Category Archives: Devolution

The Welsh Health Cabinet Secretary (Minister) Vaughan Gething AM has identified three major priorities for primary care in Wales
* maintaining the sustainability of the sector,
* improving access to services and
* delivering more care in a community setting.

Central to delivering these are objectives are the emerging GP Clusters / Primary Care Networks. There are 64 networks or clusters in Wales with a population base of 30- 60,000 patients. It is based on promoting partnership and collaborative working.

The networks allow general practices and a range of other primary and community care practitioners to get together with their local health boards to shape community based services for their populations. However, unlike CCGs model in England, they are not involved in the commissioning of secondary care.

The Health, Social Care and Sport Committee of the National Assembly for Wales is undertaking an enquiry to obtain a better understanding of how the cluster model is working in Wales. The evidence submitted to the enquiry provides an interesting barometer of the progress that is being made.

Where things are going well, a wide range of new services are bring provided, often using new models of care. Many of these more advanced areas areas want to move towards more formal structures. In the Bridgend area of the ABMU Health Board a social enterprise has been established to look a providing services. Elsewhere a number of networks see the formation of “federations” as the next obvious step.

There is not a single operational model for the networks with varying levels of professional engagement and breath of wider organisational involvement. Some networks are more active than others in their efforts to involve social care organisations, third sector bodies and the wider patient / user / public voice.

Clinical representative bodies (e.g. GPC Wales, RCN, RCSLT, Royal College of Physicians, Royal Pharmaceutical Society, Care Council ) highlight that involvement in the networks is time intensive with some concern about an over-focus on GPs and the lack of parity of esteem for other professional health and social care groups. But management evidence ( e.g various health boards, NHS Confederation, Directors of Primary, Community and Mental Health) suggests an awareness of these problems and that they are working to address them.

An important factor in improving the status of the networks and facilitating their work has been the Welsh Government’s decision to directly allocate funds to them. While most primary care funding still goes through health boards, £16 million of recent allocations have been directly earmarked for the clinical networks. This has been welcomed though some concern has been expressed that some health boards might dip into these resources in areas where the networks are making less progress.

The fragility of primary care overall and general practice in particular is a consistent feature of much of the evidence. This is in line with recent BMA survey evidence that 80% of GP respondents had concerns about the sustainability of their practices. The efforts of the Welsh Government to promote recruitment and the status of general practice were widely supported. But the factors under-pinning this fragility – patient need and expectation, system pressures and supply side issues such as resourcing and staffing levels must all be acknowledged and addressed ( Bevan Foundation).

While some individual submissions suggest that independent contractor status of general practice needs to be enhanced, overall most submissions acknowledge that this traditional model is no longer adequate on its own. Some sort of salaried GP service is required to supplement struggling practices, to staff directly managed practices and to provide out of hours care. As well the Bridgend social enterprise is looking at the option of directly employing GPs as a form of new service delivery. This is a welcome development as up to now, most Welsh health boards only saw salaried GPs being employed by independent contractors and regarded their own reluctant involvement in directly managed practices some sort of transitional safety net.

The need to relocate services to a community setting and to improve access is widely acknowledged across many submissions. Many illustrative examples are given. Some such as the use of pharmacists, better home physio and OT services and community re-ablement for respiratory and cardiac conditions builds on well established practice. But other initiatives such as Predictive Risk Stratification Model (PRISM) are being developed to support anticipatory care models while the Inverse Care Law Health checks (which was developed in the Aneurin Bevan and Cwm Taf University Health Boards) are being promoted for national roll-out in Wales.

Social prescribing is also gaining attention as a means for primary care to engage with primary prevention, health promotion and other activities to reduce the chance of becoming ill though the better use of non-medical community assets and to influence social determinants of health locally. Public Health Wales is working to create an evidence base to support this work.

While there is wide-spread support for the development of primary care networks, there are obvious issues that need to be addressed. There is uneven development and engagement both within networks and across networks and health boards. Hard pressed clinicians in areas of high need are most likely to find it most difficult to be fully engaged in these additional areas of work. Local Medical Committees, health boards and Public Health Wales need to carefully monitor the situation to ensure than this does not lead to an inadvertent widening of the health inequalities by ensuring that the areas with the greatest need are not left behind.

With some exceptions (e.g. ABMU HB, Care Council, College of Occupational Therapists) it is of concern that social care has not figured more prominently in the submissions. Social care is crucial to promoting and maintaining the independence and dignity of the most vulnerable in our community. However there are few submissions from the social care sector and there seems little awareness of the need to include social care as a key player in the management of people with multiple and complex problems.

But while there is little specific reference to social care, many of the submissions acknowledge the key role that multi-disciplinary teams (MDTs) will play in the evolution of primary care networks… both in terms of policy formation and delivery. These teams must not only embrace a wide range of primary care clinicians but also include social care. They should also explore ways to have a much more fluid interface with secondary care – as the RCP describes it, we need “hospitals without walls”. By implication, though it has not emerged in the submitted evidence, this would involve some primary care network participation in the wider planning of secondary health care services for their localities.

The absence of a rigid model for networks has many advantages as it allows clusters to develop at their own pace and in line with their own priorities. However the lack of an overall governance framework must create risks that will inevitably emerge as networks evolve and become more directly involved in care delivery.

The submissions to the Health, Social Care and Sports Committee shows there is widespread support and good will for the emerging primary care networks. The evidence suggests that they are evolving in a positive way. However there a are differing levels of maturity with differing levels of impact at a local level. The Committee will publish its own conclusions in time and hopefully its report will provide a further opportunity to consider how things should develop.

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On November 1st 2016 the Welsh Government’s Cabinet Secretary (Minister) for Health, Well-being and Sport, Vaughan Gething, announced the establishment of a Parliamentary Review which will look at the key challenges facing the health and social care services in Wales.

He said  “ … (it) will review the best available evidence to identify key issues facing our health and social care services and draw out the challenges that these will present over coming years. For example, there are challenges with NHS finances within a reducing Welsh Government budget, workforce planning, recruitment and retention, and meeting the rising demands of healthcare and rising public expectations. The review will examine options for the way forward and will then make recommendations about what the health and care service of the future could look like.”

The review was initiated as part of the “Moving Wales Forward” agreement between Welsh Labour and Plaid Cymru underpinned by wider cross party consultation and discussion.

The current Welsh health strategy, “Together for Health “ is due for revision and the Cabinet Secretary hopes that the Parliamentary Review will be completed in time to inform its replacement. This seems sensible and should give the Review a sharp operational focus.

However such a relatively short time window may not provide sufficient opportunity for the Review to engage in the innovative thinking needed to come up with the radical proposals that an under-resourced health and social care service is likely to need just to sustain itself and survive.

The Review will be led by the former Chief Medical Officer for Wales, Dr Ruth Hussey, supported by an an independent panel drawn for a wide range  of experienced backgrounds predominantly from outside Wales. It will be supported by a stakeholder reference group made up of representatives of professional bodies and social service organisations within Wales. Faced with such an strong resource, which has attracted cross party political support, the Welsh Government might wish to consider asking the Review for a relatively early report to help with the revision of its overall strategy and then requesting it to give additional thought as to what Welsh health and social care is likely to need for the medium and longer term.

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Wales is the only part of the UK where “deemed consent” to organ donation applies. The means that any deceased who is over 18 years, is mentally competent and who had lived in Wales for  12 months is deemed to have given consent to organ donation unless they have formally registered their objection.

About a decade ago, the UK had a low organ donation rates (13 / million population) compared to countries such countries as Spain, USA and France. As well it had a much lower rate of next of kin refusal. In Wales around three people per month died while waiting for an organ donation with about 300 people on a transplantation list.

