The Heart of Devolution

Following on from the publication of Catalyst or distraction?, last week the Health Foundation hosted its first ever pecha kucha event to explore the opportunities presented by devolution of English health care.

For those that don’t know, pecha kucha is a presenting style where speakers have 20 slides, each slide showing for 20 seconds and absolutely no bullet points are allowed. You basically make a speech, with pictures to accompany.

Having never presented in this format myself and finding it quite scary, I felt a little bad when asking others to do it for this event. Speakers from the Department of Health, The King’s Fund, the Centre for Ageing Better, the University of Manchester and the Health Foundation all bravely took up the pecha kucha challenge to give their differing perspectives. I shouldn’t have worried though - they were all fantastic.

Devolution is a topic which can get quite technical, but delivering such short presentations - 6 minutes and 40 seconds - forces the speakers to get to the heart of the issue quickly and therefore sparks interesting debates. To capture this further, we asked the audience – mainly people in health policy - ‘what are we really debating here?’ and got a huge range of responses.

So, what are the key issues still under debate when it comes to the devolution agenda?

Much of the discussion resonated with the challenges and questions we encountered whilst doing our own research into devolution here at the Health Foundation. One of the key issues is the changing relationships between national, regional and local players. Many people in our audience wondered whether areas with devo deals were really going to be able to do anything truly radical - do they really have a greater knowledge of their local populations than the centre? In my opinion, an investment in ensuring their person-level data is as accurate and up-to-date as possible could be the key to unlocking some of the potential of devolution. Such knowledge of the local population could give great insights into unmet need and allow for significant tailoring of services.

There is equally a question of whether the centre is able to relinquish enough control to allow changes and innovation to happen. This is especially true in the context of tighter finances and the difficult efficiency challenges given to many of the devolved areas. A recent evaluation of the integrated care pioneer sites found that the context of increasingly difficult financial pressures made whole system transformation very difficult and NHS England have already set out their bottom lines for intervention in Greater Manchester. What will really happen if performance in devolved areas drops or finances get even tighter?

Others at the event felt that the most important aspect of the debate is integration of health care with social care, which was perceived as one of main objectives for devolution of health care. It is not a given that this agenda will actually lead to greater integration. Pooling budgets does not necessarily overcome the other difficulties encountered in previous attempts to integrate services, but getting a deal could be an important first step act as a catalyst for changes on the ground.

As part of the event, the group prioritised the most important issues raised during the discussion through an FA cup style knock out. The winner was ‘will devolution make people healthier?’ a theme we’ve explored in a previous blog. In Catalyst or distraction? we found that there isn’t evidence that decentralised health care systems consistently outperform centralised ones. However, the impact of health care on the whole population’s health is actually quite minimal, and for many - including myself and our events’ participants - the real potential of devolution lies in tackling the wider determinants of health.

Engaging with the public

There were lots of other important questions raised. For me, the most salient question was ‘did people in Manchester want devolution?’ and I’m not sure that’s clear either way.

Every devolution deal to date has been made behind closed doors and has been repeatedly criticised for lack of public engagement – particularly in the initial phases. Only County Durham has been given a vote on whether they want to be part of a devolved system, in contrast to the devolution of power to Wales, Northern Ireland and Scotland. There has been fairly limited national debate on the issue too, especially whether accepting potential local variation in services provided by the NHS is acceptable to the wider public. In order to truly tailor our local services to the local population, having constructive, open conversations with the public should be critical. As areas continue thinking about their own autonomy, events like the one we held here which get past the technical detail, could be an important part of this wider conversation.

Hannah is a Policy Intern at the Health Foundation