It’s a wow moment in NHS history.  It’s the latest ‘this is the end of the NHS’ moment.  Headline grabbing proposals for Manchester (somewhere up North) are either a brave experiment or a pending disaster.

An unholy alliance of Tory Central and Labour Local government has not only dared to suggest that some decisions about health services could be taken locally by those we elect; they have actually set out to try this dangerous idea out for real.

The loathing between local authorities and health service is as old as the NHS.  The battle to stop any kind of democratic accountability for health services (or at least the exciting ones like acute care) was lost in the original settlement.  Just how real the shift will be in Manchester is a bit vague but the intention is brave enough.

At the heart of this experiment is actually the very important issue about accountability.  The old NHS was based on the principle that a Secretary of State (who was at least indirectly elected) was accountable for everything including dropped bed pans in Wales.  This long standing fiction was diluted a bit during the reforms of the 1990’s and then recently replaced altogether by the new market settlement post the Lansley changes so that nobody at all is accountable for anything.

Local government is good at accountability.  When any decision is taken you get notice of the intention to decide in advance; you get to see all the relevant documents; you see the actual decision being made (or at least recorded) in public and so you know who has taken it.  Local authorities do have occasional ‘commercial confidential’ moments but by and large there is no doubt about who has decided what and the reasons they have relied on.  The elected decision makers have to work alongside the appointed professional officers who can and do intervene and can and do make their views heard.

The NHS is abysmal at accountability.  Nobody has any real idea who is actually responsible for what, although despite this apparent advantage the NHS is almost incapable of making tough decisions – at the first sign of organised and vocal opposition decisions are mysteriously avoided for as long as possible.

The long and troubled history of contested change and of pointless redisorganisation in the NHS is not due to the battle between public and private sector at all, it’s about protecting the NHS from effective management and so from democracy and accountability.  The NHS wants to remain as an island separated from the rest of the public services; it wants to remain as a federation of vested interests compromising only to mutual benefit, it does not want to be integrated into the public service mire.  It does not even want to be internally integrated, the various tribes want to retain their independence to ensure the disconnected and incoherent system which appears when viewed by the long suffering patients.

So Super Manc is a real threat to the NHS as a separate empire. Which is a good thing as just about everyone agrees that integration would nice.

You can have integration of services without integrated structures (possibly anyway).  But there has to be some financial, structural or organisational change to overcome the years of disintegration – dating back from long before the market ideas made it far worse. There are some big issues around how funding for health care is allocated efficiently, around variations in quality for no apparent reason, of disintegration to support the outdated medical model of care and of the refusal to accept the value of shared decision making and viewing patients and communities as resources.  These issues need resolving so we can move forwards to a modern care system although many prefer to go back to the insular NHS in its golden age sometime in the 1970’s.  The old separate monolithic NHS can’t deliver what is needed, and increasingly impatiently expected, in the current day world.

So we should all welcome what is being tried in Manchester.  Let’s encourage them to try new ideas; they can’t destroy the NHS on their own.  We should all get behind the idea that we have a National NHS so long as entitlement and standards, staff terms and conditions and major priorities are defined nationally.  But we should then acknowledge that there are always local variations and it is pointless assuming that top down national imposition is better than allowing local variations as regards what priorities are set and how funding is allocated locally. And do the national bodies like the CQC, Monitor and all really achieve more than could be done by local means of oversight?

How we deliver the services people need and how we organise provision can be determined locally and can be determined by looking locally at all the many services which contribute to our health and wellbeing.  These decisions made locally should be made by people we elect, that is the role of our democratic structures – to make the hard decisions on our behalf.  Luckily we already have all the structures in place to make this possible as it does for education, housing, environmental health, transport and everything else apart from health.

It is genuinely hard to believe that so many are actually saying they prefer key decisions about health services to be made (or avoided) by unknown, unelected and  unaccountable bureaucrats rather than those we elect.

The risks that this is just a ploy to pass deficits to local authorities or a back door into privatisation and outsourcing which has been the regrettable norm for local authorities are real enough so safeguards and vigilance are necessary but surely these can be addressed; and could it really be any worse than now?

