The Greater Manchester experimentBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1611 (Published 22 March 2016) Cite this as: BMJ 2016;352:i1611
A huge experiment is about to begin in Greater Manchester. On 1 April, power to manage the £6bn (€7.7bn; $8.7bn) budget for health and social care in the metropolitan county will be devolved, and an ambitious plan will be put in motion to change every aspect of the health and care system in the next five years.
Foundation trusts will have surrendered their autonomy in the interests of planning hospital care across the city region; GPs will no longer be independent businesses but part of locality focused hubs (see box) providing a wide range health and social care outside hospitals; and a projected £2bn hole in finances will have been filled.
Taking Charge,1 the blueprint for change published in December by the Greater Manchester Combined Authority, said that GPs will become leaders of local care organisations (LCOs) running primary, community, social, and mental healthcare services, as well as some acute services, as part of a determined plan to move the centre of gravity away from hospitals.
In a few years’ time GP services “will be fairly unrecognisable,” says Tracey Vell, chair of the Association of Greater Manchester Local Medical Committees. The plans have “largely landed well [with GPs] because we’re seeing the crisis coming in some areas of general practice; everyone’s worried,” she says.
Overhaul of services
The overhaul of GP services typifies the shift in thinking and ways of working that all health providers across Greater Manchester are about to undergo, in one of the most radical NHS experiments since local authorities were stripped of health responsibilities in 1948. Greater Manchester negotiated the devolution deal with NHS England and the government, as it believes that the current system is failing its 2.7 million population.
“We have the fastest growing economy outside London, and yet we have some of the worst health outcomes in the country. Despite all that money the picture hasn’t substantially changed,” says Ian Williamson, interim chief officer for Greater Manchester Health and Social Care Devolution.
Public Health England data have put Greater Manchester at or near the bottom for a whole range of indicators.2 For example, the under 75 mortality rate for all cardiovascular diseases is 135.0 per 100 000, compared with 75.7 overall in England. The mortality rate for cancer under the age of 75 that is considered preventable is 127.6, compared with 83.0 in England.
The driving force behind the changes has been the region’s 10 boroughs, and the most obvious change to the NHS under “Devo Manc” is that councillors will be directly involved in running health services.
Howard Bernstein, head of paid service for the Greater Manchester Combined Authority, says that politicians “provide a sharper focus around leadership of place.”
“The NHS is fragmented,” he says. “Leadership is distributed, and it is very organisationally focused. When you start to address not just health and social care integration but also alignment with wider public sector reform—housing, getting people into work—you have to focus on place and people rather than organisations.
“We believe the model we are developing, which is an equal partnership between providers, CCGs [clinical commissioning groups] and local authorities, will provide that focus.”
The aim is to make the Manchester care system clinically and financially sustainable by 2021. Among the health outcomes Greater Manchester is seeking, reducing the number of low birthweight babies to the national average would result in 270 fewer very small babies (under 2.5 kg) each year. Raising the number of parents in work to the average would result in 16 000 fewer children living in poverty. Improving premature mortality from respiratory disease to the national average would result in 580 fewer deaths.
Greater Manchester estimates that, without action, it will face a deficit of £2bn by 2020-21. The outlined plans to tackle this include £139m saved by reforming NHS trusts, £836m from productivity gains, and £70m through prevention.
Having had no time to test the way the changes in the health system will work since NHS England and the government announced the devolution deal in February 2015, the first few years of Greater Manchester managing its health and social care budget amounts to a giant pilot project—which, if successful, could lead to calls for other parts of the country to go the same way.
Devolution and delegation
Yet Greater Manchester is unique in many ways, its health plan being inextricably linked with its wider devolution work to grow the economy and building on a history of collaboration across the 10 boroughs. So, while success may suggest that devolution is good for health, its strategy and the models of working that it develops may not provide a template for other counties.
In 2011 Greater Manchester established the country’s first combined authority and then secured a deal with the chancellor, George Osborne, to take responsibility for public services including planning, transport, skills, and welfare, in exchange for electing a “metro mayor” in 2017. The government and NHS England announced the health deal in February 2015, leaving barely 13 months to prepare.
Mike Burrows, managing director at Greater Manchester Academic Health Science Network, believes that the power of the health proposals lies in their link with Manchester’s wider work on economic growth.
“We can move away from the traditional NHS approach—‘let’s invest in primary care’—to saying, ‘if we invest in these care programmes we can have an impact not just on care but on crime, worklessness, the benefit system,’” says Burrows.
The governance is complicated, with a joint commissioning board of the 12 CCGs and 10 boroughs feeding into a partnership board of 37 CCGs, councils, and trusts, alongside representatives of GPs and others. The mayor has no role, which may risk the post becoming a rallying point for opposition to service reconfigurations.