The issue was considered by the National Assembly for Wales Health and Well-being Committee in 2008. Though its report did not recommend  “presumed consent”, the Welsh Government felt there was sufficient public support for the proposal and indicated its intention to legislate on the matter. A commitment to do so was included in the Welsh Labour, Plaid Cymru and Liberal Democrat’s manifestos for the 2011 National Assembly election.

The Bill was introduced into the National Assembly in December 2012. Over the next year an extensive debate and consultation took place. There was broad support for its purposes though concern was expressed, by Christian and Islamic faith groups in particular, that “deemed consent” was not real consent and that it undermined the altruistic virtue of the gift of donation.

A key feature of the legislation was its “soft opt-out” option whereby close relatives are involved in the donation decision with particular attention being paid to any evidence that the deceased may not have wished to have their organs donated.

In the run up to the beginning of the legislation in December 2015 there was an major campaign to both explain the new legislation and to raise awareness on the wider organ donation need in Wales. The legislation will require the Welsh Government to maintain a programme of promoting public awareness and to report on progress.

At the end of the first year of the legislation the Welsh Government reported “… the latest figures show that 39 organs from patients whose consent was deemed have been transplanted into people who are in need of replacement organs.

In the two years prior to the introduction of the new system of deemed consent, .. (we) made significant efforts to inform the public of the exact nature of the upcoming changes in respect of transplantation activities. During this period the number of organs transplanted increased each year, from 120 between the 1 December 2013 and 31 October 2014, to 160 between 1 December 2015 and 2016.

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Video of the three candidates Ivan Lewis, Tony Lloyd and Andy Burnham (links are to their initial statements) at our hustings on 25th June.

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First as Health Secretary, and then as Shadow Health Secretary, I have given long and careful thought to the future of the NHS and social care in the 21st century.

My answer to the challenges of an ageing society is a National Health & Care Service – bringing social care into the public NHS and creating a single service for the whole person, meeting all of their needs (physical, mental and social).

As Mayor, I would lead the building of the country’s first National Health & Care Service here in Greater Manchester and show the rest of the country that there is a better way than the Tory way. My vision is based on collaboration and integration and a rejection of the fragmentation that comes with the market and privatisation.

While I am optimistic about what we can achieve, I am under no illusions about the scale of the challenge facing our health and care system. A&Es across Greater Manchester are under intense pressure all year round. Mental health services are inadequate. And, with a £115 million deficit in our NHS and on-going cuts to council care budgets, there is a looming financial crisis.

So the risks facing the NHS in Greater Manchester are considerable and we know that, just as they did to the NHS in Wales, the Tories would waste no time in devolving a funding crisis and trying to blame Labour for it.

Given all this, you need to have confidence that the person in charge knows the NHS inside out, have a track record of fighting for it on the national stage and, most importantly, has a clear vision for where it is going. This is what I can offer.

In the last Parliament, as Shadow Health Secretary, I fought the Tory Health and Social Care Act 2012 alongside colleagues from the trade union and the Socialist Health Association here in Greater Manchester culminating with a rally in early 2012 outside Manchester Town Hall. I look forward to working with you again to nullify its most pernicious effects and actively rolling back the privatisation we have seen.

But we need to do more than that and show that fully integrating services is the only route to easing pressure on our hospitals and improving the care we provide to older and vulnerable people. Put simply, it makes no sense to provide sub-standard privatised domiciliary care based on 15-minute visits only to then spend thousands keeping people in hospital. But that is what we are doing. We can’t afford it and it’s not right – the ever-increasing hospitalisation of older people is no answer to the ageing society.

In the 21st century, the home and not the hospital should be the default setting for care. Wherever possible, vulnerable people with complex needs should be supported by a single NHS team providing high-quality, personalised care with the aim of helping them get the most out of life. We need to look at powerful rights for individuals to pull the system towards a person-centred service, with more options for care in the home particularly at the end of life; with family carers supported not ignored; and with equal value placed on people’s mental, physical and social needs.

I would expects each of the 10 boroughs to develop a single commissioning voice and a lead integrated care organisation, bringing care assistants into the NHS structure. I want to end the culture of 15 minute visits and give all staff who care for others the employment status and respect that they deserve.

Unlike the Government’s lip service to parity between physical and mental health, I will work to make it s reality. It is nothing short of a national scandal that, according to the Children’s Commissioner, 40 per cent of North West children referred to mental health services in 2015 were turned away – the second highest figure in the country. As Mayor, I will tell the NHS that any child in Greater Manchester referred to mental health services must be given the support they need.

It is not just mental health services that are often not there when needed. Parents of children with autism often face a monumental battle for support. There can also be long waits for services like speech and language therapy and crucial support like specialist wheelchairs. As Mayor, I will have a clear focus on improving the support for children with special needs. Even though the Tories have abandoned it, I will return Greater Manchester to an “Every Child Matters” approach and commit to GM-wide strategies on disability and autism.

More broadly, we need to set high ambitions for improving public health and reducing the health inequalities that still scar our region.

Sadly, Greater Manchester still tops the league table of poor health. High levels of cardiovascular disease and deaths from preventable cancers give people here some of the shortest life expectancies in the country. And, even within GM, there are huge variations in healthy life expectancy with a 15-year difference between our poorest and most affluent areas.

To tackle these health inequalities, we need to link health policy to the broader determinants of health too – housing, planning, leisure and education. I would have a major focus on improving levels of physical activity across Greater Manchester and believe there is a huge amount we can do to improve our cycling network. I will place a new emphasis on building homes with care and support in mind. In the ageing society, we need to follow the lead of Sweden and start building specially-designed ‘dementia-friendly’ homes as part of a plan to make Greater Manchester the country’s most dementia-friendly city-region.

The Greater Manchester Mayor is the first role that brings together the health policy with other key public services. As such, it represents a huge opportunity to reshape services around the person and a Greater Manchester Model of “Whole Person Care” that in time can influence the rest of the NHS.

But there are huge risks too. The concerns I highlighted when the devolution deal was first struck still stand: there is a danger that the Tories are devolving responsibility without sufficient funding to match and sufficient ability to deviate from their misguided competition policies. But I am ready to put all my passion and knowledge for the NHS to work and show that the Party which created the NHS in the 20th century had got the intellectual capacity to update Bevan’s inspiring vision for this.

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Thank you for giving me the opportunity to seek the Socialist Health Association nomination to be the Labour candidate for elected Mayor of Greater Manchester.

 My life changed at the age of 14 when I started doing voluntary work with people with learning disabilities for a locally based voluntary organisation, Outreach. Then at the age of 19 I set up a charity, Contact, supporting people with learning disabilities and mental health problems. From a very young age I was angered by the way people were too often labelled and written off despite having massive potential and their families forced to fight the system rather than receive the support they need.

I then went to work for another social care charity; Manchester Jewish Social Services which was 125 years old. This was an organisation which had lost its sense of direction and I was asked to undertake a major overhaul so it could respond to the challenges of the new era of community care in the 1990s. I served as Chief Executive for five years and oversaw a merger with another social care charity which led to the founding of the Manchester Jewish Federation.

 In 1990 I was elected to Bury Council and served as a Councillor for 8 years with four years as Chair of Social Services. My challenge during this time was very similar to that facing Labour councillors today: protecting the most vulnerable from Tory cuts while seeking service improvement through innovation and new ways of working.

I had the privilege of being elected to parliament in 1997 to serve Bury South where I was born, raised and have lived all my life. I am proud to have turned a Tory seat into a Labour seat and been elected five times. I served for fourteen consecutive years as a frontbencher in a variety of roles and was responsible for pioneering radical policies in skills, health and wellbeing and global health.

