6Health devolution
80.We had many questions about health devolution: whether it is in fact devolution at all, whether it is necessary, how it will mesh with existing integration initiatives, how it will impact on funding and how it will affect accountability in what is already a very complex set of arrangements. It has been difficult to identify what it means in practice and what it might entail for other areas. The tone of the evidence we received was fairly cautious. We understand that, of the 38 bids submitted to the Government, around half include requests relating to health and social care.193 The Devolution Bill aids joint decision making between local authorities and Clinical Commissioning Groups (CCGs) by enabling joint commissioning boards to take on commissioning functions and financial resources and enabling combined or local authorities to take on or concurrently or jointly exercise functional responsibilities from a public authority. The NHS Confederation said that the Devolution Bill could potentially allow local areas to have “much greater control over the planning and delivery of services currently outside the remit of local authorities and NHS CCGs”194 and this gives them “a new opportunity to do things differently and take a broader focus”.195
81.It is widely recognised that individuals with long-term complex care needs can ‘fall through the gaps’ between services. Over the years, various initiatives, focusing particularly on the integration of health and social care services, have attempted to address this problem, with some success. The evidence we received suggested that, when successful initiatives of this kind are in place, formal health devolution may not add much. NHS Providers said:
A great deal has already been achieved (for example, in pooling budgets) without needing a devolution deal. Therefore, for some, approaches which do not require formal devolution—based, for example, on closer joint working arrangements—may be more appropriate.196
In addition, the NHS Confederation said:
Many of the freedoms and mechanisms enabling leaders to design the system around local needs and to pool resources already exist and are being made full use of by both NHS and local authorities.197
82.On these grounds, we asked our witnesses whether health devolution was necessary. Rob Webster, the Chief Executive of the NHS Confederation, said “not everywhere” and gave Sheffield as example of a place which has chosen to further its existing arrangements, rather than make health devolution part of its deal.198 However, this may be due to the fact that Sheffield’s health system is less complicated than Greater Manchester’s and, therefore, implementing change is achievable without devolution. Ian Williamson, the Chief Officer for Greater Manchester Health and Social Care Devolution, said there was a case for “transformational improvement” in Greater Manchester and that devolution was an “opportunity to concentrate on the place of Greater Manchester, rather than just allowing the existing systems and organisations to carry on in a way that is not as coherent as it can be”.199 Rob Webster also emphasised the need to find solutions for health and wellbeing in the context of the place people live.200 The Minister of State for Community and Social Care, Rt Hon Alistair Burt MP, also indicated that the focus of health devolution was on the particular locality, suggesting:
If you give an impetus through local devolution to the work that is already going on to integrate health services, you are releasing, as best you can, as much local knowledge as possible about what people need in their particular area, how people would like to handle the finances and what priorities they want to make.201
This seemed to accord with Greater Manchester’s experience of health devolution creating an energy and positivity in finding solutions202 and speeding up difficult conversations and planning.203 The NHS Confederation also said that it has acted as “an important catalyst” to having “difficult conversations about how best to plan and deliver joined up services”.204 This is a real benefit because, as the Chairman of the County Councils Network said, there is evidence of reluctance to change on the part of the NHS.205
83.We were also interested to understand how health devolution would fit in with existing initiatives to integrate health and social care, such as the Better Care Fund, the Integrated Care Pioneer Programme and new care model pilots. Ian Williamson told us that the pilots in Greater Manchester were working closely with the devolution programme and would be replicated and built on throughout the city region. He also said that the size and footprint of the area meant that best practice could be easily disseminated across the local health system.206 However, the NHS Confederation said:
Various new models are already being set up in many different places. It is important that national and local leaders do not become overly focused on formal devolution agreements and fail to use existing or more appropriate means of pooling resources and sharing decision-making, which may better suit their needs.207
The Minister said that “devolution complements what is already going on and provides a further route for the integration of services”.208 He also said that he did not expect areas to put forward plans for devolution unless they have “pretty good ideas” about what they want to achieve.209
