A little reported Lords defeat for the government over its plans to devolve powers to major cities has major implications for local control of the NHS.
Last week an amendment was moved successfully by Labour peer Norman Warner to the cities and local government devolution bill which stops the transfer of NHS regulatory functions held by national bodies. Crucially, if the amendment is not reversed in the Commons, it will ensure any devolved services adhere to national service standards and are still nationally accountable.
The bill, part of the “northern powerhouse” drive to devolve responsibilities to major cities, has become the vehicle for devolving £6bn of health and care spending to Greater Manchester.
The amendment underscores Labour suspicions that the Conservatives want to whittle away the health secretary’s ultimate responsibility for providing a national health service. This caused a row during the passage of Andrew Lansley’s NHS reforms during the last parliament, when the government had to accept an amendment spelling out the requirement for the health secretary to remain accountable no matter how much control was passed to NHS England.
When the government announced the NHS devolution plans, shadow health secretary Andy Burnham immediately attacked the idea of one part of the country having a different version of the NHS.
This amendment means Manchester will be unable to take on any regulatory or supervisory powers from the Care Quality Commission, NHS England or Monitor and its successor, NHS Improvement.
As HSJ reported in February, the Greater Manchester authorities initially sought “a new set of relationships” with regulators and inspectors to give the oversight regime a clear focus on the local health economy.
While the precise legal implications of the amendment would need to be tested, philosophically it goes to the heart of the moves towards devolving control of the NHS. Those who see themselves as the guardians of the NHS see any erosion of its national character as inimical to the idea of universal health provision; national oversight and accountability are bulwarks against those who are indifferent to the NHS’s long term survival and are willing to contemplate systems where personal payments play a much larger role.
In the other camp the radical devolutionaries believe excessive central control and a culture of conformity are the rot at the heart of the NHS. They believe zealous adherence to its national character is undermining both the quality and long term sustainability of the service. Just as foundation trusts were the innovators of the noughties, using scale, financial muscle and clinical leadership to push quality and (sometimes) productivity, so the proponents of devolution believe they are the new radicals who will reshape care pathways, rebuild services round the patient and break down the barriers between community, acute and social care.
Changing the relationship with regulators and inspectors matters for devolution. The whole point of the Manchester move is to look at the city region as a care system rather than a disparate group of institutions and tiers. The regulators have made some progress towards systems thinking but it is too slow, which is inhibiting new ways of thinking and working in the NHS and social care.
The NHS needs to take some risks if it is going to reach 2020 in reasonable shape. Conformity to standards of quality, safety and financial management of course have an important place, but that is not the same as being compelled to meet arbitrary targets at the expense of reforms to meet pressing local needs. The regulators should be judged on their ability to support Manchester in making its care services as efficient and effective as possible, which means loosening their institutional focus to look more and more at the whole patient experience in each locality.
The NHS should have the confidence to allow Manchester to probe the boundaries of structures and accountability, testing the limits of how the power and authority of the secretary of state can be balanced with local democratic control.
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