The big devolution deal—or no deal?BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1217 (Published 19 March 2018) Cite this as: BMJ 2018;360:k1217
Two years after Greater Manchester got control of its £6bn (€7bn; $8bn) health and social care budget, the bold experiment in devolving power over health services is starting to make a difference to people’s lives. But its long term success is far from assured.
The five year devolution deal with the government and NHS England for the area’s 2.8 million inhabitants began in April 2016 and has been followed by a similar agreement in Surrey Heartlands (box).
Much of the early work of the Greater Manchester Health and Social Care Partnership— the body that oversees the devolution project—has been hidden from public view. Groundwork includes an immense effort to bind the 37 NHS organisations and local authorities together, and beginning the long journey to shift the staff and leadership culture so that people begin to think of themselves as working for a patient driven system rather than just their own organisation.
The big goals are to make the Greater Manchester health and social care system financially sustainable by 2021 and to improve health indicators such as large numbers of low birthweight babies and high cancer mortality under the age of 75.
Professor Kieran Walshe at the University of Manchester, who is leading research into the development and effect of the devolution programme, says the past two years have seen a big effort to build “a lot of institutional architecture—the provider board, the strategic partnership board, a whole host of groups [covering priorities such as] pathology, pharmacy, and acute service reconfiguration. They have been an important investment in getting lots of people from different organisations around the table and engaged in trying to work collectively.
“That is a reversal of at least 20 years of policy that has headed in the opposite direction—towards competition, autonomy, and fragmentation. That is not unique to Greater Manchester, but [the area] forms a useful sandpit where these ideas are being played out and tested.”
Stake in the system
Jon Rouse, the partnership’s chief officer, says giving every health and care organisation a stake in the system has been essential to making progress. “Partnership is incredibly rewarding but it’s hard work because as a mechanism for decision making it’s inherently complex to get a significant number of organisations to agree on a single way forward,” he says.
“The good news is that if you can pull it off you have absolute ownership of those decisions [and] you can move pretty fast.”
Crucial building blocks for devolution are getting the legal structures in place for commissioning and providing services, and distributing the £450m transformation fund from NHS England to kickstart changes.
The 12 clinical commissioning groups (CCGs) are developing single commissioning operations for health and social care with their respective local authority—or authorities, in one case. Eight CCGs match councils.
The three CCGs covering the city of Manchester have merged to form NHS Manchester, which has in turn joined with the city council’s commissioning function to form a single body called Manchester Health and Care Commissioning. Its board is chaired by a general practitioner and includes the council’s executive member for health. Aims include coordinating health and social services and making it financially sustainable.
Some of these commissioning bodies have the council’s chief executive as the accountable officer. Other services will be commissioned at a Greater Manchester level.
Local, accountable, integrated?
Ten local care organisations (LCOs) are responsible for delivering primary and community services, built around hubs serving populations of 30 000-50 000 people. GP surgeries are part of them. Each organisation aims to join up primary and social care, public health, mental health, pharmacy, and community services and to ensure effective working with hospitals. A key aim is to keep people out of hospital by identifying those at risk of admission and developing care pathways to manage their conditions in the community.
The contracting arrangements between the integrated commissioners and the LCOs is proving complicated and is being caught up in national debates over the right legal structure for establishing integrated care systems. This term is now being used by NHS England to describe the Manchester and Surrey devolution deals and the eight areas previously designated as “shadow accountable care systems.” The accountable care label has been dropped because its association with US healthcare has fuelled claims that it is a cover for privatisation.
Manchester’s transformation funding is allocated over five years; the budget for 2018-19 is £153m. After 2021 any new posts and services have to be funded from “business as usual” budgets.
Rouse says that the big focus now is “hardcore delivery—using the transformation resources and business as usual resources to implement change. We are beginning to see some tangible benefits.”
These are most visible around the community hubs. Tracey Vell, chair of the GP advisory group and chief executive of Manchester Local Medical Committee, explains that each of the LCOs are developing at different speeds with different priorities. For example, Tameside has been trialling paramedics and nurses doing virtually all the GP home visits: “This is a dedicated paramedic who is owned by the practices and gives huge continuity of care. This will change the face of general practice.”
“Eye popping change”
Greater Manchester has made some big promises on tackling the underlying causes of poor health. In Salford and Stockport “social prescribing” is being used to encourage activities such as cooking, walking, and singing. The effect of social prescribing is difficult to evaluate, but one Stockport practice claims its use has cut requests for urgent GP appointments and home visits by about 30% while increasing routine nurse led appointments. There is some evidence of reduced prescribing of antidepressants and medication for musculoskeletal problems.
Alice Tligui is chief officer of Healthwatch, which represents the views of service users in NHS planning, in Bolton and in Wigan and Leigh. She says Bolton alone has 40 programmes of work supported by transformation funding, covering everything from ophthalmology to a single care record. Increasing numbers of patients are able to see a GP at weekends, out of hours services are being improved, and new staff are joining primary care teams, she says.
“Both areas have link workers for the voluntary sector attached to GP neighbourhood hubs. They are making quite a big difference working with people with needs beyond health who keep coming back to health for answers, such as debt advice, alongside health improvement practitioners on lifestyle issues such as activity and diet.”
Bolton has added salaried pharmacists to GP teams after a pilot in Stockport liberated considerable GP time spent on prescribing and improved medicine safety through measures such as reviewing long term medication and making home visits. Bolton and Wigan are also recruiting mental health practitioners and physiotherapists, again based in the neighbourhood hubs.