I served as Care Services Minister between 2006 and 2008 when I was the first Labour Minister to raise the status of social care within the Government and wider society. I produced a blueprint for a health and wellbeing service in every community, \”Putting People First.\” Introduced an ambitious programme for greater control by people who use services and developed the first ever national dementia plan.

My platform for the Mayoralty is clear. I want the Labour family in Greater Manchester to unite behind a new mission to fight inequality. This will mean prioritising a long-term reduction in health inequality in every part of Greater Manchester.

Throughout my working and political life I have been troubled by the link between social class and ill-health which has shortened far too many people\’s lives and denied many a decent quality of life and the chance to fulfil their potential. In truth, this has been made worse by long periods of Tory Government and ideology but we should have done more during our thirteen years in Government. I know from personal experience how social care was the poor relation in the Department of Health, that for a long time we had no strategy for the ageing society, and the acute NHS part of the Department did everything possible to undermine the integration agenda.

I am proud that I started to change that and now want the chance to show how here in Greater Manchester we can become world leaders in the fight against health inequality.

My Health and Social care manifesto

It is important to recognise that NHS resources are not devolved to the Mayor but to each of the ten local Authority areas which currently make up the Greater Manchester Combined Authority. So while there is scope for Mayoral strategic leadership this will be in partnership with the ten council leaders who will form the cabinet, lead Councillors, Clinical Commissioning Groups and provider trust leads, front line staff and people who use services in all those areas.

Strategy is important but what matters most is delivery. That is why it is important to have a politician overseeing this radical programme of change who will protect Labour values, treat frontline staff as partners and understands what needs to be done to create a single system in every community organised around the needs of people who use services and their families.

1. A fair not flawed deal.

The current DevoManc Health and social care deal is setting us up to fail. If elected Mayor I will fight from day one (when I will have maximum authority) to demand a better, fairer deal from Osborne.

A fair deal will include:

  • £1 billion to support the integration of Health and social care not the inadequate existing Transformation fund of £450 million.
  • A clear understanding my cabinet and I will not collude with NHS privatisation. I will initiate a review of the potential benefits of eliminating the internal market in Greater Manchester and how this could be done with minimal organisational reorganisation. If necessary, I will also coordinate a national campaign across local Government to ensure TTIP includes watertight safeguards to prevent the fundamental values of the NHS being put at risk.
  • An end to the dangerous ambiguity about where financial responsibility will lie for trusts which end up in deficit and fighting pandemics which may affect Greater Manchester in the future.
  • More revenue funding for councils social care budgets or the power to levy a precept of up to 5% per year to partially fill the funding gap.
  • An agreement that building on the work of Healthwatch and council  scrutiny committees Greater Manchester will trial new approaches to public and patient involvement in decisions including commissioning which affect their communities.

2. A Greater Manchester Anti-Poverty strategy.

I will recommend to the cabinet, which will be made up of the leaders of the ten local councils in Greater Manchester, that we adopt a comprehensive anti-poverty strategy accompanied by a delivery plan.

At its heart would be a plan to ring-fence resources for an integrated approach to early childhood development. Poverty in all its forms is the biggest driver of poor health and health inequality. But this perennial problem is being made worse as a result of the rigid austerity and cuts of this Tory Government. The poor are being hit the hardest by benefit sanctions, bedroom tax and food bank Britain.

Rising homelessness requires a Greater Manchester wide project management approach which removes unnecessary barriers connected with local Authority boundaries. I am committed to ensuring young people leaving care receive the emotional and practice support they need for as long as is necessary.

3. Health and Social care integration.

In addition to a properly funded Transformation Fund I would work with cabinet colleagues to go well beyond a traditional model of health and social care integration. We must make a reality of shattering organisational silos and moving to prevention and early intervention.

  • All future plans to reduce acute services in a locality will include costed and timetabled plans to improve community based services and influence my decisions on improving public transport connectivity across Greater Manchester. We may need to invest more initially to support these improved community services.
  • Create single community based Health and wellbeing networks/ centres which bring together primary care, local authority services including housing, social care, leisure, adult learning and public health, third sector organisations and active community networks.
  • In partnership with GPs and primary care professionals agree realistic access targets for appointments which would apply across Greater Manchester.
  • Ensure people with chronic illness and/ or complex needs have a designated lead professional, access to person centred planning and transparency about the budget available to meet their needs.
  • End 15 minute home visits by care workers.
  • Create a 24 hr Greater Manchester Carers helpline for people caring for loved ones in the community.
  • Create a distinct funding source for small third sector and community based organisations who are cut out by current commissioning practices.

4. Mental Health

In too many areas access to community based mental health services remains woefully inadequate. After significant improvement in the Labour years Children’s mental health services are once again at crisis point. For all the talk of parity of esteem, cuts mean once again that \”Cinderella “services fall even further behind. I believe this will only change if there is political will at the highest level.

Therefore, my commitment is to take personal responsibility for working with colleagues in each district to improve community mental health services including children\’s mental health services and support for people with dementia.  I will work with users groups, Carers, frontline professionals in statutory and third sector organisations to identify the top three priorities for improvement and deliver transformational change in my first term of office.

I will ask the Deputy Mayor with responsibility for criminal justice to work with me on a plan to prevent people with mental health problems entering the criminal justice system and improve access to mental health services for offenders.

5. Public Health

Clearly, public health will be central to our anti-poverty strategy, health and well-being networks and improved mental health services. But it must also tackle distinct challenges such as obesity, early childhood development and smoking.

I would seek for Greater Manchester to be leading the country on:

  • identifying and tackling the causes of the shocking gap in cancer survival rates linked to social class.
  • Self-care through the use of the most modern forms of available technology.
  • Work with employers to increase job control with a focus on mental health and heart disease.
  • Health checks available in non-medical settings and at the workplace.
  • Encouraging walking (referred to in my green deal), agreements with retailers to remove sugary foods from checkouts, bringing sports organisations and schools together.
  • Improving mothers experience of labour and the support vulnerable mothers get during the first twelve months of a baby\\\’s life so they are able to get some rest.
  • Supporting people to give up smoking in a way that is most likely to succeed e.g. allowing e-cigarettes on NHS premises.
  • Providing grants to grassroots based community organisations to deliver public health interventions in areas which have the greatest levels of health inequality.
  • Creating a centre of best practice where we can identify and disseminate what works across Greater Manchester.
  • Working with our universities to develop and publish research to support our fight against health inequalities.

6. The workforce.

We have serious workforce shortages in most frontline services. This is due to inadequate investment, growing pressure on the professions and in social care low pay and low status.

I will:

  • Identify the scale and mix of workforce necessary to shift from a sickness service to a world-class Health and well-being service.
  • Seek agreement and a plan to minimise the use of agency staff and zero hour contracts.
  • In my first year in office work with Trade unions and employers to identify fair terms and conditions for care workers which means at minimum the real living wage and proper travel allowances. I would use the consequential funding shortfall to inform future negotiations with the Government.
  • Launch a high-profile Greater Manchester campaign including through work experience in schools to raise the status of care workers and allied health professionals. Workers in the care sector need to be valued as we develop a work force to support a growing older population. It is these staff who support families from ‘going under’ and prevent unnecessary costly admissions to hospital.
  •  Create citizens juries of Frontline Health and social care practitioners to provide feedback and ideas.
  • launch a Mayoral Awards scheme focused on projects/ individuals delivering programmes which have a tangible impact on health inequality.

My values are summed up in the phrase \”it\’s not the title you hold, but the difference you make which truly matters.\”

 Despite all the challenges of austerity and Tory cuts we owe it to the people who depend on us to make that difference and fight inequality together.

