Integration. prevention. personalisation. The buzzwords that indicate the reforms our health and care system needs are as widely recognised as they are overused. So too are the problematic features of current service provision: fragmentation, barriers and silos. The challenge is not one of rhetoric, but of moving beyond words to practically forge a system that works for people – and enables us all to live healthier, happier lives.
The context is a challenging one – on this there is also widespread consensus. People are living longer, and many more with long-term, complex conditions. The medical advances and increased life expectancies we can all celebrate mean that demand for services has evolved from the point when the National Health Service was first established in 1948. A hospital-based model set up to treat illness when life expectancy was 65 is now being required to tackle challenges it was not designed to cope with. Pressures are created as a consequence of this: A&E wards are struggling to cope with too many crises that could have been avoided if appropriate care was in place, and hospital beds are over-relied upon because community based infrastructure is insufficient. The funding cuts to local government of 40 per cent over the last parliament have had an inevitable impact on social care provision: the coalition government’s approach to salami-slicing Whitehall budgets without reform exacerbated the situation.
Against this backdrop, the announcement that responsibility for health and social care would be devolved to statutory organisations in Greater Manchester was certainly a bold move. The circumstances of the announcement months before the general election distracted from much of the substance of the proposed framework, which was to enable joint decision-making on integrated care to support physical, mental and social wellbeing. The intervention also exposed some of the fault lines that exist in debates over health and care reform: between centralist and localist perspectives, and between the medical profession and the local government sector.
As a consequence there are a few myths around the content and the implications of the Memorandum of Understanding which set out the terms of the devolution deal in Greater Manchester that need to be addressed, prior to a realistic appraisal of the measures. Some media coverage referred to the agreement as a local government “takeover” of the NHS. In fact, the framework was developed between Greater Manchester partners together – 12 NHS clinical commissioning groups (CCGs), 15 NHS providers and 10 local authorities – and each will retain their existing statutory responsibilities. The parties to the agreement are the Greater Manchester CCGs and local authorities (collectively known as GM), and NHS England. The mischaracterisation of the approach reflects precisely the obsession with professional hierarchies and sector-based territorialism that true integration needs to break through for new arrangements to be more than the sum of their parts.
Fears have been expressed in some quarters that the measures herald the end of the “N” in the NHS. However, the first principle of the agreement is clear that“ GM will still remain part of the National Health Service and social care system, will uphold the standards set out in national guidance and will continue to meet the statutory requirements and duties, including those of the NHS Constitution and Mandate”. The charge that the creation of new models of inclusive governance and decision-making would equate to the dissolution of a national system is ill-founded. The NHS has always been delivered in practice by local units such as primary care trusts, which lacked strong public accountability or visibility but worked within geographic and bureaucratic boundaries to make decisions about resource allocation and service provision. When considering the ‘N’ in the NHS, we need to be clear how this fits with the aspiration to craft a system suited to whole person needs, which are by definition different. What balance should be struck between national ‘one-size-fits-all’ rigidity on the one hand, and responsiveness to the needs of people and places, on the other? A public service reform discussion about the role of the national and the local very often quickly alights upon the phrase ‘postcode lottery’ in the negative – this is interestingly most often used with respect to local inputs rather than variations in outcomes nationally. The postcode lottery that people living in Greater Manchester should be most concerned about is the fact that they can currently expect to live nine years less than the average person in England. This is the motivating force behind the new framework being created by GM partners: tackling the existence of some of the worst health outcomes in the country – outcomes which have emerged and persist under a centrally-accountable national system.
The devolution agreement, while not in itself an automatic shift to positive outcomes, presents real opportunities for transformation beyond the existing baseline. Taking the starting point of making an analysis of whole population health needs across Greater Manchester, partners can work towards the twin objectives of closing the health inequalities gap – moving from having some of the worst health outcomes to having some of the best – and aligning provision to prevent ill health and promote well-being, from early age to later life.
