solution to the correct question – how can we integrate health and social care locally under a national framework which would preserve the ‘risk-sharing’ that is essential in a national service?
It is apparent that this agreement was made in a hurry that by-passed any wider democratic input or consideration. There are also unanswered questions: What happens to Manchester’s services if the budget proves inadequate? Who funds any gaps and what is the mechanism for further funding? Does an agreement such as this make privatisation moves and postcode lottery more likely?
The statement is comprehensive because the issues raised are serious and complex. We hope it is a useful effort in trying to understand developments in UK health and social care.
THE DETAIL
Greater Manchester has agreed with the ConDem government a devolution package. This includes transport, infrastructure, various elements of public sector reform, health and social care integration and certain measures to allow Greater Manchester to enjoy the benefits of local economic growth, including retention of business rates and the potential to retain welfare savings that result from getting people back into work.
The proposal for health and social care integration and the devolution of health and social care spending has led to concerns that this may be a prelude to further breaking up of the NHS and MPU is deeply concerned at the precedent that might be set.
It is however impossible to respond fully to the GM devolution package without an understanding of the context. This context must include our attitude to health and social care integration, to localism in the NHS, to the GM approach to public sector reform and economic growth and to the fact that the GM devolution package was hurriedly adopted in response to the threat of English Votes for English Laws.
HEALTH AND SOCIAL CARE INTEGRATION
Health and social care spending closely interact and many of the problems of the NHS result from the failures of social care. This makes it seem natural to propose the integration of the two budgets but this leads to fears that integration will allow NHS resources being diverted. Ironically the absence of pooled budgets has not prevented NHS resources being diverted – increasingly the cuts in social care funding that flow from local government austerity have imposed burdens on the NHS. The NHS has often locally bought out such burdens by a variety of mechanisms and the Better Care Fund institutionalised this by transferring NHS funds into social care.
For so long as austerity budgeting continues it follows that unless social care is protected by becoming part of the NHS it will continue to suffer cuts which will impact on NHS finances either directly or indirectly.
The situation in Wales, where health and social care funding has been cut less than in England but health spending has been cut to protect social care, has been cynically criticised by the Tories, but draws stark attention to the political problems of Labour areas (like the majority of the councils in Greater Manchester) trying to pursue policies which combine the protected NHS budget with an unprotected social care budget.
Protecting social care funding as part of the protection of NHS funding is essential. In that context health and social care integration would be rational. Without that it is a trap.
Rendering it legally part of the comprehensive health service in the same way as public health is and using the term “the NHS” to mean the whole of the comprehensive health service is the simplest way of delivering that protection and is philosophically desirable.
This raises the issue of social care charges. They should be abolished. There will need to be an increase in taxation to fund this but the public are intelligent enough to understand that they will be paying more tax in order to remove a hated charge and there is no reason to suppose that this will be unpopular if properly presented.
We can support health and social care integration if, and only if, social care is seen as part of the NHS, its funding protected as such, social care charges abolished with funding provided to replace them, and a process put in place for progressively reversing the cuts in social care funding that have taken place over the last few years.
There are no proposals in the GM devolution package for additional social care funding or for the abolition of social care charges.
LOCALISM IN THE NHS
MPU’s original proposals for an NHS in 1925 envisaged the NHS being run by county councils as did the BMA’s proposals in 1930. However concern about disparity in the performance of local government hospitals in the 1930s led both organisations to cool to the idea of local government control of the NHS and Nye Bevan was equally suspicious.
From 1948-1974 local government played an important role as one of the three wings of a tripartite NHS. The role of local government was to manage community health services and to address the social and environmental determinants of health. We often forget that it was the Health Departments of local authorities, part of Bevan’s NHS, which cleaned the air and cleared the slums. The NHS was at that time seen as an institution by which the people would collectively address the improvement of health. The provision of healthcare according to need not ability to pay was an important element of that concept but by no means all of it.
The hospitals and the family health services were not run by local government and formed the other two wings of the tripartite NHS but they were nonetheless run by local bodies. However this localism took place in a context of a national responsibility vested in the Secretary of State for the provision of a comprehensive health service. This balanced the localism of the local bodies
In 1974 the NHS was reorganised as a centralised bureaucracy committed only to the provision of health care with its broader role in addressing the determinants of health essentially disregarded, left only as some residual environmental health regulatory functions located in local councils but separated from any wider vision and excluded from the definition of the NHS.
The original vision of the NHS as a mechanism for the people collectively to pursue the improvement of health as a social goal must be restored and a degree of localism is essential for that to happen. However we also need the restoration of the duty on the Secretary of State to provide a comprehensive health service and localism needs to take place only in that context and only with guaranteed standards and protected funding.
The GM devolution package does not include these protections. There are serious doubts about the performance of public health duties by at least one, and possibly two, Greater Manchester councils, reinforcing the fact that, even in an area where performance of public health duties is generally good, there can still be serious variability of exactly the kind that concerned Nye Bevan in 1948.
THE GREATER MANCHESTER ECONOMIC PACKAGE
Greater Manchester is a deprived area which has been savagely affected by ConDem cuts that have irrationally transferred resources from deprived areas to areas with large elderly populations, neglecting the fact that in deprived areas people become dependent on services earlier in their life. In response to these cuts it has been pursuing a programme of public sector reform which is based on rethinking the functioning of public services so as to focus on reducing need by preventive measures and early intervention and achieving efficiency through interagency working.
Greater Manchester, in partnership with local businesses, has also been pursuing an economic strategy aimed at getting people back to work. Greater Manchester has experienced the highest level of economic growth outside London.
There is much for the eight Labour-controlled, one Tory-controlled and one Lib Dem-controlled authorities in Greater Manchester to be proud of in their approach to economic growth and to public sector reform. It is a powerful object lesson in the success of the kinds of economic strategies which Labour advances in the current election. Labour should make more of it as a case study.
It is understandable that GM should seek to find ways in which its public services can benefit from this success and understandable that the local NHS leaders should want to be part of that. It is doubtful however if this context is itself sufficient to make good the defects in the GM model of health and social care integration. It would in any case set a precedent for areas where even this protective context is absent.
ENGLISH VOTES FOR ENGLISH LAWS
GM devolution was pursued hurriedly, and with minimal consultation, debate, detailed analysis or democratic process. This would be unjustifiable were it not for the fear that the introduction of English Votes for English laws would lock us into present public sector models, including present legislation on the NHS. For some this justified the speed of these proposals. But this risk is exaggerated. The last three Labour governments would still have had a Commons majority even without Scottish MPs.
English Votes for English Laws is a threat to the NHS by making it difficult to reverse the present disastrous pro-market ideologically-driven legal framework, but not an inevitable threat, especially in the current political climate when all three establishment parties, Labour Conservative and Lib Dems, are losing their hegemony to challenger parties on the left and right. It is understandable that areas should seek to find their own ways to escape this consequence. However this is no substitute for a concerted political programme aimed at ending the domination of English politics by a minority of the English people sustained by an unfair electoral system and a distortion of political debate that results from that.