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Welcome to my fourth NHS Check Oldham Report, part of a series of reports that examine how national policies from the Government are affecting local health and care services in Oldham East and Saddleworth. These reports are informed by national and local statistics as well as data from other sources, such as patient experiences and think tank reports.

This report is focussed on the devolution from central Government of £6bn of health and social care funding to the combined Greater Manchester Authority – commonly referred to as ‘Devo Manc’ – and the challenges and opportunities the changes may have on health and care services, particularly for my constituents in Oldham East and Saddleworth.

Debates about where responsibility for health care should lie are not new and were widely debated during the formation of the NHS in 1948. The resulting NHS Act saw the transfer of local authority-run hospitals to the new National Health Service. Local government remained responsible for a wide range of community health services and public health until 1974, when reorganisation saw these too transferred to the NHS.

As the King’s Fund report reveals, this legislation, along with the National Assistance Act, which also took effect in 1948, gave rise to the separations between health and social care that we see today – an NHS largely free at the point of use and funded through general taxation, with means-tested social care funded either privately or by local authorities, and in recent years, for those reliant on public funding increasingly available only to those with the highest need.

Devolution of powers and funds from central to local government has emerged as one of the Government’s key policies, and although there is consensus on the principle of devolution, the details and means of implementation remain controversial.

Collaborative working between the 12 Greater Manchester CCGs and 10 local authorities has been ongoing for some time through the Healthier Together programme, established in 2012 to look at Greater Manchester wide reforms to Primary Care, Joined Up Care, and Hospital Care. Clinically led, the programme’s stated aims are to provide the best health and care for the people of Greater Manchester (GM).

Along with powers over housing, skills and transport, the Devo Manc deal between the Treasury and Greater Manchester has paved the way for the councils and NHS in Greater Manchester to take control of the region’s health and social care budget.

I have expressed my concerns about the scale of the deal and the risks for Greater Manchester and particularly Oldham East and Saddleworth of the devolution of health and social care. This report examines the context of the deal and the devolution agreement itself, the response of key experts and commentators and the challenges and opportunities Devo Manc presents for local health and social care services.

Overview of Devo Manc

The first ‘devolution deal’ was announced by the Government and the Greater Manchester Combined Authority in November 2014. This deal was negotiated in private between the Government and local authority leaders.

The Greater Manchester Agreement set out proposed new powers for the Greater Manchester Combined Authority. The Agreement also included establishing a directly-elected mayor for the whole Greater Manchester area. Meanwhile, the Greater Manchester Combined Authority itself will be able to plan the integration of health and social care, amongst other powers.

The Government published the Greater Manchester Health and Social Care Devolution Memorandum of Understanding on 27 February 2015. This paper envisaged a new Greater Manchester Health and Social Care Partnership Board, which will produce a joint health and social care strategy for Greater Manchester. Crucially, no impact assessment has been undertaken on the Greater Manchester Health and Social Care Devolution Deal.

The Greater Manchester Health and Social Care Partnership Board ran in shadow form in 2015-16, before going live in April 2016. It had two sub-groups: a Greater Manchester Joint Commissioning Board (JCB) and an Overarching Provider Forum. Members of the former are the 12 Clinical Commissioning Groups (CCGs) in Greater Manchester; the 10 Greater Manchester boroughs; and NHS England. Members of the latter are service providers: acute care trusts, mental health trusts, ambulance trusts, LMCs (local medical committees), and others.

Through the Joint Commissioning Board, strategic decisions regarding commissioning of health and social care services in Greater Manchester will be agreed by NHS England, CCGs, and local political actors. The Joint Commissioning Board will commission health and social care services across Greater Manchester on behalf of its constituent organisations, combining the pooled commissioning budgets of the CCGs and the social care budgets of the boroughs.

At local (borough) level, Health and Wellbeing Boards, made up of representatives from CCGs and boroughs, will ensure that health and social care services are provided in a joinedup fashion, in line with the Greater Manchester Health and Social Care Partnership Board’s Strategic Sustainability Plan.

The Memorandum of Understanding states that the parties to the agreement (NHS England, CCGs and local political actors) share 7 key objectives:

  • To improve the health and wellbeing of all of the residents of Greater Manchester (GM) from early age to the elderly, recognising that this will only be achieved with a focus on prevention of ill health and the promotion of wellbeing. We want to move from having some of the worst health outcomes to having some of the best;
  • To close the health inequalities gap within GM and between GM and the rest of the UK faster;
  • To deliver effective integrated health and social care across GM;
  • To continue to redress the balance of care to move it closer to home where possible;
  • To strengthen the focus on wellbeing, including greater focus on prevention and public health;
  • To contribute to growth and to connect people to growth, e.g. supporting employment and early years services;
  • To forge a partnership between the NHS, social care, universities and science and knowledge industries for the benefit of the population.

These devolution proposals are being implemented via section 75 of the National Health Service Act 2006, which permits agreements to share functions and budgets between NHS bodies and local authorities. The elected mayor will not have any formal control over the integration of health and social care. The Greater Manchester Health and Social Care Partnership Board has appointed its own chief executive, Jon Rouse, as of 31 March 2016; however he will not take up his position until 22nd July 20165 .

So far, the only other areas to take steps in devolving health and social care services are Cornwall and some London boroughs. A document entitled NHS Devolution: Proposed Principles and Decision Criteria, published in September 2015, sets out the NHS’s preferred approach to proposals for health and social care integration.

A dedicated website covering new arrangements for health and social care in Greater Manchester has been established. This states that the early priorities of the new bodies will be: seven-day access to GPs; children’s mental health; mental health and work; better care for dementia sufferers; a joint public health strategy; and aligning the workforce policies of health provider organisations.

Reaction to Devo Manc

Helen McKenna, of the King’s Fund, has suggested that health and social care integration in Greater Manchester could have a transformative effect: “Although what is currently happening in Manchester is technically more a case of delegation than devolution, particularly as formal accountabilities will remain with the national NHS bodies, it is nevertheless a far cry from ‘business as usual’….In exchange for more of a say over its own future, Greater Manchester is promising to deliver changes to health and care services that we and many others have long been calling for… But what makes Greater Manchester’s devolution project so exciting is the fact that their ambitions go much further than the integration of health and social care to consider public services in the round. This creates the opportunity to look beyond the role of health services in determining health outcomes to the (Far more influential) wider social determinants of health – for example, the roles of early years, education, employment and housing.”

Chris Ham, Chief Executive of the Kings Fund said: “Devolution to Greater Manchester should enable decisions to be taken much closer to the population being served, with councillors having a bigger influence on future decisions. …The unanswered question is how much freedom public sector leaders will have to depart from national policies in taking greater control of NHS resources.”

Nigel Edwards, Chief Executive of the Nuffield Trust highlighted the requirements needed to ensure Devo Manc would succeed in his blog Devo Manc: Small steps, great leaps concluding, “Manchester’s proposals are bold and potentially transformative, but they carry risks – especially at a time when the public finances are in a perilous state. We will be watching with interest.”

Mark Dayan, Policy and Public Affairs Analyst at the Nuffield Trust examined the role of the N, for national, in NHS under devolved powers. Looking specifically at finances, he said, “When hospitals are financially struggling, or a care scandal is unfolding, the local or regional authority will feel the force of public demand to do something about it – the same force that drives the Secretary of State and the Department of Health today. National and local authorities could catch the NHS in the middle as they both push for their own initiatives and plans. Or they could step back to scapegoat one another – with the local authority blaming problems on austerity from the centre, and the national government professing to have nothing to do with the situation.

“We need more clarity from the Government about the crucial question of whether funding will follow these functions. Will the money currently given to CCGs based on NHS patient need, under at least some local plans, move into the same pot as other grants and local taxation?”

