Devolution: the plot thickens

It seems like a lifetime ago that I wrote about the recently submitted devolution deals, but it was only September. A lot has changed in devolution policy since then, keeping true to its beginnings: a year ago it wasn’t on the health agenda at all.

So what has changed since September?

• The Cities and Local Government bill has completed its journey through the Commons. The provisions added in the Lords keeping health regulation national and emphasising the responsibilities the Health Secretary has for providing a comprehensive NHS have been maintained.
• The spending review has happened: the settlement was expectedly grim for local government, but did include the potential for more fiscal autonomy through the ability to retain business rates. The crisis in social care was recognised, but the settlement remains well below what is needed and there were no devolution deals announced on the day.
• Simon Stevens, the most powerful person in health (according to the HSJ at least), has gone on recordas being decidedly lukewarm about devolution.
• Several devolution deals have been reached including Sheffield, Leeds, the West Midlands and the North East. Most recently a London health specific agreement was announced this week.

The deals announced so far, and intelligence from the system makes the devolution map look decidedly different than the equivalent we drew in September (again drawing on material from the Local Government Chronicle).

So what does all this mean?

Firstly, devolution in health is going to be a slow burn if it happens at scale.

Deals to date have included less health content than we might have expected from the example set by the Greater Manchester deal. There is no single model for devolution: the 5 deals with some health content vary significantly. People involved in devolution are now talking about negotiations taking place over the next year and beyond, with an evolving approach to health. This style of devolution is reflected in the agreement in the North West to create a commission to consider health and social care integration, in the West Midlands, and also in London. In the capital pilot areas are tasked with creating detailed business cases and showing benefit before any negotiations on transfers of power take place in earnest.

Secondly, the centre has mixed feelings about devolution.

While it is still a priority for Treasury (especially for areas within the ‘Northern Powerhouse’), health bodies are clearly less keen. NHS England’s devolution board paper set out 9 decision criteria for agreeing deals with areas. They set a high bar, including: making full use of existing powers, demonstrable leadership, a track record of collaboration, securing consistent delivery, public support for devolution proposals and financial risk management. Stevens’ intervention this week shows further scepticism, which is perhaps shared by Parliament. Changes in the Bill around national regulation and accountability for health care have not been matched by similar concerns in other policy areas: education could be completely transferred under current legislation. The cautious approach is evident in the range of approaches taken to devolution deals, and is exemplified by the London agreement - it is ridden with caveats. For instance, London wanted control over bailouts to trusts, instead central bodies only commit to: ‘explore collaborative and co-operative decision-making with London Partners’ - hardly a transfer of power.

Finally, devolution is here to stay.

Even if it only happens in London, Manchester and Cornwall over 20% of the English population will be using ‘devolved’ health services in the next couple of years. This has the potential to change the shape of the central bodies managing the health system, and perhaps the national / local relationship. Even without significant transfers of power (we haven’t seen any yet) a more co-productive relationship between national and local bodies feels positive, as does local areas organising to agree and pursue what is important to improving health of their populations. Both of these are achievable without devolution, but if the devolution ‘brand’ helps them come into being that may be no bad thing.

Ultimately, what devolution means for how our health system works in the long term depends on organisational politics. How the tensions between NHS England, the Department and other parts of central government, between national and local health organisations, and between local organisations play out will determine what happens. The opportunity is for those working in health, wherever they are, to take advantage of political changes to do what works for the people they serve.