For the first time, strong democratic accountability puts local people at the heart of the emerging new framework. Where previously decisions would be taken by remote bureaucracies or distant Whitehall departments, they will now be taken involving democratically elected representatives. This can inject a new responsiveness to the local system which will be driven by stronger direct incentives to evolve to meet people’s demands: good access to high quality, joined up services which provide the right care at the right time. GM partners are already focussed on ensuring early, tangible benefits for people which also begin a shift to wider systemic reform, such as proposals to offer seven days a week GP access by the end of the year and a Greater Manchester-wide plan to join up fragmented dementia services.
While the devolution deal does not bring with it any more or less funding – the £6bn package identified refers to existing resources – a more strategic approach across Greater Manchester can seek to make the best use of these by allocating them more efficiently and effectively. Full place-based commissioning and delivery can ensure public investment is committed on the basis of shared intelligence and is geared to provide the right balance between medical intervention and social support. The GM framework is an opportunity to develop a more coherent long-term strategy to ease pressure on hospitals, while building up services in the community that bring health and social care closer to people’s homes. This will mean removing funding ring fences to make sure funding goes where it is needed locally, identifying duplication caused by service silos, and strengthening formal collaboration between providers. New budgeting models such as year of care funding can be developed, which begin to engineer a system-wide shift away from a focus on single episode and crisis treatment towards longer term preventative care. This can all create space for precisely the innovation and adaptation healthcare systems need: a research, innovation and growth strategy is a major strategic thread through GM partners’ joint work and they are prioritising the early implementation of an academic health science system.
Creating a preventative whole-system approach that shifts from treating illness to promoting wellness involves recognising individuals not as patients but as people. In a different relationship with statutory services, individuals have responsibility for their own health outcomes but are also given the right support. Traditionally, building-based health services like hospitals and GP practices focus on treating illness and operate largely in isolation from wider provision that impacts on good health outcomes such as employment and housing. There is now a real opportunity to align priorities across services and within communities. For example, poor health is too often a barrier to sustained employment, so another early implementation priority from the GM partners is a new programme to help people with mental health conditions get back into work.
Stakeholders in Greater Manchester are continuing to develop the relationships, trust and mutual respect between the professions and services involved. Nonetheless, there are real risks to the new approach which will need to be recognised and managed as the process evolves.
First, the funding context within which the GM partners operate is something of a burning platform. It won’t be until the new Conservative government’s first comprehensive spending review that partners will have confirmation of what resources they have to work with, and how longterm a settlement they can predicate their plans on. A strategic business case will be developed by the end of the year which will need to find a way to bridge financial gaps, which will be no small challenge in the context of further austerity
Second, the huge ambition set out in the early Memorandum of Understanding was matched by an extremely tight timetable for the translation of these principles and framework into action and outcomes. Partners are already part-way into a ‘buildup year’ ahead of full control of health and care budgets in GM by April 2016. While a roadmap and delivery plan are to be developed and agreed between the partners and wider stakeholders, governance arrangements will be agreed in parallel. A careful balance will need to be struck between moving forward where possible while also ensuring that effective system-wide leadership is forged. Governance arrangements will need to simplify accountability rather than add to complexity. They must be robust enough to realign accountability for the use of public resources sufficiently to meet the huge ambition of the framework.
A priority within all of this is to ensure constant and substantive public engagement and involvement: both in the process of devolution itself, and on an individual level in relation to health needs. There will be a new responsibility for local politicians to articulate the ambitions of the GM partnership and ensure that public dialogue focusses not simply on institutional arrangements but on health outcomes.
The latter must remain a driving force for partners as well as a measure of their success. Public engagement shouldn’t happen solely through democratically elected institutions but that a new transparency and accountability is created across the whole health and care system so that people have greater opportunity to become genuinely more involved and engaged in decisions which affect their lives.
GM partners are not complacent about the scale of the challenge they face. As the business case is developed they will need to identify the risks and ensure plans are in place to mitigate and overcome them. There is a shared recognition that they have a unique opportunity to move beyond traditional ‘vertical’ organisational silos and pioneer the development of ‘horizontal’ arrangements across a place which have more potential to tackle demand pressures and create more responsive services. The ultimate prize motivating all involved would be to overturn the trajectory of health inequalities which a centrally accountable system has failed to. Then words like ‘integration’ and ‘prevention’ would move from being just aspirations to standard practice.