The Local Government Association commented on the Devo Manc Health and Social Care Deal stating: “The LGA has welcomed the announcement as a significant step in devolving control of social care and health spending to Greater Manchester. We have long argued that truly integrating social care and health and taking decisions closer to where people live is crucial to improving services and keeping older people living in their homes for longer. We also welcome the commitment to focus on prevention of ill health and on closing the health inequalities gap.” and “There is no doubt that a transformation of this significance will require the active support of NHS England but we would like to see a firm commitment to the subsidiarity principle to ensure real and meaningful devolution of decision-making. While this announcement is a good start, government needs to now set out a new settlement for England which includes devolving decisions on health and social care down to local areas as part of a wider package of reforms.”

Kieran Walshe, Professor of Health Policy and Management at Manchester Business School expressed his scepticism of another NHS reorganisation and warned against focussing on organisational change, rather than service improvement, saying: “Greater Manchester could spend a lot of time and effort in the next two or three years on organisational change rather than service improvement. That could even make services worse. My apprehension about the devolution proposals is borne from experience. Over the last two decades, the NHS has suffered (and that is the right word for it) some form of organisational structural change or reform about once every two years, all of which have been visited upon it by the government of the day. Each time we learn the same three things: it costs a lot of money; it takes a lot of time and effort; and it adversely affects performance during the reorganisation and for at least two years afterwards.”

Challenges and Opportunities

The Labour Party supports the principles of devolution, including devolution of health and care budgets. In addition, in last year’s General Election, Labour’s manifesto pledged to integrate health and social care planning and delivery. However, there are real concerns about the Devo Manc deal, and the lack of a comprehensive assessment of the potential impacts of these changes on the health and wellbeing of people across Greater Manchester, including Oldham and Saddleworth.

The lack of democratic principle and accountability is a fundamental issue. The deal to devolve further powers to Greater Manchester was negotiated in secret between the Chancellor and leaders of Greater Manchester local authorities; it has never been subject to a vote or consultation with the people of Greater Manchester, who it will affect. This has led to much speculation about the Government’s approach and intentions.

As the Centre for Public Scrutiny has stated: “Local people – anyone, indeed, not involved in the negotiations – need to understand what devolution priorities are being arrived at and agreed on. … At the very least, the broad shape and principles of a bid for more devolved powers should be opened up to the public eye.”

The role of the elected Mayor will also be crucial. Although the Mayor will have no formal responsibility for the integrated health and social care bodies, there may still be pressure upon them to broker agreements across the devolved institutions and a perception they are accountable for areas they do not actually control.

In terms of accountability for the delivery of health and social care services, the NHS England Board Paper NHS Devolution: Proposed Principles and Decision Criteria suggests arrangements that veer more to delegation than of formal devolution – keeping accountability with NHS England and CCGs rather than being transferred to combined or local authorities. So is this more about shifting political and financial risk to GM while NHS England delegate to local NHS but retains control? Who is the accountable officer until Jon Rouse takes up his post in July? What is the current GM accountability framework and how will the principle of subsidiarity be applied?

The King’s Fund report suggests that this approach has its advantages, minimising organisational change, ensuring the continued involvement of CCGs and local authorities and leaving statutory accountabilities clear. However, in practice, real questions remain about how major decisions will be taken about services and who is ultimately responsible for them. Anecdotal evidence indicates that the Greater Manchester Health and Social Care Partnership Board, set up in shadow form in 2015 with representatives from all GM CCGs, local authorities and NHS England as well as the JCB, is less inclusive now. Concerns have been expressed that central Manchester may be the key beneficiary of the new arrangements.

At a time when funding agreements are not long term, there are likely to be difficult and unpopular decisions about the configuration of local services, as has already been seen with Healthier Together. The impact of greater involvement of locally elected politicians in health has yet to be seen. In addition, to date there has been no formal engagement of or communication with GM MPs regarding their role in scrutinising these health and social care developments on behalf of their constituents.

The powers of the key regulators (Monitor, CQC and others) are to remain in place nationally; but Greater Manchester is clear that the key principle is that there should be no decisions made concerning health and social care in Greater Manchester “without Greater Manchester in the room”.

Representatives of the national bodies will sit on the independently-chaired strategic partnership board. The King’s Fund report that the regulators have recently begun to develop approaches to regulating whole health economies which may be helpful for regulation in devolved areas.

Finance is also a key concern and one highlighted in the devolution Plan which states that there is an estimated financial deficit of £2bn by 2020/21. The population of Greater Manchester has a forecast spend of £7.7bn on health and social care services, which includes £6.2bn on health services, and £1.5bn on local authority, public health and social care services.

Given that the legal accountability of the Secretary of State for Health remains unchanged, the assumption is that the Department of Health would be expected to cover the costs should a provider go into deficit. Given that all but one acute trusts in Greater Manchester are in deficit, there has been no clarity to date on this point. This is a major risk to the GM health economy. The principles of the NHS are that treatment and care are free, based on clinical need and universal; as a former Chair of a Trust I know how money moves around the national system to enable this to happen. With a smaller health economy this is more difficult.

In addition little has been said about how the calculation for the funding being allocated to GM has been determined. I have grave concerns that this will be used to mask cuts. We shouldn’t forget the Government’s record over the last 5 years, where the most deprived council areas have borne the brunt of funding cuts.

The financial frameworks and cultures of the NHS and local government are also very different, with NHS providers able to ‘plan for’ and continue operating when in deficit, unlike local authorities. Which set of rules will apply to the devolution of Health and Social Care in Greater Manchester as no revenue raising powers were included in the Memorandum of Understanding?

On top of this, the signed Memorandum of Understanding states that “Greater Manchester will be able to access any new or additional health and/or social care funding streams that become available during the CSR period.” However, the footnote for this statement suggests this is not certain, saying “Access to any new NHS funding streams will clearly depend on the extent to which those funding streams are made available to the GM CCGs (or to NHS England) and their relevance to the designated commissioning functions.”

Furthermore, the lack of clarity from Government on what contingency funding is in place for a major health emergency, such as a flu pandemic, is a real concern. It is imperative that should such a situation occur, there is not only a coordinated response from the Department of Health and NHS England to ensure consistent and effective action, nationwide but that funding is available should GM exceed their finite budget.

There are also concerns that the Devo Manc deal could lead to the creation of subregional markets of public services, ready for privatisation. Adam Fineberg, an adviser on public service design and provision, warned that “devolution will ultimately disrupt the traditional organisation of council services, potentially bundling them into parcels suitable for outsourcing” and that “devolution will relaunch the previous government’s attempts to privatise more public services – with this government’s offer to local government potentially leading to several unintended consequences.” In addition, the Health Service Journal reported in March 2016 that “council leaders in Greater Manchester have had “exploratory discussions” with private investors as they seek capital investment for the NHS.”

There are also concerns that the devolution may become Manchester-centric, with Manchester at the geographical centre of the deal, as well as with the largest population and it is essential that the smaller authorities, including Oldham, within the Greater Manchester Combined Authority are heard.

Of course, the Devo Manc deal for Health and Social Care presents opportunities as well as challenges. The focus in the Memorandum of Understanding and the Plan on tackling health inequalities, chronic ill health, primary care services, and the rising burden of illness is encouraging.

The authors of the Plan state that fundamental to the success of the agreement between the Government and Greater Manchester will be “our ability to draw together a much wider range of services that contribute to the health and wellbeing of Greater Manchester people.” The impact of air quality, housing, employment, early years and education and skills on health and wellbeing is well understood. In Greater Manchester GPs spend 40% of their time dealing with non-medical issues and the stated purpose of the devolution Plan is to bring together “whole-system public service reform”.

