The quiet local revolution reshaping the NHS
(6 May 2015)
Professor David Hunter describes how the shift of health policy from London to the English regions could reshape the future of the NHS.
In the closing days of the election campaign, the political parties continue to slug it out over who is going to save or wreck the NHS. They seem to have forgotten the quiet revolution getting underway in the north-west of England which could prove decisive in determining the NHS’s fate.
Trapped in traditional command-and-control mode, the secretary of state for health is pulling levers in Whitehall hoping, often in vain, that they are attached to something. But the politicians fighting the election this week seem to have forgotten the historic event which took place earlier this year.
Following the Greater Manchester Health and Social Care Devolution Memorandum of Understanding, published in April, the focus of much health policy is destined to shift from London to the English regions. Make no mistake, what is happening in the north-west will quickly be followed after the election by similar demands in the north-east, Yorkshire and Humberside, the south-west and other regions. The regions are already queuing up.
From April 2016, around £6 billion will be devolved to the Greater Manchester Strategic Health and Social Care Partnership, covering a population of 2.8m people. And, for the first time since the NHS was created, local government will be in charge and lead the transformational changes in the way future services are delivered.
The handover of power is not so outlandish. Aneurin Bevan, founder of the NHS, foresaw that one day local government would take over responsibility for the NHS. Those wishing to see a return to the original pre-Lansley NHS model are unlikely to have their hopes realised.
But is it really as bad as many of them fear?. Rather like the SNP being considered by those on the left as the only hope for bringing about an end to deeply flawed and unnecessary austerity – which they see as ideologically driven as an excuse to shrink the state – local government may be the saviour of a health system urgently in need of a makeover to render it fit for the 21st century. Who knows, it may make a better job of running the NHS than Whitehall has – for the most part, anyway.
Reasserting local government
The UK, and certainly England, remains the most centralised country in Europe. Perhaps this would matter less if competence in government was assured, but as King and Crewe’s masterly book detailing the blunders of successive government concludes, such systemic failure needs fixing. A rejuvenated local government offers hope for fixing our broken political system from the bottom up.
Critics of DevoManc, many of them apparently hankering after some mythical golden age, fear that it is a fast track to outsourcing and privatising services. But it might also be a way of ensuring that such a fate does not befall the NHS. It may seem counter-intuitive in the midst of the coalition government’s full-frontal assault on local government but precisely for that reason, the time is surely right to reassert the important role local government has in charting a progressive future.
Focusing democratic renewal on local government creates possibilities for participatory decision-making inconceivable at a national level. A combination of elected members and social movements developing policy, tackling inequalities and opening up local decision-making to scrutiny and challenge is possible and examples can be drawn from the contemporary context in which local government operates. One example is the North East Child Poverty Commission. Through lobbying, influencing and campaigning to raise awareness and build public support for giving children in the north-east equal life chances.
Democratic renewal may be a bold vision for local government when it is on its knees but its survival demands nothing less. A sense of renewed purpose is sorely and urgently needed. The DevoManc experiment may be exactly what is needed to break the mould, rescue both local government from the central assault and the NHS from a similar fate, and restore faith in the public realm.
On a more practical level, and echoing the whole area approach to public services, known as the total place pilots, which were supported by New Labour towards the end of its term of office, DevoManc holds out the real prospect for joined up, place-based policy-making that has so far proved so elusive.
DevoManc’s objectives go to the heart of what a renewal of health policy demands: a focus on prevention, public health and promoting well-being; closing the health inequalities gap both within Greater Manchester and between the region and the rest of the UK; integrating health and social care and creating healthy communities that are also economically productive ones.
Of course there are risks. Elected members will in some cases be seduced by neo-liberal ideas concerning the alleged superiority of markets, despite the evidence suggesting otherwise in areas of public policy such as health. But it will be up to local communities to decide whether that is what they want and act accordingly. As Bevan said about the NHS at its birth in 1948: it “will last as long as there are folk left with the faith to fight for it”. Without that faith the NHS will not long survive under any form of governance.
If DevoManc is to be an early implementer and a test bed for new thinking in health systems that reflects the needs of local populations, then that is surely to be welcomed.
First published in The Conversation.