Devolving health and social care in England: an opportunity to transform how we approach health and care?

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In recent years, the Department of Health and Social Care (DHSC) has increasingly encouraged the transfer of powers over health and social care in England away from central government and towards city regions. These bodies, DHSC argues, are uniquely placed to understand the challenges faced by their local populations, the capacities and expertise of their local NHS and to develop plans for the future. This should enable them to approach health at a local level, promoting increased delivery of care in the community, and a greater integration between health and care services.

Putting local places at the centre of “Build back better”

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, like taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

The NHS Long Term Plan has also outlined a new direction for the NHS based on the principle of collaboration rather than competition, and the introduction of new structures such as Integrated Care Systems, Integrated Care Providers and Primary Care Networks. These partnerships bring health and social care commissioners together to plan and deliver integrated and person-centred care.

In the context of “building back better”, awareness of how our external experiences and contexts impact our health and wellbeing (for example the impact of poverty, deprivation, housing, and unemployment) is increasingly important.

Beyond the immediate recovery from the pandemic, health devolution could be one way of opening up the possibility of integrating not just disparate services within the NHS – or even NHS and social care services in a locality – but bringing together in a combined strategy and structure all of the services, systems and partners in a community that have an impact upon the health of a local population, and the care services to better meet their health needs.

“It doesn’t have to be a battle”- partnerships and balance are the key to effective devolution

The move away from centralised processes and organisations towards more local ones can sometimes be portrayed as a rejection or an attempt to “break free” from central government. However, practitioners have been increasingly stressing that devolution does not mean complete independence, and that while improved local decision making will improve outcomes for local people, that does not mean that the need for some centralised decision making is completely removed.

On the contrary, some decisions should and will be taken at a national level, but the ability to distribute power, decision making and accountability to a local level will have significant positive impacts for improving “citizen voice”, transparency and co-production in decision making.

This is where the Health Devolution Commission argues that balance, communication, and partnership between the local and national infrastructure needs to be aligned so that devolution can be successful and sustainable. Integrated planning and management of long-term health care strategies is important, as is the ability to bring citizens and local decision makers into discussions about national health policy.

The Voluntary, Community and Social Enterprise (VCSE) sector, including patient voice and carers organisations, also plays an important role in linking together services and communities. As well as partnering to deliver services, these organisations also often offer vital bridges between statutory systems and those communities which can often be excluded from engagement with services or who can find it harder to access them. The commission also emphasised the importance of bringing these bodies into the conversation on devolution going forwards as they will be invaluable partners in the process.

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DevoManc providing the blueprint?

In 2016, as part of a pilot, control of the health and social care budget for Greater Manchester was transferred to a partnership team in the area comprising local authorities, clinical commissioning groups, NHS foundation trusts and NHS England.

The combined authority identified that the health of its population was one of the key obstacles to its economic growth. By relating the concept of regional economic prosperity with health, they began to see health in a completely different way – as part of a wider plan and an investment for growth, not a burden.

“It’s better to have decisions made locally, because local people understand what local problems are and what Greater Manchester needs. We need to work together.”

Lord Peter Smith, Chair of Greater Manchester Health and Care Board

The Greater Manchester Health and Social Care Partnership are working in partnership with other sectors including education and housing to support everything from good eating habits and exercise to education and everyone’s ability to earn a decent living. The partnership is taking action to give children the start they need, support independence in old age, tackle illness earlier on and even prevent it altogether by improving the lifestyles of local people.

Other areas of England are also currently undertaking their own health devolution journeys, including London, West Yorkshire and Harrogate, as well as some other combined authority areas. However, one of the big challenges is that currently, while we can learn from the experiences of those already on their devolution journey, there is no common, consistent or comprehensive understanding of what good heath devolution looks like, full evaluations of the benefits it brings or overarching strategies on how it should be developed.

This is something that will need to be addressed if health devolution is to be successfully rolled out across England.

Final thoughts

Devolution of health to a more local level provides an opportunity to tackle the big public health challenges of our time at source, and to create a better, more joined up community health ecosystem. It also provides the chance to share and collaborate, learning from best practice and delivering improved health and social care services at a regional and national level.

It has been suggested that the coronavirus pandemic, while traumatic in more ways than one for the NHS and its staff, may provide the re-setting point needed to implement some of the changes proposed in relation to greater health devolution. Proponents of this view argue that improved funding to support effective and high quality care, improved integration between health and social care, and greater positioning of health and assessment of the impact of decisions on health across all policy areas, should be among the top priorities as the country looks to recover from the pandemic.

As the Health Devolution Commission underlines:

The pandemic has shown we cannot go back to the way things were. We need a ‘new normal’ and we believe that comprehensive health devolution is the only viable solution to the challenges the country now faces.”


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