As mentioned earlier, Labour has long argued for full integration of health and social care. The Devo Manc deal has the potential to deliver a ‘whole person’ health and care system, integrating health and social care, focussed around the individual. As noted by the King’s Fund, Greater Manchester has a track record of collaboration, integration and successfully managed change in health and social care with a CCG association (previously PCTs), a group of acute chief executives, the Greater Manchester Public Health Network and an interim umbrella Health and Wellbeing Board. The Healthier Together programme received the largest public response to a regional consultation about health services in England in a decade.

Given the scale of powers devolved to Greater Manchester through Devo Manc, including on transport, housing, job creation and business investment, further education restructuring and the Work Programme there is the opportunity for greater flexibility and collaboration across a wide range of areas which impact on health and social care.

There is the opportunity for ‘silo working’ to be reduced and should the joint working arrangements work as envisioned by the Plan, the focus on prevention, early intervention and using best practise to achieve the best outcomes for the people of Greater Manchester come to fruition, this will be welcomed.

Numerous commentators have remarked on the sheer speed of change under Devo Manc, at a time when public services are already experiencing unprecedented pressures. The King’s Fund state that in practise there is little formally stopping NHS England or other national bodies from seizing back or retaining control, as well as overriding local decisionmakers. As discussed previously, if this does happen then Devo Manc becomes nothing more than an exercise in devolving risk and blame.

Some think tanks believe that the current energy associated with devolution in Greater Manchester has the potential to act as a game-changer in health and social care, bringing about genuine integration and better outcomes for our population. However, a number of challenges, as outlined above do remain, notably financial and governance issues.


Although there is cross party support for the principle of devolution and making sure decisions about public services are made with the people they serve and as close to where they are delivered as possible, there are key risks associated with the arrangements for the devolution of health and care in Greater Manchester.

Fundamentally, the lack of clarity regarding financial and governance arrangements is of grave concern and needs to be addressed as a matter of urgency. The fact that the Chief Executive of health and social care in GM will not take up his post until 4 months after devolved arrangements commenced is a case in point.

In relation to this, there is a need to define the accountability framework more clearly, and within this ensuring both CCGs and local authorities on GM’s circumference are not marginalised. This should also include the relationship with NHS Trusts and local authority care providers.

A comprehensive, independent assessment of the impacts of the Devo Manc health and social care arrangements, including the distribution of impacts across the Greater Manchester conurbation and populations, should be completed as soon as possible, so that the potential positive effects of an integrated GM health and social system can be enhanced and risks mitigated against.

Closer scrutiny of health and social care devolution (and other aspects of Devo Manc) by parliamentary representatives needs to be instigated immediately, for example, by establishing a Grand Committee. The Health Select Committee also has a scrutiny role here and for other areas where health and care is to be devolved/delegated.

I want to see the vision for the greatest and fastest possible improvement in the health and wellbeing of the people of Greater Manchester, and the reduction in health inequalities, being achieved. But we must mitigate against the risks that exist.

This was first published on Debbie’s own blog.

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Voluntary sector

What could stop them?

Greater Manchester Strategy

Ed Cox of IPPR cautioned in 2014 ‘we should be wary about getting too excited until the rhetoric become a reality’. The Taking Charge and Locality Plans could be viewed as a solid step forward in the devolution agenda, and the Voluntary & Community Sector-positive language is undoubtedly promising, however, at this stage it is still language. Alex Whinnom stated that ‘although all the right words are there…there is no guarantee that ‘alignment’ and ‘partnership’ will necessary translate into a share of the available resources’. The Manchester Evening News recently questioned whether the ‘Northern Powerhouse’ was starting to look like an empty slogan, and, although both devolution and the Powerhouse are still in their relative infancy, organisations are right to be wary until words turn into actions.

Rhetoric of devolution

The devolution and ‘Northern Powerhouse’ agenda has not been designed around or focused on the Voluntary & Community Sector and its strengths. McInroy argues that ‘the present agenda is undoubtedly narrow. It has come out of an economic growth agenda and it is not driven by issues of democracy or problems of national inequality or a voracious refocus on closing the gap between rich and poor’. This is a debate alongside NHS deficit reduction, transport, skills, planning, Chinese investment… In this context, is the Voluntary & Community Sector a priority for anyone other than those within it? Lee views the whole devolution process as ‘technocratic pragmatism’ involving a ‘series of elite-to-elite negotiations’; the Voluntary & Community Sector (and the public) have been informed after the agenda has been set.

Austerity and the voluntary sectorThe Rochdale Locality Plan is pragmatic in its assertion that the VCS has been ‘significantly financially challenged’. The sector is not operating in a climate of abundant funding, where the ability to explore new ways of working and collaboration can fit alongside their everyday functioning – organisations are stretched. At a recent devolution event, one attendee decried that ‘at this rate, there’ll be no VCS left to pick up the pieces if this all goes wrong’. Devolution is occurring in parallel to funding cuts, crises in mental health, increasingly visible homelessness, and greater demand for services. Funding for innovation, such as the ‘Transformation Fund’, has been accused of being unable to act as anything more than a ‘deficit mop-up’ within this climate

Strengths of the Voluntary Sector

The general thinking behind devolution is that it brings power closer to the local level; ‘subsidiarity’ is the buzz word of the moment and is a notion that could indeed benefit the VCS by moving their voice (and communities) closer to the decision makers. However, critics have argued that devolution actually involves an ‘upscaling to the regional level’. Organisations may find themselves functioning (and being commissioned/funded?) on a pan-GM level; Okotie surmises that devolution is ‘scaling up local strategic activity and thinking, and scattering in more layers of bureaucracy not less – adding in complexity and difference’. The VCS may find itself further away from the decision making table than it was before.

Bureaucracy and devolution

Every Greater Manchester Locality Plan references the VCS, all recognise its value and potential contribution to delivery. However, a recently quoted GM wide survey of the voluntary sector found that over 70% of respondents said they had no input into the Locality Plan for their area. VCS leaders, speaking at various devolution events, have revealed a level of uneven involvement across localities. For example, one GM organisation stated they were contacted directly by the authors of their area’s Locality Plan and asked to contribute, whilst an equivalent organisation in another GM locality stated they struggled to even see a draft of their Plan. Will inconsistent involvement in planning, result in inconsistent involvement in delivery and outcomes?

Critical thinking

• Cox, E (2014) Leading the Charge for New British Politics. In: VSNW, Devolution our Devolution: Perspectives on the Meaning of Devolution for Voluntary and Community Groups
• Dunhill, L (2016) North by North West: Devolution on a leash. Health Service Journal
• Gainsbury, S (2016) ‘Transformation Fund’ or deficit mop-up? Time for an honest conversation. Nuffield Trust.
• Hudson, B (2016) Will 2016 push the NHS over the edge of chaos? The Guardian
• Kirby, D (2016) Homeless people in Manchester sleeping in Victorian-style secret subterranean ‘cave’. The Independent.
• Lee, S (2016) The ‘devolution revolution’. In: Hayton, Giovannini & Berry, ed., The Politics of the North: Governance, territory and identity in Northern England, pp.17-19.
• Lowndes, V & Gardner, A (2016) Local governance under the Conservatives: super-austerity, devolution and the ‘smarter state. Local Government Studies
• McInroy, N (2014) A Devolution for All. In: VSNW, Devolution our Devolution: Perspectives on the Meaning of Devolution for Voluntary and Community Groups
• Okotie, T (2014) Devolution Revolution? In: VSNW, Devolution our Devolution: Perspectives on the Meaning of Devolution for Voluntary and Community Groups
• Schafran, A & Taylor, Z (2016) Post-Scriptum: Slouching towards Barnsley. In: Hayton, Giovannini & Berry, ed., The Politics of the North: Governance, territory and identity in Northern England, pp.17-19.
• VCSE Leaders (2015) Contribution of the VCSE to Devolution of GM – Letter to Tony Lloyd.
• Whinnom, A (2015) Opportunity Knocks. Charity Finance Magazine
• Whinnom, A (2016) VCSE Groups urged to act on health and social care plans: GMCVO Initial Review.
• Williams, J (2016) Five Reasons the Northern Powerhouse is starting to feel like an empty slogan. Manchester Evening News.
• Williams, J (2016) Manchester’s mental health services are in crisis and people are suffering – the human cost of the cuts revealed. Manchester Evening News

