Is devolution good for health?

Three new devolution deals were announced alongside the Budget this week - East Anglia, Greater Lincolnshire and the West of England. Other than updating the devolution map, these deals contain little for the NHS. They include a further push for integration with social care but no transfer of powers and all conducted through NHS England’s Sustainability and Transformation Plans (STPs). Liverpool city region also received further control over business rates and indicated that they are still considering whether they want any transfer of powers over health care.

Formally, devolution is the transfer of powers held by central government to a lower level of government. While this term can be broadly used for the other public services involved in the deals, it doesn’t describe what is happening in health care. Even in Greater Manchester, the biggest deal so far, the NHS remains firmly accountable for services. Devolution is a form of decentralisation, which also encompasses delegation – perhaps a more accurate descriptor for the current agenda in terms of health.

However, if our goal is to improve health outcomes more broadly, it might not matter that there is little in the latest deals for the NHS.

The impact of health care on the health of the population is actually fairly minimal compared to the wider determinants of health such as housing, employment, and social networks. Any improvement of the health of people in an area with a devolution deal could be the result of the transfer of powers over public services which have nothing to do with the NHS at all.

The potential benefits

The main driver of the current devolution agenda has been economic growth, particularly in establishing Osborne’s Northern Powerhouse. If the deals can improve prosperity, the health of the population may improve with it. Lower socioeconomic status is intrinsically linked to poorer health - good employment and wealth can contribute to both mental and physical health. But even if devolution isn’t as economically successful as the Chancellor hopes, this agenda could drive better health outcomes.

Any devolution deal will bring changes to public services in that area. For one thing, local leaders will want to legitimise the effort of obtaining more power in the first place. Whether health care is included or not, the real challenge is ensuring reforms to other public services consider the impact on the health of the population in a meaningful way.

Most of the deals so far include more local power over housing, employment and transport; sectors where huge impacts can be made in disease prevention and promoting wellbeing. This provides an opportunity for bold and innovative thinking about improving the health of the population. Could Liverpool implement a city-wide programme which makes active or public transport easier and quicker than driving? Or perhaps East Anglia could design a housing programme which encourages social cohesion and reduces fuel poverty? These are just examples; the most important factor will be a real understanding of what is driving poor health in the population.

One thing the leaders in Greater Manchester have realised is that it is the opportunity to change behaviours and the momentum behind devolution which sets this agenda apart, not necessarily the actual powers. Any areas with devolution deals have a strong context for enacting changes: devolution is cross-sector, it is fast paced and it has both national and local political backing.

Will devolution improve the health of the population?

Unfortunately, the question of money still remains – a devolution deal does not mean a bigger budget. In a time of austerity, including big cuts to the public health budget, it will be easy for the focus of reforms to be more on cost-saving and the impact on health to be considered as a secondary goal.

Without the transfer of health care budgets to local areas, there may not be the money to invest in anything radical to impact health. Greater Manchester’s prevention agenda is likely funded from their £6bn health and social care pot, which presents huge opportunities for innovation and change. The weight of the health care budget could help overcome the challenge of engaging other service leaders on the importance of considering health, and in particular disease prevention, as integral to plans across all sectors. However, even with the health budget situated at a more local level there isn’t a guarantee of further investment in disease prevention – especially in a time of financial constraint on the NHS itself. 

So if you really want to improve health in your local area, do you seek powers and budgets for health care or not? It’s very hard to say. With greater powers comes greater scrutiny, especially in health care. Local leaders will need to ask if this is a price worth paying if improving health can be achieved through the devolution of other services.