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Devolution is a growing trend in England, with local areas and regions increasingly taking over services and budgets previously under national control. The process started to gain momentum in 2014 with the introduction of combined authorities. And, in 2015, the government negotiated a landmark devolution deal with Greater Manchester, creating the first region in England with devolved health and care responsibilities.

Soon afterwards we commissioned a major study aimed at understanding the impact of devolution on health and inequalities in the region. Initial results, published in 2022, found a small improvement in life expectancy compared with a control group based on similar places in England. At the time, we welcomed the research while also urging caution about interpreting this as a ‘slam dunk’ for devolution.

This week saw the publication of the study’s final paper, exploring the impact of devolution on a wider range of outcomes. 

What are the headline findings?

Between 2016 and 2020, life expectancy increased by 0.233 years, or about 12 weeks, compared with what we might have expected without devolution. There were also welcome improvements in healthy life expectancy and self-reported life satisfaction. But as before, this doesn’t tell the whole story.

The research is ambitious, evaluating 98 measures linked to health system performance. These include a wide range of health system indicators like waiting times, public health indicators, including screening coverage and obesity rates, and broader indicators such as employment rate and first-time offending. 

All in all, the researchers found a mixed bag of positive, negative and equivocal results. Alongside improvements in healthy life expectancy and life satisfaction, the study found fewer alcohol-related admissions and improved cancer screening coverage. So far, so good. But there were also increases in adult obesity and higher waiting times for treatment in A&E. 

A complex picture

The research shows some positive signs that Greater Manchester is making headway in the face of an incredibly challenging time for health and social care. But devolution is complex and studying the impact of system-level changes on outcomes is hard. 

The researchers introduce their paper by explaining the head-spinning interplay of overlapping structural changes, lines of accountability, funding flows and devolution arrangements in Greater Manchester. They also track interventions across 170 policy documents to see who did what in response to the health and social care deal. Qualitative work has helped to show how devolution led to closer relationships and service coordination, and the policy review usefully illustrates plans from the different organisations involved. 

However, as the authors acknowledge, it is still difficult to know to what extent interventions were implemented in practice, and which interventions were a direct result of devolution or would have happened anyway.

These uncertainties and complications make it hard to interpret which aspects of devolution may have helped and to what degree shifts might have been driven by the wide range of other changes taking place in the region. 

Further, life expectancy itself is complex – affected by social, economic and environmental factors across a person’s lifetime, many occurring in early years. The changes in life expectancy seen between 2016 and 2020 are therefore likely to be heavily influenced by events long in motion before the devolution of health and social care. 

We need to view the findings in a broader context

Places are complex and so is devolution. This study is important for showing that life expectancy improved relative to the control group throughout the first 4 years of devolution in Greater Manchester. But the nature of this complexity, and the mixed results across the 98 indicators used in the study, means we’re still not entirely sure why.

Much of what makes us healthy and determines how long we live sits outside of health care systems. It is instead largely determined by the building blocks of health – such as secure housing, stable employment, good education. Much of this relies on well-resourced local councils, a social safety net, and partnership working across government departments and public sector organisations. 

Public finances have rarely been so stretched and latest data show life expectancy falling across England and inequalities rising. Supporting closer working and more coordinated service planning between organisations is likely to help – whether through integrated care systems, local partnerships, or formal devolution deals. This is why the Health Foundation has setup a £1.6m programme looking at how combined authorities can improve health and reduce inequalities by taking action on the levers they hold.

But closer local partnerships aren’t an alternative to national action. Little will change without significant reinvestment in public services and a coherent whole-government approach to improving the nation’s health.

Caitlin Barrand is a Research Manager at the Health Foundation.

Adam Briggs (@ADMBriggs) is a Senior Policy Fellow at the Health Foundation.

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