Strategic documentation

• GMCA, NHS in GM (December 2015) Taking charge of our Health and Social Care in GM: The Plan
• Bolton Council, NHS in Bolton (23rd November 2015) Bolton Health and Care 5 Year Locality Plan
• Team Bury (30th October 2015) Bury Locality Plan: Bolder, Braver Bury – Towards GM Devolution 2016 – 2021
• Manchester City Council, NHS Manchester (2nd November 2015) The Manchester Locality Plan – A Healthier Manchester
• Oldham Council, NHS Oldham CCG (18th December 2016) The Oldham Locality Plan for Health and Social Care Transformation
• Rochdale Borough Council, Heywood, Middleton and Rochdale CCG (30th October 2015) Rochdale Borough Locality Plan for Health and Social Care and Wellbeing 2016 – 21
• Salford Council, Salford CCG (2nd December 2015) Locality Plan for Salford: Our Vision for a Healthier Salford
• Stockport Together (9th November 2015) Stockport Locality Plan
• Tameside Metropolitan Borough Council, Tameside Hospital NHS Foundation Trust, NHS Tameside and Glossop CCG (12th November 2015) A Place Based Approach to Better Prosperity, Health and Wellbeing: Tameside and Glossop Locality Plan
• Trafford Council, NHS Trafford CCG (November 2015) The Locality Plan for Trafford 2020
• Wigan Council, NHS Wigan (30th October 2015) Further, Faster Towards 2020: The Wigan Locality Plan for Health and Care Reform

Devolution and the VCS in GM was produced by the Lifeline Project


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Co-chairs Councillor Zahid Chauhan and Councillor Jo Harding

In attendance: Michael Kelly, Wyn Dignan, Cllr Riaz Ahmed, Gill Campbell, Karen Atkinson, Caroline Bedale, Rob Ward, Peter Firth, Wayne Shields, Ivan Lewis MP, Mike Livingstone, Martin Yuile, Martin Rathfelder, Cllr Abdul Jabbar, and Annette McKay

Opening remarks and purpose of meeting: Ivan Lewis is running to be Labour candidate for Greater Manchester Mayor. He has worked in social care since he was 19 years old when he set up a charity in social care. He has also served as a Minister in the Department of Health where he brought to light the low status of social care and the need to integrate the NHS with social care, as well as focusing work on an ageing population and the first ever dementia strategy.

Ivan will personally lead on mental health which is a scandal across Greater Manchester. He will fight for more resources to tackle the £2 billion black hole in the NHS budget, and the already slashed social care budgets.

In addition to this Ivan paid tribute to the excellent Strategic leadership Lord Peter Smith has shown around the Health and Social Care agenda within our conurbation.

Devolution could be the most important decision of our lifetime. There is huge health inequality across Greater Manchester, and seemingly better off communities still have their issues. Devolution must work for the whole of Greater Manchester. If it doesn’t, people will become disconnected and the project will fail. There are concerns around funding and deficits in the acute trusts and we need more scrutiny. We need to make sure that our workers are retained, valued and trained. Public health is critical as is asking people to take charge of their lives.

However Devolution is a great opportunity. Decisions made at a local level are the best ones. We must use these new powers to fight inequality. We have a chance to make a real difference on prevention and early Intervention. We must look at housing and include the voluntary and community sector as well as professionals and patients. There must be no collusion with the Tories for further privatisation in the NHS.

The Integration of services must be bottom up and designed to give people maximum control of their lives and their health. The system should support them at every level to make the right choices.

We need to show capacity to be innovators

Staff and frontline workers

There are still some reservations about the devolution deal and the impact it will have on workers’ rights, pay and training. Though there is already a vague protocol, staff in NHS and social care need guarantees for their terms and conditions.

Cutting pay is a simple way of enacting the cuts but short- sighted. So is relying on volunteers or charities to pick up the roles that paid staff are doing at the moment. They do have a role in delivering services (for instance peer mentoring) but need paid support in order for it to work properly.

We need to protect national pay rates and national training standards and not allow our services to be damaged by lack of investment in our staff.

The deal as it stands

No one disagreed with challenges and aspirations set out in the Memorandum of Understanding. However there needs to be more clarity for who is responsible for the deficit and what happens in pandemics.

There is a lot of wishful thinking, without clear ways the deal can be delivered, and without an understanding that both our Health and Social Care are at breaking point and only have capacity for crisis management. It presumes that everyone needing help is already receiving it and therefore efficiencies can be made to cut the cost. In reality there are still a lot of people out there not accessing services and efficiency will just free up more resources to increase number of people being reached, not cost less.

Already services like mental health have had large cuts to their services. Devo Manc could see the Break-Up of the NHS which could mean we lose national standards, pay agreement and training. We need to make local decisions but maintain national standards.

In practice what’s the difference from Whitehall to Manchester Town Hall? We need more transparency instead of a handful of people making the decisions. We need the general public and local authorities to be involved, not just the leaders.

There is a shortfall in resources to deliver these changes.

The challenges

At the moment CCGs are in consultation, but the process is not outcome driven. Most people know what they can do to live healthier lives yet they don’t stop drinking, smoking, or take more exercise. Why? It’s too hard, they are too stressed; there are other factors at play. The system is not structured to deal with these factors.

We want to give staff a decent wage, especially in social care. Changes to terms and conditions like this are not in the deal but will cost extra money.

We must make sure that money isn’t spent on buildings or projects that look good for politicians; but on patients.

We need solutions not crisis management.

Solutions and opportunities

Money is wasted in the NHS with an over bureaucratic tendering process for service tendering. One recent example was the need for a 45,000 word bid for work. This is money that could and should be spent on patients. Not anti-competition but pro-collaboration.

Keep away from expensive pilots like 7 day GP opening.

Precision public health – the health engine is a driver to bring together all the parts of public health. If we put obesity as a national risk, we can use this to address a lot of other health problems too.

Social care is commissioned by local authorities but there is no consistency on how the systems work. We could bring a consistency into bidding and delivery that will create efficiencies.

There already is a postcode lottery for health and social care across Greater Manchester. Devolution can address that by setting a minimum standard of service and consistent key indicators for outcomes.

Patients should have one key member of staff who they deal with, rather than a multiple of agencies they deal with. Evidence shows this is really how we tackle problems around substance misuse for example. We need to make sue the service is built around the individual because having many different professional bodies involved is just wasting money.

The Voluntary sector is a good way to consult with communities. Not all CCGs work with the voluntary sector but involving them at the beginning not the end of a process can avoid loss of time and expensive mistakes.

There are opportunities to tie health to Local Authorities in a more effective way. Oldham has recently opened a new leisure centre. This can be used in innovative ways for rehabilitation, public health etc. In addition, working with Councils may show new and innovative ways of working. Councils already have to do this in the face of massive cuts to funding.