84.Witnesses from Greater Manchester were clear that their aim was to make the best use of the money available.210 NHS Providers, however, thought that it was “not clear that pooled budgets or devolved arrangements will necessarily release efficiency savings”.211 On the impact on funding, the NHS Confederation said that health devolution would “not be the single panacea or silver bullet to solve the finances of either health or social care”212 and, until this happened, their members feared that the effect of health devolution would be to make a national funding problem a local one.213 The Minister hoped that health devolution would help with the funding challenges, although he did not suggest that it would solve them:
The work we are trying to do in relation to greater integration of local authority and NHS services is predicated on the fact that the more you can bring services together, the more likely it will be that you will find the sort of efficiencies everyone is looking for in the delivery and the provision of services anyway.214
On our visit to Greater Manchester, we were told that there was no need to use the powers set out in the Devolution Bill to transfer health functions to the Greater Manchester Combined Authority and that there would be no separation from the NHS.215 Ian Williamson explained that in his area “The chief officer for devolution […] will be an employee of NHS England, and therefore the line of accountability will flow up through NHS England to the Department of Health”.216 The Minister said that arrangements in Greater Manchester were a mixture of both delegation and devolution217 and, referring to amendments made in the House of Lords, emphasised that the Devolution Bill did not allow the Secretary of State and the NHS to completely devolve responsibilities. We are unpersuaded by the use of the word ‘devolution’ to describe what is happening to health in Greater Manchester: it actually appears to involve delegation of responsibilities or joint working.
85.Health devolution has great potential. In the context of some areas, such as Greater Manchester, it is a necessary step to design health and care to suit the circumstances of a particular place, to speed up and enhance existing work on integration and help address the cultural challenges posed by joint working for the NHS and local government. In other areas, however, health devolution may not be needed in the short term to advance and improve health and social care. But, to achieve a great deal more in the longer term, real devolution and a transfer of more power to local government is needed.
86.However, health devolution has arrived at a particularly difficult time for the health and social care system and its staff: there has been significant structural change in recent years and there is now an unprecedented level of financial challenge. With such uncertainty, we are concerned about the long-term consequences and recommend that, over an appropriate timescale, the Government gathers evidence on the impact of these reforms. It is important that areas should not pursue formal health devolution at the expense of health and social care initiatives with similar aims that are proving fruitful. Areas that do wish to pursue health devolution must have clearly defined objectives for what they expect it to deliver.
87.We were struck by the level of concern shown by the attendees of our question and answer session in Manchester about the lack of public consultation on the changes to health in the city. A representative of the Royal College of Nursing said that nurses and healthcare assistants in the North West did not understand what devolution was and what it entailed.218 Rob Webster told us that, according to an NHS Confederation survey, only 40 per cent of people knew or understood enough about the NHS to discuss changes to the health services and this meant that “we are starting from a position where we always need to communicate clearly and well, and engage with people over time”. He added that:
If this is about driving better outcomes, having clinical leadership and support for change, and being accountable to the local public, then we need to make sure that those tests are passed in all the changes that we make.219
We agree. We discussed some of the reasons why public engagement was limited in Greater Manchester in chapter 4 and were pleased to hear that there are plans for public sessions on health devolution in 2016.220 We reiterate, however, that, from now on, the public must be engaged, consulted and communicated with throughout the devolution process and once a deal has been agreed. Public engagement is particularly important in the case of health devolution where the complexity of the systems in place make understanding the consequences of change more difficult in an area where the public’s response is likely to be more emotional.
88.In this context, we are concerned about accountability in situations like that in Greater Manchester where the elected mayor will act as a public figurehead, without formal responsibility for health and social care. As well as redirecting complaints, Mr Williamson said that the Greater Manchester Combined Authority would need to communicate clearly to people about how the arrangements would work and that:
We think that these arrangements add to transparency and accountability at a local level. For example, holding meetings of our new strategic partnership board with all the 37 organisations in public will aid that accountability and transparency.221
Accountability in health and social care is already extremely complex and further changes, such as the creation of an elected mayor, are likely to leave patients feeling confused about who they should approach for information or to pursue complaints. Any health devolution agreement should be accompanied by plans for how the changes taking place will be communicated to residents. Residents should be informed about the new structures and responsibilities and be told where to go for information and advice and to make complaints.