“It’s quite eye-popping how much change there is,” Tligui says.
The big question is whether there will be money to pay for the posts once the transformation funding runs out. “Even if you move everything to the community, [acute] demand will still keep going up,” says Tligui. “The idea that it’s going to make a difference to the amount of service you need at acute level is debatable. So if our funding for new community posts is transitional and we are not going to save any money out of acute care at the end of it, that’s the conundrum.”
Board papers indicate that providers are on course for a deficit of £34m in 2017-18, £13m worse than planned.
Acute services are also beginning a period of upheaval. Rouse says the plans cover “over 70% of our acute services, including orthopaedics, paediatric, cardiac and respiratory, women’s services, neurodisability, and critical care.” The changes are intended to improve quality and efficiency and make better use of hospital buildings.
Sorting out problems with urgent care is a big priority this year—“it’s our weakest suit,” says Rouse.
Eventually most areas will have two GP led urgent treatment centres, one in a hospital and the other in the community. But integrating them with emergency departments and other services is tricky. There will be a specialist centre for stomach and oesophageal cancer surgery, with similar plans being developed for kidney, prostate, bladder, breast, and bowel cancers.
Speed of change
Rouse accepts that such a blizzard of activity has created problems: “The thing I am always torn by is have we gone too quickly or not quickly enough? If I had my time again I think I would have phased the work more than we did. I think we developed too many plans and strategies all at once.
“If there is a risk we run at the moment it’s expecting the system to implement too much change on too many different themes all at one time.”
GPs are under particular pressure, notably in getting a grip on urgent care: “I’m worried that we are asking our GPs to do multiple things. We ask an awful lot of them. We can only stretch them so far.”
Despite the workload, Rouse claims that “only a small minority” of GPs are not on board “because we involved the primary care leadership from day one. They have equal voting rights on our governance, we have a primary care advisory group. Getting that constructed right from the beginning was very important, to show to primary care that they owned this as much as anyone else.”
A complication in Greater Manchester is the election of a mayor—former health secretary Andy Burnham. Although he does not have any direct control over health services, the health and social care partnership has been careful to embrace his priorities, particularly around homelessness and mental health.
Actions include registering almost 500 homeless people with a GP and hospitals working to ensure no one is discharged from hospital straight onto the street.
Rouse says: “Andy has this huge democratic authority and legitimacy, which means we take his manifesto very seriously and have embedded the things he wants to achieve into our business plan.”
Rouse accepts there could eventually be a formal role for the mayor in leading health and care.
Health Innovation Manchester, the academic health science network bringing together the NHS, universities, and industry, is trying to capitalise on devolution. Executive chair, Rowena Burns, says: “There is nowhere else that has a single partnership governing £6bn across health and social care, and it has made industry beat a path to our door. We mustn’t underestimate what we can deliver as a result of that opportunity.”
Projects include developing a new pathway for chronic obstructive pulmonary disease, a programme to eliminate hepatitis C, improvements to social care for people with learning disabilities, and rapid access to psoriasis treatment.
Greater Manchester is a long way from involving the mass of clinical staff in its plans. “I’ve got to be honest—there will be large numbers of frontline workforce who will not have noticed a huge difference because of devolution to date,” says Rouse.
Vell admits there is a lot to do in changing staff culture: “We need to look at the quality of our workforce. Have we got the right training programmes in place for transformation? Is everyone comfortable with the changes?”
This lack of engagement could prove a serious weakness. Whatever the structural and contracting arrangements, truly integrated care comes when frontline staff feel empowered to do the right thing for their patients, while managers and clinical leaders clear the obstacles to collaboration out of their path. As a Wigan resident tartly observed after hearing an eloquent presentation about joined-up care in the town, his father’s rehabilitation team still seemed incapable of talking to the district nurse about pressure sores.
Manchester is matching big ambition with a massive work programme that is beginning to improve services. But its two biggest challenges are still ahead: getting staff buy-in and making it all financially sustainable by 2021.
Surrey Heartlands follows Manchester’s devolution lead
Surrey Heartlands is almost the mirror opposite of Greater Manchester—an affluent Home Counties population of just 850 000. GP Claire Fuller, senior responsible officer for the devolution partnership established last year to bring together the NHS together with local councils, says the large number of retired people means many of their service users are “articulate … with a lot of time on their hands.”
“Whole [plans] can get derailed by these individuals. So, to stop that, we worked with the local authorities and made sure we spoke to members of the population in each one of our demographics and asked them about priorities.”
This has led to the creation of an extraordinarily active online panel of 2000. Recent questions on mental health prompted 1500 replies in a week.
Surrey Heartlands is not grappling with major hospital changes: “We are focusing on stuff we should be doing in the community at a population health level. Our four priorities are out-of-hospital and primary care, mental health, prevention, and winter.”
Primary care services are good but “GPs are still really stressed—the workload is enormous because of our population of frail elderly people.”
New posts being created using £80m transformation funding include psychiatry, mental health liaison, a nurse education lead to improve diabetes care, and GPs working in emergency departments.
The recruitment of a chief midwife shows how transformation funding is supposed to work. It is a temporary post to unify midwifery services across the patch. The gamble is that new ways of working will be embedded strongly enough to continue after the post is scrapped.
Fuller says devolution “gives you a licence to just get on with it. That is what is so energising.”
DevoManc by numbers
£6bn total health and social care budget in the devolved area
2.8m inhabitants covered
NHS and local authority organisations to link together
£450m transformation funding from NHS England
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.