England & Wales Health and social care

Devolving health and social care: challenges and rewards


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Janet Sillett takes a look at the Devolution Bill and finds much that gives pause for thought for the NHS and social care provision.

The Cities and Local Government Devolution Bill isn’t wildly exciting at first glance. And it isn’t at all detailed. It is a framework Bill – proposing an ‘enabling’ framework within which devolution deals can be negotiated. In addition, the Bill was envisaged as being largely about devolving local government functions, not health.

But local government knows it is potentially very significant. It could even be significantly radical when it comes to health and social care. Why is that?

It provides an enabling structure to transfer functions of many public authorities, including NHS bodies, to local authorities. It applies to all NHS bodies – NHS trusts and foundation trusts, Care Quality Commission, NHS Litigation Authority, Monitor, clinical commissioning groups (CCGs) and NHS England – and even the Department of Health. Of course, the government is not likely to transfer the Department of Health en masse to local government any day soon. But the Bill does contain these powers – what can we expect from them?

Firstly – we can’t know how far the powers will be used. The Bill envisages a series of local deals, like the Treasury’s with Greater Manchester – and there will be different outcomes to negotiations. This is clearly right – what will work in Manchester may not work in other places. There is a problem, however, in the Bill lacking detail. Debates in the Lords and Commons so far have tried to pin Ministers down, especially over NHS safeguards. Ministers in the second reading are now introducing amendments to take on board these debates and are attempting to clarify the role of the Secretary of State, the core responsibilities of the NHS and of the regulatory bodies.

Although questions of safeguards and governance are being debated in parliament and to some extent being made clearer, there are bound to be issues at the local level when devolution takes place – who is finally accountable for decision-making locally; what is the relationship between the combined authority, the new set up for integrated health and care, individual councils, and the elected mayor (if there is one)? The Minister at the second reading talked about a breakdown or failure in a service – if there was, for example, a dispute between two constituent areas of a combined authority, one of which claimed that there was some inequity between the service that it was receiving and the service being received by the other, “the buck would stop with those who were making the decisions locally, and that is the combined authority”. The matter wouldn’t go anywhere near the Secretary of State. What the Secretary of State retains responsibility for “is the standards and whether or not there has been a breach of NHS duties in relation to anything that falls within his own overall responsibility”. It isn’t, though, always going to be obvious where the line is to be drawn.

Going back to a previous preoccupation of mine in relation to the whole devolution agenda – accountability and engagement locally. And surely this is even more critical when it comes to health services. There is still little evidence of local people being involved in the development of models or ‘bids’, and the government’s very tight deadline to get in bids to the Treasury hardly helped. Are care providers, health professionals and the third sector involved in discussions at an early enough stage?

It clearly isn’t easy to construct legislation that allows for local decision-making but without fragmenting or undermining what is perceived as a national health system. How far will local devolved health and social care bodies be able to exercise discretion? If and when health is increasingly devolved how will ‘national’ be defined in the future? This could obviously be highly sensitive politically – local government, as well as national government, needs to think through how these issues will be handled.

The other big political issue could be that of funding. Devolution is taking place at a time when social care and health are severely stretched. There won’t be additional money for devolved areas. There is probably an expectation at Westminster that savings can be made. It isn’t clear how overspends in health will be dealt with. Health is not so used to making savings as local government. There may also be difficulties over the boundary between free healthcare and a means-tested social care system. Of course that isn’t a new problem but it may be highlighted as devolution progresses.

The rewards of greater integration at the local level have been well argued – improving services that meet the particular needs of local areas, using the resources of local authorities to “go beyond integration of care to focus on population health”, as aptly put by the King’s Fund.

There are also clearly many technical and practical questions not yet fully answered, but the key question is perhaps more philosophical – how can a national health service be reconciled with a system that allows for local variations; how can we define ‘national’ in this context and can genuinely flexible and local solutions safeguard the principles which underpin the NHS?

The Bill and the deal in Greater Manchester do not fully answer that question. Answers will be shaped by what happens in Greater Manchester in the build up to full devolution in 2016, by the response of residents and communities, by how local areas and the NHS develop working arrangements, and by politics. The prize is certainly worth fighting for – winning it may well be tough going.

This blog is based on the recent LGiU members briefing: Health and social care devolution: a commentary