89.Considerable concern has been expressed about whether health services in areas with devolution deals would remain subject to national standards. Clause 19, inserted into the Devolution Bill in the House of Lords, confirms the continuation of NHS accountabilities and the regulatory responsibilities of the Care Quality Commission, Monitor and others under devolved arrangements. When we asked about accountability for services, the Minister told us:
Depending on which bit is under pressure, the buck stops with providers for providing services and they remain responsible under a devolved process, as they would anywhere else. […] But the Secretary of State remains responsible for the core duties of the NHS and how they are carried out. […] The buck remains with those who currently have the responsibility for the services or who will be commissioning the services. Locally, electorally, a new devolved authority or a combined authority will need to answer to their own electorate as to how they are running services and in what configuration, but in terms of quality and standards, we have made very sure that the regulatory regime remains the same as it is and, ultimately on NHS services, the buck stops with the Secretary of State.222
We found this explanation confusing. It is unclear to us how accountability will work in practice.
90.In terms of regulation, we heard that regulatory bodies, such as Monitor and the NHS Trust Development Authority, would adapt to regulate the devolved area and make sure their powers covered the “wider footprint of the areas that will be commissioning and providing”.223 However, it would appear that their powers do not extend to regulating a local authority’s financial contribution to a pooled budget and it was not clear which body was in fact responsible for checking their financial position. There is also a lack of clarity about the audit and regulation of pooled budgets and, in particular, oversight of the sustainability of local authorities’ contributions.224 Again, we were left feeling that the arrangements the Minister described were more aspirational than a thought-through and watertight system of financial regulation.225 There is a need for a clear articulation of how health devolution will work and for clear governance arrangements set out in a way that residents, patients and staff can understand. This will ensure there is no adverse impact on the quality of local services and that services are accountable. We are not satisfied that there has been sufficient consideration as to how pooled budgets will be regulated and audited and how they will be handled in practice. Unless this is carefully considered, we risk both not having the flexibility to use budgets to reflect local priorities and facilitate joint working and replicating locally the silos that exist at national level. This applies to services devolved from all Government Departments, not just health. We would like the Government to revisit this issue on an ongoing basis as health devolution is rolled out and embedded in local areas.
91.Our evidence revealed several other issues to be kept in mind in the health devolution context. Firstly, the need for better sharing of information between Government Departments, the NHS and local government, such as information from the Department of Work and Pensions (DWP) about local people in receipt of Attendance Allowance, which is payable to people with care and support needs. If the DWP kept authorities informed about their residents in receipt of this benefit, they would be better able to predict and plan for those needing social care. We appreciate that privacy issues often create difficulties for data sharing but were encouraged to hear the Minister say that it was a key part of the integration of local services.226 The Government should set out the steps it will take to ensure the relevant Departments share data, for example relating to Attendance Allowance, with the NHS and local authorities.
92.In addition, the treatment of specialised services under devolution was drawn to our attention by patient groups concerned that, in taking responsibility for specialised services,227 local areas may give preference to services with greater economic impact. Mr Williamson told us that, from Greater Manchester’s point of view, this would enable them to make “more sensible joined-up decisions” and ensure that patients are treated as soon as possible and that NHS England would continue to take responsibility for rare conditions.228 We asked them to explain in detail how they intended to manage these services and, while we were satisfied with the plans we received,229 we highlight this as an issue which needs to be carefully monitored in emerging health devolution agreements.
198 Q112
199 Q100 [Mr I Williamson]
200 Q100 [Mr R Webster]
201 Q223
202 Q113
203 Q101
205 Q151
206 Q110
208 Q227
209 Q224
210 Q123 [Mr I Williamson]
214 Q238
215 Q68
216 Q116
217 Q231
218 Communities and Local Government Committee, Public question and answer session in Greater Manchester, 26 October 2015
219 Q110
220 Q69
221 Q118
222 Q233
223 Q244
224 Qq244-253
225 Q252
226 Q236
227 Specialised services are used by comparatively small numbers of patients and are not provided in all hospitals. The commissioning of specialised services has traditionally been a direct commissioning responsibility of NHS England.
228 Q119
© Parliamentary copyright 2015
Prepared 29 January 2016