Fabians have been intensely involved in the NHS since its birth and long may our engagement – as clinicians, NHS staff, analysts and political supporters of the collective interest in good health – continue. Our aim is, at one and the same time, to secure good care for all while ensuring it is financially supported. Arguing the case for money means not just tax but for a buoyant and confident and (yes, that toxic word) welfare state, the opposite of the shrivelled starveling thing Cameron’s neo-Thatcherites are pushing towards.
But we accept there will always be tension between state (local) and state (central). The challenge is finding a reasonable balance between local variation and reliable standards. Diversity will always trade off against equality.
That point of balance has to be where people can live the healthiest lives. We recognise that the NHS remains too much of a sickness and not enough a wellbeing service. But health outcomes don’t just depend on nurses or even public health doctors. People live well if they have good public services and, critically, enjoy decent incomes derived from work and social support. The Department for Work and Pensions is a health department. So, the point of balance is going to be found where assent to redistributive taxation can be maximised.
Another point of balance is where public accountability scrutinises at the same time as affirming professionalism and vocation – as much among the staff at the coffee bar in the clinic waiting area as the nurse taking blood.
So, do we find those points of balance through local control or in a national service? Could Manchester town hall or Truro county hall substitute for the Department of Health and NHS England?
Let’s try to avoid the almost religious faith some place in localism. I suspect they haven’t spent much time in council meetings – or looked up which party is in control. For every local instance of innovation and energy, there’s a corresponding example of inertia and do-nothingism. For every progressive local authority there’s a Kent, Essex, Barnet or Wandsworth, where market dogma rules along with a fervent determination not to tax and provide the wherewithal for services; also there is a Rotherham and a Doncaster, where public services have failed.
That variation – and the evidence that local public services are often not good – is why we should be so suspicious of the new-found enthusiasm of George Osborne and other Tory ministers for devolution.
They might have said: ‘for good, historical reasons going back to the old metropolitan counties Greater Manchester functions like a city-region and could integrate health and social care so let’s give Richard Leese and colleagues their head in a sort of natural experiment’. Let’s see how it works, incrementally, empirically – the Fabian way.
Instead we’re witnessing a deliberate rush to devolve political blame for austerity and further destabilise public service provision, including health.
The problems of the NHS are money, primary care, clinical engagement and dealing with the car crash of the 2012 Health and Social Care Act. Along the way there’s the residue of the Labour era dogma, including foundation trusts – which were once hailed as localism in action.
The practical question behind DevoManc and the localist thrust is whether councils can provide solutions to those persistent problems. On money, the only way councils might contribute is by agitating strongly for property tax or (additional) local taxes on income and wealth. From the Local Government Association, there’s deathly silence on taxes, and part of the reason of course is that areas vary so much in their taxable capacity, meaning you need a strong centre to distribute between rich and poor. So, no joy from localism on finance.
What might councils bring to questions around integrating primary, community, mental health and acute care? Here the evidence is even more ambiguous. Let me pose another question by way of answer. Under Labour, accelerating under the Tories, councils have been deprived of their integrating role in education. Schools, including schools in Greater Manchester, have been removed from local authority management. Suddenly, however, healthcare is to be localised while schools continue their journey out. It doesn’t make much sense to put consultants into a council envelope when headteachers are long gone.
But this debate has already had too much assertion and rhetoric. We need evidence that localising decisions could address the myriad problems of healthcare and finance. Conduct a trial in Manchester, but let’s wait at least a few years and collate the results before rushing into another NHS reorganisation.
David Walker is contributing editor to the Public Leaders Network and former director of public reporting at the Audit Commission.
Click here to read our new report ‘The Local Health Service?’, which explores how to balance local control and national standards in access to health care.