The Fire and Rescue service in Greater Manchester have changed their focus to prevention and with great success. We can transfer that principle into health with Fire and Rescue service as a critical friend. There are ways to collaborate with delivery, not to take jobs or budgets from the NHS and social care. They need to maintain core workforce in case of emergencies, but so much more they can do to help.

The ambulance service is already doing a lot of health care. Only about 5% of the time is spent on ambulance emergency work. The rest is health provision at people’s homes or over the phone. This helps with capacity at hospitals but more can be done. Sometimes ambulances are queuing for 2,4 or even 6 hours which could be time spent elsewhere.

This waiting could be due to hospital inefficiency or more money needed. But more can be done. Paramedics are skilled clinicians. With extra training they could provide more out of hour’s service. Hospitals or walk in centres could commission paramedics to relieve pressure. The ambulance service can be used to put care back into the community.

The health system doesn’t change easily. It’s very evidence-based and sometimes you just need to take a leap of faith.

Money at the moment primarily follows treatment not prevention (with some exceptions). We can redirect funds to drive outcomes we want. This can also be done with check-ups and scans from birth or even before.

A lot of ill health and social care needs are connected to housing and poverty. A lot of poverty is hidden but it is there. People feel under siege and make bad health choices and treat NHS staff badly. Addressing poverty can help health outcomes.

In a critical case of a heart attack one person had suffered, care was given by the community – paramedics – doctors- physios – Community-Self, in that order. We should do more to increase the community and self-care. For instance life-saving should be on the national curriculum.

The ambulance service currently has 2000 trained volunteers to use defibrillators, but what other care can be offered using a similar model?


An elected Mayor should give leadership on these changes with a clear delivery plan. We must close the reality and rhetoric gap when discussing integrating and service delivery.

Communities, voluntary sector, charities, patients and professionals should be involved. At the moment this is being done about us but without us.

Ivan will hold further seminars on health and social care to widen the input but building on this summit and hopefully attendees can make future events too.

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Is integration all it’s cracked up to be?

A new architecture

With the Cities and Local Government Devolution Act receiving royal assent at the beginning of the year, we may be a very big step closer to a new kind of architecture for local government and public services in many parts of the country.

With devolution deals working their way through the Treasury pipeline and local political tensions yet to be fully resolved, we are facing a paradoxical situation where things seem to be moving very quickly and yet very slowly at the same time.

In Greater Manchester, of course, it is full steam ahead, with Mayoral elections set for May 2017 and the Combined Authority taking direct control over a health and social care budget of £6 billion in April.

Northern powerhouse rhetoric

For trade unions devolution poses a number of risks and challenges but some real opportunities too. So what does this mean for unions and how do we intend to respond? Greater Manchester is a good place to start.

But first let us consider the bigger picture. The new devolution proposals for the English regions are a priority issue for the TUC, indeed ‘making devolution work’ has become one of the five key themes of our campaign plan this year.

Our members know from bitter experience that the highly centralised political economy of the UK has left too many parts of the country behind. In fact, recent reports suggest that regional economic imbalances are growing.

The TUC has long been a champion for a more dynamic approach to regional development – enhancing democracy and accountability through bringing decision-making closer to communities, designing and delivering public services more responsive to local needs, harnessing the voice of public service workers and the people they serve and stimulating economic growth through local control over infrastructure and an active industrial strategy.

Yet the Osborne model being driven through the new Act poses real concerns. The ‘northern powerhouse’ rhetoric clashes with the reality of massive cuts to public services, reform to local government funding that may exacerbate regional inequalities, disproportionate public sector job losses and a government washing its hands of strategic industries like steel.

Devolution deals

The devolution deals agreed seem light on both resources and democracy, characterised by backroom deals between council leaders and Treasury officials with few stopping to ask what local people want out of it, while imposing directly-elected Mayors on communities that had previously rejected the model.

Few of the deals so far have used the new powers to restructure public services and authorities have displayed understandable caution given the financial constraints they face. But we can assume bolder approaches will be taken in future. Public service unions are wrestling with the implications for the workforce, employment standards and collective bargaining.

What will it mean for jobs? What will it mean for national agreements and will we see new attempts to push through regional pay? And how will we achieve closer integration of workers on very different sets of pay and conditions? Nowhere is this more pressing than in health and social care. Which brings us back to Greater Manchester.

Health and social care integration remains the most eyecatching and problematic component of Manchester’s deal. Achieving a coherent and deliverable plan that brings together two very different public services across a complex and fragmented commissioning and provider landscape is an enormous challenge. Not to mention the ambitious aim of achieving financial sustainability with a £2bn funding gap to plug. Then there is the existential question about how to maintain the ‘National’ in a devolved NHS.

Much of this will remain unresolved. Some of it necessarily. The TUC welcomed safeguards in the legislation that protect national standards and regulation in health but this will complicate lines of accountability in a devolved setting. Likewise, we will be adamant in our defence of national collective bargaining. Health unions successfully saw off previous attempts to break away from Agenda for Change by the South West cartel and will be vigilant against moves towards regional pay that emerge from any devolution deals.

With the potential for significant changes to service provision, it is crucial that unions have a voice in this process. We have worked hard with the leaders in Greater Manchester to agree structures to build dialogue and partnership with unions across the public sector.

The Joint Protocol signed by the leaders of GMCA and the North West TUC establishes a Workforce Engagement Board bringing unions together with leaders to discuss and manage the changes arising from redesign and integration. We are under no illusions that change will be easy but this approach may help build the kind of robust relationships that will help mitigate some of the worst impacts.

Financial straight jacket

There is much to admire in the GMCA Plan. Bringing services and providers closer together will help address some of the dysfunction and fragmentation across health and social care. Arguably, the plans represent a positive move away from the chaotic dislocation of the government’s 2012 reforms – with the 37 different participant organisations in Greater Manchester talking more of co-ordination and collaboration and less about competition.

But all of this is over-shadowed by the financial straight jacket imposed by the Treasury and the government’s obsession with arbitrary budgetary surplus targets and their on-going failure to seriously address the funding crisis in the NHS and our social care system – both absent from the Chancellor’s budget statement in March.

The much vaunted up-front funding given to the NHS in the Spending Review is already looking meagre, much of it disappearing into bailing out astronomical provider deficits and increased employer NICs payments. Elsewhere the budget for public health has been slashed, just the kind of investment into preventative measures that are integral to the success of the Manchester plan. The 2 per cent precept allowed to councils to raise money for social care will raise barely a third of the £6bn funding gap identified by the Health Foundation.

The government may be dismayed to hear calls for more funding so soon after delivering what the Chancellor described as the “biggest ever commitment to the NHS since its creation”. But this is a crisis of their own making. After all, contrary to George Osborne’s claims of largesse, average yearly increases in NHS spending amount to around 0.9 per cent across this spending review period, compared to an historical average of 3.7 per cent.  Government spending as a proportion of GDP is falling.

Plugging the gap

Manchester will have its work cut out plugging the gap in this fiscal climate. Many agree the long-term solution lies in funding increases linked to productivity gains delivered through new ways of working, focusing on prevention and integration. But we should caution against glib assumptions that greater integration and prevention, with increased care in primary and community settings, will inevitably lead to significant savings, even though it might be the right thing to do for patients.

Few people have faith in the NHS finding the £22bn savings targeted in the Five Year Forward View and research shows that, while patient care improves, there is no evidence to support assumptions that integration between health and social care leads to significant cashable savings or reduced hospital admissions.

So while integration remains an essential, albeit often elusive, aspiration for improved health and care services, it may prove to be far from the silver bullet that many in NHS England, the Treasury or indeed Greater Manchester are hoping it is.

First published by Manchester Policy Blogs

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Recorded on 18th March 2016 at the Health and Social Care Summit

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