Health Service Focus

Devo manc: ‘overcoming a decade of difficult relationships between commissioners and providers’

Greater Manchester’s councils and CCGs have won control of virtually all health and care spending in their patch in an innovative devolution deal with central government. Adam Hewitt reports.

Dr Ranjit Gill, chief clinical officer on Stockport Clinical Commissioning Group (CCG), is not the first to notice that Greater Manchester has some of the highest health spending but some of the worst outcomes in the country. 

Money alone is not the answer, he says – which is why he and so many other clinicians in the region say that the new devolution deal represents a chance to really change things. 

Financial sustainability is important, as Greater Manchester, like the whole NHS and care system, faces a potential black hole in funding unless something changes – one analysis suggests a £1.1bn shortfall in the health and social care economy by 2017-18. 

This proposal should forestall that bleak forecast.

Revolution? 

As you’d expect with a big announcement that made a national splash, there was some hyperbole and inaccuracy – some media outlets seemed to forget that Greater Manchester’s CCGs already control a substantial budget, and that joint working across organisations, while rare, is not unique. Some tried to claim there was a ‘town hall takeover’ of the NHS, even though this is legally and practically impossible. 

This is not to play down the extent of the change. While the vast majority of English health economy areas are seeking to integrate care and to have more local control of specialised and primary care commissioning, this announcement does go further. 

Dr Gill said that money previously spent nationally that will now be spent locally includes budgets for specialised commissioning (where appropriate), primary care (particularly general practice), potentially the local element of the Health Education England budget, and other resources held by the Department of Health and Monitor to support trusts at times of severe pressure. 

The formal parties to the new agreement are the councils, CCGs and NHS England – but 15 of the region’s provider trusts and the North West Ambulance Service are supportive and have pledged to act in good faith to support its objectives. The scope includes the entire health and social care system in Greater Manchester, including adult, primary and social care, mental health and community services and public health – plus, subject to more talks, health education and research and development. 

The agreement outlines a framework for governance and regulation, resources and finances, the property estate, health education, workforce and information sharing and systems being brought together. A transition plan comes into effect from 1 April, with ‘full’ devolution expected by April 2016. 

This could depend on the results of the upcoming general election, of course – although most of the local authorities supporting the move are Labour-controlled, the party nationally has raised concerns that this type of deal could undermine wider NHS principles and lead to “a Swiss-cheese NHS where some bits of the system are operating to different rules or have different powers or freedoms”. 

Working together 

The deal brings together commissioners, providers and NHS England to work together like never before. 

Dr Gill told us: “Clearly, [provider trusts], in how they work with us, are central to whether we succeed or fail. Part of the reason that Greater Manchester has among the highest health spending but some of the worst health outcomes is that there has been more than a decade of difficult relationships between commissioners and providers. 

“So, we need to overcome that immediately if we’re going to actually make a difference. Our challenge is to make a big difference to outcomes and financial sustainability. That means making sure the trusts, for the first time, work together with each other.” 

Dr Gill hoped to see some re-prioritisation of spending in the region to improve overall outcomes, equality and the wider determinants of health – he suggested that currently emergency and specialist care is getting a disproportionate amount of spending compared to primary care, mental health and community services. “Spending is distorted,” he said. 

Having truly joint control over health and social care spending is a dream that goes back to the founding of the NHS, Dr Gill suggested, “but it’s never come about”. He said: “This is our one chance to get that absolutely right. Because there’s an intimate link between health and social care. 

“Equally, for example, we know that in parts of Greater Manchester some children are still going to school and do not even know that they have a name. What are the likely health and care outcomes for that child, long-term? Not good. So the interplay between health and the wider determinants of health is here for us to not just grasp but to change and improve. 

“This will become the norm of business for CCGs significantly, because time will be spent a lot more working together with each other and local authorities. This will become the new norm.”

Limits 

Greater Manchester has not been given a free hand, or allowed to opt-out of anything – it must still “uphold the standards set out in national guidance and will continue to meet statutory requirements and duties, including those of the NHS Constitution and Mandate and those that underpin the delivery of social care and public health services”. CCGs and councils will still have the same statutory functions, responsibilities and accountabilities for current funding flows. 

For now, “accountability for resources currently directly held by NHS England during 2015-16 will be as now, but with joint decision making in relevant areas to reflect the principle of ‘all decisions about Greater Manchester will be taken with Greater Manchester’”, says the memorandum of understanding. 

The risks inherent with transfers of commissioning responsibilities will be “shared with NHS England”, and there will be “transfers of skills and responsibilities” to reflect this – though the practicalities of this have not yet been ironed out. 

Healthier Together 

The new deal should not disrupt the Healthier Together clinically led transformation programme, which was covered in detail in NHE during autumn 2014. Indeed, the Greater Manchester Combined Authority says the devolution deal “resonates with the Healthier Together proposals and shares the same principles of improving the health and wellbeing of residents and patients, and improving standards of care”. 

Those reconfiguration proposals are continuing, with final decisions due this summer on changes to services at the region’s hospitals, which proved very controversial with politicians, the media, trusts – and even some of the CCGs behind the original proposals, who backed an alternative ‘North-West Sector Response’ plan in league with the acute trusts in Wigan, Bolton and Salford. 

Commissioning support 

The NHS North West Commissioning Support Unit (CSU) is not mentioned in the memorandum of understanding. The CSU, which serves CCGs in Greater Manchester as well as Cheshire and Merseyside, was denied accreditation in January on the Commissioning Support Lead Provider Framework for end-to-end commissioning support or medicines management, though it did win a place on Lot 2b (supporting Continuing Healthcare and Individual Funding Requests). 

According to Stockport CCG board minutes, the CSU “has now entered a process of transition to ensure service stability, as CCGs finalise their commissioning intentions and arrangements post April 2016”. 

The CCG paper adds: “We have started to identify which services we wish to bring in-house, those we would want to share with other CCGs and those we wish to re-procure.” 

The devolution documentation says the CCGs themselves, with partners, “will determine the scale, style and configuration of technical commissioning and business support services and ensure that they align with the wider three-level business strategies within Greater Manchester”.

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