Could Manchester pioneers save the NHS?
Greater Manchester will begin taking control of its health budget from April, after a devolution agreement was signed by the Chancellor, George Osborne.
What is being proposed?
At the moment, decisions about what kinds of health and social care services are available - or commissioned - are split between:
- local authorities - for social care and public health
- clinical commissioning groups - for hospitals, community health and mental health services
- NHS England - for primary care and specialised services
The idea is to bring together the separate budgets for all of these services - £6bn in total for Greater Manchester - and give these to a new body covering the whole of the area.
Its job will be to make many major decisions about the future of services across the area.
This is likely to mean that most health and care services - hospitals, community health services, primary care, social care and mental health services - will be commissioned within Greater Manchester.
|A tale of two systems|
|Services: Hospitals, GPs, mental health care and ambulance crews||Services: Care homes, domiciliary care at home and day centres|
|Budget: £100bn||Budget: £17bn|
|Funding shortfall: £30bn by 2020, according to NHS England||Funding shortfall: £4.3bn by 2019, according to councils|
|Structure: Run by NHS England and 211 GP-led clinical commissioning groups||Structure: Overseen by 151 councils, but many services are provided by private care firms|
|Cost: Free at the point of need, but charges made for dentistry and prescriptions||Cost: Only those with assets under £23,250 get help from the state. The rest have to pay all their costs|
|Numbers helped: One million every 36 hours||Numbers helped: 1.3 million a year get some contribution to care|
A new strategic body will be formed - the Greater Manchester Strategic Health and Social Care Partnership Board - supported by a joint commissioning board drawn from the 10 local authorities, clinical commissioning groups (CCGs) and NHS England.
They have signed an agreement to work together, with the aim of having new arrangements in place from April 2016.
Why is this being done?
The idea of public bodies working together to use their resources collectively for the benefit of local people is not new.
This was encouraged by the previous government through its Total Place programme and continued by the present administration through "whole place community budgets".
It is generally accepted that the NHS and local authorities should work much more closely together and share resources to meet the mixture of health and care needs that arise from an ageing population.
This is currently being done on a smaller scale across the country through the Better Care Fund.
There has also been talk of Whitehall devolving some its powers and money to groups of local authorities so decisions are made closer to local needs and to promote economic growth - this is behind Chancellor George Osborne's idea of a "northern powerhouse".
Manchester's local authorities have a history of working together, so it has been at the forefront of this agenda.
Towards the end of last year, the chancellor announced that powers for housing, planning, transport and policing would be devolved to a new directly elected mayor for the area.
What are the advantages of Devo Manc?
If it can be pulled off, there is a big prize for the people of Greater Manchester - drawing together the pieces of the health and care jigsaw into a more joined-up system that makes it easier to co-ordinate care around individual needs, prevent illness and promote wellbeing. This has been an aspiration of successive governments for decades.
The new set-up should mean that big decisions about future services, for example major hospitals, which affect the whole area, could be made within Greater Manchester, not outside it.
What are the risks?
Much depends on the detail of how it will work - which has yet to be agreed.
The biggest concerns are about accountability - who carries the can for the big sums of public money involved? Will decisions still be made by clinical commissioning groups and local authorities locally or will the new joint body be another layer of bureaucracy that will reduce local control? How will the risks be shared across organisations in Greater Manchester, for example if a major service runs out of money?
And with both the NHS and councils struggling to make ends meet, there are bound to be worries that Greater Manchester is being handed a poisoned chalice.
Some are concerned about giving elected members of local councils a bigger say in how the health service runs, but others argue that the NHS lacks local democratic legitimacy. The involvement of GPs and other NHS representatives in the joint body that will make decisions should allay some of these concerns - this not a wholesale transfer of the NHS to local councils.
Will it catch on?
All parts of the country need to work out how best to join up public services so they meet the changing needs for health and care that many more of us will have in future - and how to keep the whole population healthier.
But what works for a densely populated conurbation like Greater Manchester will not work for smaller towns and cities or for dispersed rural communities.
Greater Manchester's progress has been helped by good working relationships between local government and the local NHS. Elsewhere these are patchy.
The best examples of integrated care owe more to good relationships than they do to organisational structures.
How has the King's Fund come to these conclusions?
The King's Fund set up an independent commission, led by Kate Barker, to explore the current health and social care systems in England and propose a new approach that redesigns care around individual needs.
Its finding in 2014 were:
- The commission recommends moving to a single, ring-fenced budget for the NHS and social care, with a single commissioner for local services
- A new care and support allowance, suggested by the commission, would offer choice and control to people with low to moderate needs, while at the highest levels of need the battle lines between who pays for care - the NHS or the local authority - will be removed
- Individuals and their carers would benefit from a much simpler path through the whole system of health and social care that is designed to reflect changing levels of need
- The commission also recommends a focus on more equal support for equal need, which in the long term means making much more social care free at the point of use
- The commission largely rejects new NHS charges and private insurance options in favour of public funding