A rational discussion about the role of the whole public sector in wellbeing, and so about accountability and local decision making would be valuable but we have not had one for the last 65 years.

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  1. Good to have this perspective at last on the Gtr Manchester news, after all the cold water that was poured posed on this exciting development. This IS a Labour council — one that saw the need to integrate health commissioning and local authority service delivery more than 10 years ago.

  2. Prue Plumridge says:

    Our NHS in the hands of local politicians. Sounds like a recipe for disaster. I can see nothing good about this – it will just lead to more fragmentation and will suit an ongoing privatisation agenda.

  3. bhfisher says:

    Very clear paper – thank you. With the HASCA in charge, all restructuring carries the risk of privatisation. If Labour got in and actually did remove the market from the NHS, Devo-Manc will be a most interesting and much safer experiment. I know that many NHS people view with great concern the prospect of an NHS run by a LA. Their argument is that shifts in political allegiances will result in sweeping changes to provision and plans with no concern for any clinical imperatives. That seems to me a small risk – with many benefits outweighing it. However, if the Tories stay in charge and privatisation continues apace, this sort of experiment is far more likely to end in fragmentation. And a risk that the NHS will get treated more like social care, with charges, means testing and top-ups seen as appropriate.

  4. Richard Grimes says:

    “Local government is good at accountability. When any decision is taken you get notice of the intention to decide in advance; you get to see all the relevant documents; you see the actual decision being made in public and so you know who has taken it.”

    Not when it is applied to commissioning of Sexual Health Services in Warwickshire, where the contract was cut by 12.5% (that we know) and the contract put out to competitive tender and *no one* bid, so George Eliot Hospital was awarded the contract under a process, or contract value, that we do not know. The things I learn from this are

    – local authorities cut funding, even when the cut is so deep that no one wants to have anything to do with it;
    – local authorities will put any (and in some cases all) services out to competitive tender to the private sector; and
    – when their tendering fails they resort to private deals behind closed doors (which is the way that Devo Manc was agreed).

    I am not sure I want local NHS services to be subject to this.

    Perhaps, first, what we really need is a top-down re-organisation of local government!

  5. Martin Rathfelder says:

    It’s not a Labour Council. It’s 10 councils, not all Labour. And whatever else happens we will have a different government before any of this comes into effect

  6. I’ve examined the Manchester arrangements in this piece It builds on the piece I wrote here earlier this month about health and social care integration and our critical analyis of the wider DevoManc deal. Briefly this is what I argue:-
    Democratic governance of the NHS would be a good thing. This deal does not deliver it. Read the Memorandum of Understanding on the AGMA website.
    Integrating Health and Social Care and working on health inequalities would be great, but not under conditions of austerity that disporportionately affect social care in a policy context that leaves the determinants of health (and other) inequality untouched.
    This is a neoliberal stitchup, parasitic on the failed model of trickle-down growthism.
    And the indecent haste of the closed-doors deal should ring alarm bells.

  7. lallygag26 says:

    The more I read of the SHA blog posts the more I wonder in which universe you would be considered to be socialists?

  8. A socialist piece cheerleading an imposed George Osborne pet project?!? I really have seen it all now.

    We in Manchester are to have a “Mayor” forced upon us even though we decisively voted against such a thing three years ago and we’ve now had the “devo manc” “deal” pronounced to us by Respublica the dodgy right wing think tank in Glasgow with absolutely no public consultation or public involvement whatsoever?!? Their “modern day Magna Carta” charter reads like neo liberal porn.

    Regardless of what this piece says the people of Greater Manchester have been organising for the fight of our lives with the mobilisation of a broad church of grassroots and political organisations from Left Unity, Greens, Unions, GM Pensioners, social justice, anti cuts and anti fracking groups and we call on folk from all over the UK to help us fight this abhorrent attack on our democracy as you WILL be next

    No pasaran

  9. Dave Bradney says:

    I see the NHS as a herd of bison encircled by a hungry pack of wolves. What the wolves really want is to cut out one animal from the pack. Then they will have it. Then they will be stronger, and the flagging pack will be that much smaller. Too Aesop for you? Why else has George Osborne become the new champion of local democracy? How stupid are you, or is it worse than that?

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