Devo Manc is as much delegation as devolution: the government’s aims for the NHS set out in the mandate to NHS England still apply, Manchester will deliver national strategies on everything from cancer care to mental health, and national targets remain. NHS England employs the chief officer.
Critics of devolution
Among critics of health devolution is Raymond Tallis, a retired geriatrician. He believes that it undermines government accountability for providing universal healthcare and that it will allow ministers to duck the issue of adequate NHS funding.
“This is dismantling under the guise of devolution,” he says. “The debate about how much we should fund the NHS will turn into a debate about how badly local authorities are managing the NHS.
“It will finally cut the umbilical cord to a national government responsible for providing comprehensive healthcare. We have already seen those parts of the health service which are the responsibility of local authorities, such as sexual and public health, savagely cut.”
Manchester says that adherence to the mandate and NHS constitution show that the national character of its health services will be retained. But it may not be that simple for future devolution deals elsewhere under the Cities and Local Government Devolution Act, passed in January.3
As Helen McKenna, senior policy adviser at the King’s Fund, explains, “The NHS Constitution is not a comprehensive reflection of the NHS offer. Areas with health formally devolved could [for example] choose to take a different approach to NICE guidance.
“While areas have the flexibility to do this within the current system, the secretary of state and NHS England have the power to tell areas to up their game. It would be much more difficult to issue such edicts where health had been devolved.”
A liberal regime
NHS England and the regulators are allowing Manchester to operate under a more liberal regime. While freedoms elsewhere are giving way to firm central oversight, Manchester is getting latitude to work differently.
But Manchester foundation trusts are also losing autonomy, to the partnership board. Services will be planned across the region and across sub-regions to reduce duplication and concentrate resources in specialist centres. Ann Barnes, chief executive of Stockport NHS Foundation Trust, sees the loss of autonomy as necessary to find a “way out of an intractable problem” and now sees weaknesses in the foundation trust model. “Being a foundation trust was asking us to look at ourselves only, and that’s a difficult position to take. Our patient focus should have been at a bigger scale,” she said.
Devolution can be seen as an attempt to reboot commissioning, after clinical commissioning has failed to reshape the NHS to tackle issues such as keeping frail elderly people out of hospital. As Adrian Masters, executive director of strategy at NHS Improvement, puts it, “Commissioning has so far failed to drive the system at the speed we need to go; it is difficult to wrest control from providers and change the pattern of care.”
Manchester takes commissioning to a regional level, Masters adds: “The regional approach is something we want to put more of a push behind. Greater Manchester is the best idea we have had to do this so far. They have a two year window to show what can be done.”
NHS Improvement will largely look at Greater Manchester as a whole. Andrew Foster, chief executive of Wrightington, Wigan and Leigh NHS Foundation Trust, explains, “If Greater Manchester is hitting the [accident and emergency] target and Wigan is missing it, then the Greater Manchester authority will do the regulation rather than NHS Improvement.”
Evaluation of success
Greater Manchester is working with the Health Foundation charity and with the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, to evaluate the devolution programme. The research team is led by Kieran Walshe and Ruth MacDonald, professors at the University of Manchester. The project started in autumn 2015 and will run for two years. The aim is to map the service improvement plans, analyse key initiatives, and set out how progress can be measured. It will include analysis of governance, accountability, organisation, and costs.
Despite the scale of the project the legal underpinnings for health devolution are weak: the government could rescind the deal without having to go back to parliament. McKenna says, “This stuff could easily evaporate. NHS England could take back control very easily if it doesn’t like what is happening.”
The risk will come, she says, when Manchester begins to tackle the projected £2bn shortfall it faces: “Innovation often involves failure. Do the national bodies and politicians have the stomach for seeing failure happen as Manchester finds its way to better health outcomes?”
A new way of working for GPs
Local Care Organisations (LCOs), typically serving populations of 30 000-50 000, are intended to be where most people access their care. As part of an effort to take pressure off hospitals, they will aim to provide alternatives to the emergency department, support hospital discharge, and keep people well once they return home.
Depending on the area, services will range from triage and phlebotomy to home care. LCOs will define new, community based care pathways, and each LCO will have a common patient record.
The LCOs will be organised in different ways depending on local circumstances, but all will follow the models outlined in NHS England’s Five Year Forward View.4 These include accountable care organisations (groups of providers coming together to manage the health of a defined population) and multispecialty community providers (GPs combining with nurses and other community health services, hospital specialists, and often mental health and social care to create integrated out-of-hospital care).
This will all take several years—the plan anticipates having the new community services established in every locality by 2021. Contracts and governance are still being decided, and new ways of working are being piloted. Around £2.7bn of health and social care spending will be pooled locally by the CCGs and the 10 councils, and this will be used to commission these services jointly.
Rapid action to relieve the immediate pressure on GPs will include help with clinical staff recruitment.