English devo bids: healthy or not?

Last Friday was the deadline for ‘devolution bids’ (proposals from groups of councils for greater control over public spending), and no doubt the end of frenzied negotiation and planning up and down the country.

Since the news in February that devolution in Greater Manchester would include health care, English devolution has been a hot topic in health. Perhaps surprisingly, the inclusion of health in devolution bids has been mixed. The map below (inspired by the Local Government Chronicle) shows the extent of bids including health devolution.

Around 25 bids were submitted in total - many aren’t published and some areas are submitting late, so we don’t know exact figures. To date, 11 areas have included greater control of health in their bid. The proposals vary – the majority include greater integration between health and care, while some ask for powers that may cause central government more consternation: Greater London is asking for control of its deficit regime; Cumbria wants to buy out its PFI; and Surrey, West Sussex and East Surrey are asking for a cross public sector transformation fund.

So some local government areas think devolved powers in health will be to the benefit of their populations, while others are taking a more cautious approach. What explains this difference in approach? Decisions will have been influenced by local context and relationships – and they may also have been pondering:

• The importance of symbolism. Many of the health goals cited in devolution bids can be achieved without changes to the current set up: bodies can pool health and social care budgets, public health can coordinate across councils, and models of care can be engineered to better fit with a place based approach to public services. However, Greater Manchester has generated a huge amount of enthusiasm and goodwill through their devolution agreement – a critical factor in making large-scale change happen. Explicit central permission for change is also incredibly helpful for transformation, which a devolution agreement may embody.
   
• Whether health financial woes are worth taking on for the opportunity to support other services. Health has not had the 30% cuts experienced by local government, and so may represent a source of funds for those struggling services. However, the yawning future financial gap in health may deter areas from taking it on: Greater Manchester is expected to deal with pressures of almost £1bn within a £6bn budget by 2020. Making health local areas’ responsibility may mean they are expected to cut other areas of spending before getting national bail outs for struggling hospitals.
   
• The future national approach. National relationships with devolved areas will practically determine how bold they can be: no plan that national politicians are consistently speaking out against will be workable. When services must be redesigned for financial viability, being vetoed by national bodies may feel like a real risk – no matter what devolution agreements say. On the other hand, devolution may provide some protection from future national health decisions, giving local areas more license to prioritise according to their needs and values.
   
• The cost of restructuring. Changing governance structures, working out new responsibilities and building trust between partners all take time and effort, and can distract from improving services. Any benefits of new governance arrangements will take time to manifest, and local areas may have more pressing priorities for change, perhaps improving quality, better integrated provision or more efficient services. 

A difficult set of factors indeed. Interestingly, there are reports that in areas where local government has not bid for devolved health powers, NHS England is involved in discussions with health leaders on greater regionalisation of power. This highlights ongoing central interest in decentralising health responsibilities, and perhaps reflects nostalgia for some of what Strategic Health Authorities did.

It’s clear we’ll have a mixed system in England: some local government areas with devolved health powers, the scale of which are likely to vary widely. Other areas will have health bodies working together on a wider scale than currently, or will continue to experiment with new models of care for health. There will remain others who for this parliament at least have services set up and managed in much the same way as they are now.

Will people living in areas with devolved health powers have better health and care? Or would no structural change and a ruthless focus on efficiency mean more and better care can be provided? These are the real questions for local leaders – and at the moment we have little in the way of answers.