What do the government’s devolution plans mean for a national health service?

Democracy Devolution

We thought we had a political narrative on the shape of the NHS. David Cameron famously slams “pointless reorganisations” in 2011 but foolishly allows Andrew Lansley to run amok with his Health and Social Care Act in 2012. Jeremy Hunt is then brought in to steady the ship – Lansley having been deemed politically toxic – and we all settle down to making the 2012 structures work as best we can. Yet now we have a new kid on the block – George Osborne, chancellor of the exchequer – shaking up the NHS in revolutionary ways and with no scrutiny or transparency. What’s going on?

The starting point is Osborne’s surprise decision to devolve the £6bn NHS budget of Greater Manchester to a combined authority of the constituent local councils pending the arrival of a directly elected mayor in 2017 – a huge leap from the previous “city deals” that were confined to matters like planning and transport. The chancellor said this deal “set a trail for the rest of the country to follow” and, in responding to his recent arbitrary deadline for devolution bids, several combined local authorities have taken him at his word – Cornwall, Gloucestershire, Liverpool and London, among others, have all tabled bids to control their NHS funding.

This potentially amounts to an administrative revolution in the NHS that makes former shadow health secretary Andy Burnham’s pre-election proposals for stronger health and wellbeing boards look decidedly tame. The cities and local government devolution bill wending its way through parliament would, for example, give the secretary of state for communities and local government the power to transfer the functions and properties of other public bodies to these incipient, unelected combined local authorities. As things stand there is no exemption for NHS bodies from this clause.

We really need to start asking some serious questions about this silent administrative revolution:

What is the purpose?

Apart from some vague ideas about integrated care and service transformation, no clear reason for these changes has been expressed or debated. Indeed, since the various deals are undertaken as secret bilateral negotiations between central government and regional political elites, there is not even the opportunity to scrutinise and challenge whatever assumptions are being made.

Where are the providers?

Even in the case of Greater Manchester – the golden boy of devolution – the deal has been a secretive top-down arrangement between regional commissioners, national NHS agencies and the treasury. GP leaders in Manchester have described the announcement of the devolved NHS budget as “a total shock”, while third sector and independent providers of social care (accounting for almost all of it) have been completely sidelined. History tells us that top-down reforms alone rarely result in sustainable change at the frontline.

Where are the citizens?

In principle it would be reasonable to assume that devolution is something to do with empowering citizens of regions and localities, but democratic governance is absent. The public will be mystified at the multiplicity of directly unelected bodies like combined authorities and joint commission bodies running their affairs, and in due course greater control will be in the hands of a single directly elected mayor. The latter will certainly help to pinpoint responsibility but heroic leadership is a flawed model of governance. Already there is a wave of resistance in Greater Manchester by a range of activist groups, trade unions, MPs and the third sector. What sort of devolution deal has no seat at the table for citizens?

Where is the money?

It is far from clear who will hold the purse strings in a devolved NHS, how overspends will be addressed and how the boundary between free healthcare and means-tested social care will be negotiated. There will be no additional funding and the chancellor and health secretary will be only too happy to lay responsibility for rationing at the door of the devolved authorities. In this way a Tory government with a mission to run down the role of the state will have effectively removed the ‘N’ from the NHS and paved the way for a balkanised healthcare system across the entire UK. Politically contentious decisions on clinical thresholds for accessing services and support will no longer land in the lap of Westminster politicians.

Devolution to English regions is a clever political tactic – nobody is really against it, the rest of the UK already has it in varying degrees, Labour has been left flat-footed and regional political elites are keen to grab whatever powers and responsibilities are on offer. It may well, in principle, be a good idea to regionalise the NHS – there are arguments for and against. The problem we have is that this debate is not taking place. The NHS and local government is being transformed at pace and scale, yet most people have no awareness of this, have had no consultation and even less involvement. Lansley’s NHS bill was famously paused in order to reflect and gather fresh evidence. Maybe it’s time to do the same with the cities and local government devolution bill?

This was first published by the Guardian