Should local leaders pursue devolution deals for health care?

Place-based and integrated care is fashionable in health and social care policy. There are a plethora of initiatives aiming to make them happen. Examples include the better care fund, Integrated care pioneers, Vanguards, Sustainability and Transformation Plans and devolution deals.

Devolution deals are somewhat different to the other schemes – led by local government rather than the NHS, and potentially more amenable to integration with services outside of health and social care. They also come with increased local political involvement and scrutiny (and uncertainty about whether this is compensated by a reduction in national interference).

Local areas are left with the difficult decision of how to use their limited time and energy. Should they choose one initiative and make it work? Is it better to do as many as possible? Is an under the radar approach more likely to succeed? Or should they go for a devolution deal?

The health care deals agreed so far do not involve any devolution (transfer of power between political levels), and only modest delegation (transfer of power between administrative levels). Indeed, the most recent deals only mention health care when describing future negotiations, rather than anything concrete. Leaders might perhaps wonder if all the negotiation to get to a deal was worth the effort.

As we set out in our report Catalyst or distraction? The evolution of devolution in the English NHS there isn’t empirical evidence that devolved health care systems consistently outperform their centralised cousins. Theoretical arguments can be made both for and against devolution. For instance, proponents argue devolution will enable health inequalities to be better recognised and addressed, centrists counter that it will lead to fragmentation that ultimately increases inequalities.

Internationally, devolution decisions are a product of their political and cultural context. It is no different here – the devolution agenda is strongly politically driven, and in health care there are centralising pressures and financial risk for local areas countering this drive. Widespread deficits are leading to ever increasing central ‘grip’ on the NHS, unlikely to be countered by the stated interest of NHS Improvement in creating a permissive environment for local change.

Whether to pursue a devolution deal for health care involves a certain amount of crystal ball gazing: will command and control continue in the NHS or slacken if the finances are bought back under control? Will a deal be an aid or a hindrance in difficult local and national conversations about reconfiguring services and making savings? Will it make the leadership of an area pull together for common purpose, or try and outmanoeuvre each other to get a better slice of the pie? How will the public react to a deal?

Greater Manchester have judged the odds and decided they can do a better job of managing their services than the current arrangements (although central priorities, such as 7 day services, still appear in their work). Others have decided that they will fare better without the scrutiny and resources involved in seeking a deal.

Change, including the taking of educated risk, is urgently needed in the NHS. But evidence implies that any benefit for the NHS from decentralisation is not just uncertain, but unlikely; local leaders and policymakers alike need to proceed with care.

Felicity Dormon, Senior Policy Fellow at the Health Foundation, is currently on secondment to NHS England. You can follow Felicity on Twitter @FelicityTHF