NHS reform: Devolution is not the only path to integrated healthcare

Plans to devolve control of health services to local areas are moving ahead quickly in parts of England. But handing powers to local authorities is not the only way to achieve health and social care integration, argues Socialist Health Association vice president Dr Brian Fisher - and devolution carries significant risks for the NHS.

In my area of Lewisham, the CCG and local authority have agreed to be a devo pilot. It will result in better services, possibly new powers, more integration. What’s not to like?

Devolution has real risks and I’d like to explore them here. And I am not convinced it’s needed at all.

Integration, on the other hand, is definitely needed. We know that patients fall through boundary cracks, and communication and culture is often a problem between sectors and organisations. Integration means many things. Including spanning the NHS and social care; primary and secondary care; community care and primary care; third sector and the NHS. Patients would benefit from better integration and communication across all those fences.

NHS integration

But integration and devolution are not the same thing. We have moved a great deal on integration without the need for devolution, and we could do a lot more. It seems a convenient elision to automatically link integration and devolution.

Devolution is the transfer or delegation of power to a lower level, especially by central government to local or regional administration. There are two kinds of devolution: the Sporadic kind, such as Devo-Manc and the Lewisham form – and the Systematic variety coming down the road in the shape of a parliamentary bill. This has big implications.

As I understand it, Devo-Manc has not attracted any new powers to either the NHS nor the LA. So, it may stimulate new conversations, but it doesn’t actually change anything fundamental.

It also brings no new money. Quite the opposite – the costs in money, time and resources of another local redisorganisation may be quite high.

There is little democracy or accountability in the NHS in any case, but devolution does not seem to help. The Devo-Manc changes have gone through with no consultation whatsoever, with even a local MP being unaware of them. Similarly in Lewisham. In addition, much decision-making then appears to take place on a much larger scale, with committees-in-common merging CCGs and localities – it takes planning even further from the citizen.

NHS privatisation

People on the ground in Manchester say they see no privatisation now or in the future. Indeed, they say that the Manchester arrangements militate against privatisation. Nonetheless, in principle, devolution is likely to lead to more shifts in contracts, new organisations – and all that, with the mechanisms in place through the HASCA, will lead to more tenders and more privatisation.

I understand that in Manchester, they are using devolution to carry through cuts to as much as a third of their hospital beds and estate. This, led by the leader of the council. In the current climate this kind of group think is very dangerous.

Meanwhile, the Cities and Local Government Devolution Act will enable local authorities to run NHS organisations.

The Act enables a transfer of local functions of the NHS to a local authority or 'combined authority', with a local authority’s permission. The 'core duties' of the health secretary - including roles set out in NHS England's mandate, cannot be transferred. The local authority could take on a current NHS role, or carry it out alongside or jointly with the NHS. The NHS may or may not continue to provide that service itself. There is provision to abolish the public authority where it will no longer have any functions. It allows for a joint committee of the devolved bodies, including at least one CCG, to establish a pooled fund to manage NHS cash.

In principle, it makes sense for NHS services to be run by a local authority: they are structurally democratic; they understand commissioning; much of our health is determined by areas under the control of local authorities; there could be a rapid integrative process; everyone knows their local authority, but is often ignorant of their CCG.

Deregulation of NHS services

But, do you really want your local NHS run by a politician - and particularly a Tory - in the current climate of austerity? Do you want an organisation, your local authority, which has privatised virtually every public service to do the same to the NHS? Do you want an organisation whose life blood is means-testing, trying to do the same to your health services?

The Devolution Act could lead to the deregulation of NHS services, too. The Act mentions 'standards and duties to be placed on that authority having regard to the national service standards and the national information and accountability obligations'. The phrase 'having regard to' is weak in legal terms. It becomes possible for the nationalised standards of care and practice to be slowly abandoned. Surely highly dangerous. And we have seen this in so many other areas of work, for instance banking and food.

The kind of integration we should seek includes the following:

  • Integrated national standards with nationally recommended treatments.

  • Integrated methods of allocating resources to areas of greatest need.

  • Integrated funding through national taxation.

  • National accountability, democratic control over commissioning, effective PPI, shared power with communities.

  • An integrated national system of pay, terms and conditions for NHS and social care staff.

Meanwhile, making social care free at the point of need is an essential prerequisite for integration. It would transform the whole scope, scale and landscape of care. The King's Fund think tank has calculated that it is possible – and we need this to be the direction of travel. It may take some time, but it is absolutely necessary. 

So, in short - integration definitely yes. Let’s do more. Devolution, however, seems to have far more risks than benefits, so, in the current climate – beware.

  • Dr Brian Fisher is a GP in Lewisham, east London, and honorary vice president of the Socialist Health Association.

Photo: Dan Wootton

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