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
All rapid responses
Richard Vize provides an invaluable service by attempting to sum up for readers of the BMJ progress on DevoManc.
It doesn’t seem to be easy. For all the commitment to transparency and openness that is supposed to suffuse public life we often have to scramble around for the crumbs falling from the table of the powerful.
The truth is that for all the bluster, and the bluster is “world-class”, the mundane truth can be, modest.
In place of bold and credible plans we have extravagant, aspirations. Instead of evidence we are asked to place faith, in faith. The glue holding the complex web of 37 separate institutions and stakeholders together, the promise of a share of the £450m offered in the Devolution deal seems to have withered to £153m, to last until 2021. The evidence that spending this will carve out the resources required to fund new models of care initiatives on a recurring basis in the future remains, elusive.
It doesn’t seem to have helped that two years have been spent in the back room trying to get agreement. This was always going to be tricky. It so happens I have professional experience in looking at collaboration projects within the NHS since the late 1970s onwards. To be blunt if the NHS cannot organise laundry services across a locality, or pathology services or incineration services, whilst NHS organisations remain sovereign and separate and can walk away from agreements in principle without being contractually bound to another NHS body, the chances of first getting agreement and then holding each within such agreements is remote. The alternative of hiving off all services into third party controlled contractual agreements over 10-15 years with 37 partners even more forbidding.
So it’s no surprise that Professor Walshe compares efforts to a “useful sandpit” where ideas can be tried out and tested. But it seems to have cost £300m to get to this stage.
Vize reports that the money for Transformation in Manchester is £153m. It is not clear what has happened to the £450m; nor indeed whether the £153m is any different to transformation funding earmarked for every STP; nor whether there will be any money left over for “transformation” if the first call will be propping up acute deficits; said to be £34m and rising for 2017/18. It all looks like the rest of the country, focussed on coping with the financial crisis within the provider sector rather than able to consider fully new ways of doing things.
The way seemingly chosen of focussing , of merging into fewer larger bodies ,will make it administratively easier but not reduce the inherent tensions as local communities are sticky when it comes to losing local access to services, in return for a bus ticket. In NW London following the rationalisation of local maternity and paediatric cases patients in Ealing face a two stage journey and average waits of five to six hours before they are seen , if they turn up at the “Rapid Access Clinic”. Not surprisingly patients have stopped bothering, and probably now call an ambulance instead. Emergency admissions have continued to rise. Closing two A&E departments has turned A&E services in NW London from one of the best to one of the worst services in the country. Closing two more is unthinkable, but that’s what local plans say.
Talk of integrated care may sound good (or better than accountable care organisations) but it all depends on who will be doing the integrating and to what end. If all it does is put a private sector integrator in charge, immune from scrutiny and public accountability, it seems unlikely that the public will accept this, particularly if it means closures, secrecy and no ability to scrutinise or render accountable.
Thus when Rouse, the chief officer in Manchester, identifies problems with urgent care, and getting agreement to the complex contractual issues so that the focus can move to delivery instead of on organisational and governance issues we are not surprised. What is surprising is that after two years and hundreds of millions in experiments in new ways of working the talk is only of …“beginning to see some tangible benefits.”
It’s going to take a lot more than that. The marketing blurb for Devo Manc said that the sustainability gap would be £2bn by 2021. One would have hoped for rather more than “some tangible benefits” by now.
The issue for us is that as people who monitor the evidence for new models of care closely is that we know that if good evidence exists we would all be told of it by now. But the precautionary principle seems to be true in reverse in this case. Unless the lemmings preparing to throw themselves off the cliff are presented with irrefutable evidence that alternatives exist the cliff is, in the words of the Kings Fund, “the best available option”.
Vize exposes that aspirations are being fed by transformation funding but as it expires there is likely to be little left to sustain the aspirations of those that thought that investment in expansion of Out of hospital care would radically change the NHS.
Various scapegoats are implied: resistance by staff and the wider community; lack of the right legal and organisational frameworks; lack of future commitments of funding etc. The truth that dare not speak its name is that the evidence to justify the hype and heightened aspirations was never there in the first place.
A bit more openness and transparency would have flushed this out sooner. As it is the sooner that full evaluations of the plans and their progress to date are revealed the sooner priorities can be re-assessed and changes made to the change programme. Or are the change masters resistant to change? That would be ironic wouldn’t it?
1. “We also need a new generation of Joseph Chamberlains – strong, far-sighted city and civic leaders, with bold, credible plans, for the amenities and infrastructure their localities need, working in close partnership with business and social leaders, to make their towns and cities magnets of new and better jobs. And they need the tools for the job. Whitehall needs to hand down budgets and powers for this purpose – not just talk about handing them down, as the Coalition has done since the Heseltine Report. England’s business leaders and local governments need empowering to invest in infrastructure, skills and economic development” Letter of introduction by Andrew Adonis to:
MENDING THE FRACTURED ECONOMY:Smarter state, better jobs Final report of the Adonis Review An independent review for the Labour party, supported by Policy Network July 2014
2. Ealing CCG Paediatric Transition Review September 2017
Competing interests: Our company acts as advisors to local authorities involved in scrutinizing NHS plans.