At what scale are things best organised? That is at the heart of so many of our big debates today – Scottish independence, UK independence, devolution.

And yet the debate rarely takes place with a deep look at scale and what should be done at different levels. That is not to say that there is not informed debate, even if some of that is rooted in an emotional sense of the desire to regain control in a complex world, and the perennial promises and illusions of nationalism and regionalism. But scale is something, ever since Leopold Kohr argued for the breakup of nations in the last century, that is hard to pin down.

Herman Daly, the great ecological economist, for example argues that economics has focused on the twin goals of distribution and efficiency, when it should also have focused on scale. Fritz Schumacher, the doyen of “Small is Beautiful” agreed. His argument was never that we should do everything at the local level, but that “we need freedom and order: the freedom of lots and lots of small units and the order of large-scale, possibly global, organisation.” He pointed in the 1970s to the catholic tradition of subsidiarity, or devolution as a working principle – as small as possible.

The world has moved his way. Every national politician seems to profess localism. Devolution has spread and won its spurs, changing for good the national settlement at the UK level.

The latest variant is Devo Manc. This is the proposal (albeit without the legislative basis of the nations within the UK) to devolve spending to the Greater Manchester authorities. It isrecognition, on the one hand, of the centrifugal dominance of London as close to a city state, and, on the other, of the widely praised governance and leadership of Manchester.

By chance, I met with two dozen leaders in the health and social care system in Manchester on Tuesday evening, just as the rumours hit the wires of Devo Manc taking on health spending across the region, devolved from NHS England. I was just one participant in a room full of passion and expertise. One of the reasons I was there though was to talk to the potential for genuinely participatory approaches to health and care – not least the social co-operative model now emerging in Wales, which offers an ownership model fit for the concept of co-production, of a partnership between service users, carers, community and the precious teams of professionals.

None of Devo Manc (health and care) is going to happen quickly and it is right to prepare the ground and to think through very carefully what needs to be done at different scales. There are still very good reasons to have an NHS, possibly even a European Health Service, for example around negotiating with Big Pharma on product and price or around aspects of food regulation. Public health ought to be easier in a national system than in the fragmented landscape of providers in the US – we need to be careful not to lose that in a devolved system.

But the consensus from the evening was that here was an opportunity to get things right. A statement prepared for the Manchester Evening News by Martin Rathfelder of the Socialist Health Association later that evening captured the mood:

“Under the right conditions this can be an opportunity to ensure that our Manchester Health Service – MHS  – brings much greater benefits to patients and communities. 

MHS patients must be equal partners in decisions about their own care and of their families.  The MHS should be much more democratically accountable than the NHS has been in the past.  Manchester still has huge inequalities in health.  The average age at death of people living in the most deprived parts of the conurbation is ten years less than among those living in the most prosperous areas.  The NHS has never been able to tackle inequality on its own but the MHS will be the biggest employer in the region and with local councils must use its muscle to reduce inequality.  At the same time we want to see an end to wasteful and damaging competition between hospitals. 

MHS should bring much closer working  between social services, citizens, patients, carers, families, communities, hospitals, family doctors, pharmacists and other clinicians, researchers and the voluntary sector. and to establish real parity of esteem between mental and physical health.”

The key to success in devolution seems to me to be one that many co-ops would recognise – you do things together only those things that are done better together, and if you prove that you can do that, you can build the mandate and collective will to do astonishing things for the common good.

This first appeared on Ed Mayo’s blog.


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One Comment

  1. Neo-Liberalism started to affect us in the 1970s with Milton Friedman telling us that freedom came when the individual was liberated by shaking off the shackles of government.

    During that period I worked as spare parts manager for a small import export company. My Boss, who was the son in law of the owner of the company had a favourite expression , which was: “It’s all down to finance, ideas men are ten a penny.”

    I later understood the true meaning of what he was saying in that Neo-Liberals control society by controlling the money, Manchester can have all the autonomy in the world but without proper levels of finance it is in exactly the same trap that the rest of public services are.

    The other small point is in a capitalist world where power comes from how big you are, not how small you are, then when it comes to bargaining with suppliers, it isn’t little Manchester that holds sway, it is the National Health Service that has the whip hand. All it has to do is use it just like Tesco.

    There are far too many in SHA that appear to believe that there is something fundamentally wrong with the NHS, when in fact it has been Neo-Liberal governments interfering by introducing market philosophy and driving their dogma by deliberate under-funding.

    Clearly there are those in the SHA that want further market penetration into the NHS for truly bogus reasons and not down to efficiency. Local councils up and down the country are outsourcing their services, which of course fits neatly into what the Kings Fund believe that New Labour will create in the NHS, the NHS will just become a logo and the body for outsourcing health care, not the provider of care.

    Anecdotally I have a German friend that lived here where I lived as an Au pair that was a family friend to a local doctor. This doctor arranged for her to spend six months of her stay here to work as an auxiliary Nurse at Standish Hospital, her experience there overwhelmed her as she had not seen the technology that we had at that time (1966) in German hospitals, noting that she had trained in Marburg, one Germany’s main training hospitals.

    What this should tell you is that we need to go back to those days and fund our NHS properly so that we can adequately staff and equip it to those same standards.

    We have the money, it is just that lying Neo-Liberal politicians pretend that we don’t, but when it came to saving the corrupt Banks, we suddenly plucked £375 Billion out of thin air, and do those same politicians worry where the money comes when they decide we should fight America’s wars for them.

    Why are we going backwards instead of forwards, after all we should know better in the 21st century.

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