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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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Guest post: Three things I’ve learned in my local coffee shop

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By Steve MacDouell

If you were to walk into my neighbourhood coffee shop, you’d see the usual suspects: Joey, a body and mind professional, who would be talking to someone about Finnish saunas, metal music, and the human condition; Arielle, the local city councillor, who would be conversing with her constituents about their ideas and hopes for the neighbourhood; Alexis, a writer, who would be sipping an americano, plugging away at her book, and scrolling through funny dog gifs; and Brittney, Jen, and Emily, three friends who, on a weekly basis, come together to talk about the joys and complexities of life all the while trying to keep their pre-school aged children occupied. This coffee shop, like many others, is a place where people are invited to sit, to catch up on some email, and to, potentially, encounter a few of their neighbours — all while enjoying a hot, caffeinated beverage.

Third places — that is, places where people can enjoy the company of others outside of their workplaces and homes — are critical to the well-being of our neighbourhoods. From public parks and libraries to pubs and playgrounds, these places are impacting our localities in both subtle and significant ways. For our communities to thrive, we need third places where ideas can be shared, where everyone is welcome to belong, and where relationships, over time, can be fostered. Ray Oldenburg, urban sociologist and author of The Great Good Place, emphasizes the importance of these kinds of places in this way:

“Most needed are those ‘third places’ which lend a public balance to the increased privatization of home life…Though a radically different kind of setting from the home, the third place is remarkably similar to a good home in the psychological comfort and support that it extends…They are the heart of a community’s social vitality, the grassroots of democracy.”

After a few years of sitting in the same coffee shop, I’ve come to realize that third places have much to teach us about our neighbourhoods and the people we share them with.

In the spirit of celebrating the third places in our cities, here are three things that I’ve learned in my local coffee shop:

People want to linger in places where they can be seen, heard, and known

There is something about your local barista knowing your coffee order that grounds you in a place. It’s one of the small, subtle ways that I started to feel like a character in the story of my neighbourhood. This vague familiarity would go on to spark brief conversations between the staff and I, which led to more robust exchanges around our unique interests, our vocational endeavours, and our shared hopes for the neighbourhood. They began to introduce me to other locals in the shop which led to more conversations and to a broader network of connection. Additionally, the shop is small, so sharing tables with my neighbours became a normal practice. At times, these shared table experiences sparked meaningful interactions, and at other times, it just led to more spilt coffee. As weeks turned into months, strangers became friends, a sense of community started to be formed, and feelings of familiarity began to take root.

It’s often within the relational ecosystem of a local coffee shop that we encounter the people we’ve actually shared close proximity with for a long time. We start to put names to faces that we’ve seen in passing, and we begin to feel a little more noticed ourselves—which taps into our human longing to know others and be known by others. In this sense, coffee shops provide far more than local economic benefits and enjoyable products; they offer a space where trust can be formed — and where hospitality can be extended — between neighbours. While turning up, sipping coffee, and being open to connection seems like a small act, the cumulative impact of doing so can’t be quickly dismissed.

People long for places where contextual ideas—for the common good of the neighbourhood—can be inspired

The collision of humanity that occurs in a local coffee shop has a way of catalyzing ideas that, if leveraged well, can go on to improve the well-being of our neighbourhoods. This occurs, in part, because the individuals who spend time in these places will have some sense of the contextual opportunities that exist locally and because the social nature of a coffee shop can lend itself to a high concentration of neighbourly interactions. Over the years, spending time in my local coffee shop has opened up different collaborate engagements with my neighbours: from cocktail nights, dinner parties, and social clubs to playgroups, TED-style events, and tactical urbanism projects. The seeds of these ideas were planted and cultivated through ongoing conversations over lattes and laptops.

The local impact that can come out of a coffee shop is nothing new; historically, these places have played a key role in shaping the social, political, creative, and intellectual pursuits of cities. Take, for example, the coffeehouses of London in the 1670s. The open, political dialogue that occurred in these places was subversive enough that it caused nervousness in the powers that be, so much so that Charles II tried to have them shut down. If you were looking to be involved in political dialogue during the French Revolution, you could find it in a Parisian café, and if you were an anti-Communist dissident in Prague after the Soviet Union invaded Czechoslovakia, you could conspire with kindred spirits at Café Slavia. Some, like German sociologist and philosopher, Jürgen Habermas, have even gone on to argue that the coffeehouses of the seventeenth and eighteenth centuries helped lay the foundation for the liberal Enlightenment.

While revolution might not break out in our local coffee shops, these important places still inspire dialogue, ideas, and collaboration, all of which can go on to make a tangible impact on neighbourhoods and cities.

People are attached to the places that they experience with all of their senses

Over the past few years, I’ve taken a number of road trips across the United States. Whenever I’m in a new city, I try to sit in a few local coffee spots to taste their product, to meet a few locals, and to get a sense of what’s happening in the neighbourhood. While I’ve enjoyed some great coffee and met some interesting people along the way, I’ve always felt like a visitor in these places—and this makes sense. The coffee tastes a little different than what I’m used to; the aesthetic, while often similar, is not quite the same as my local coffee shop; and the people are friendly, but I’m not connected to their stories in the same way that I am to those of my neighbours. Visiting these places is always a welcomed experience, but it never quite feels like home.

The hours I’ve spent in my local coffee shop have increased my level of attachment to my neighbourhood and the people who inhabit it—which, over time, has made me less likely to dream of being somewhere else. While I love to travel, being elsewhere has made me more appreciative of the people and the places that are familiar, reminding me of just how much I continue to receive within the ordinary rhythms of life in the places I call home.

Third places play a critical role in the strength, resilience, and interconnectedness of our cities. Whether your third place is a coffee shop, a community centre, or a local McDonald’s, spending time in these places can move us toward the people, the stories, and the opportunities that exist all around us. While these places will not solve all of the urgent problems that our cities face, the tangible benefits that they offer our communities should be celebrated.

Steve MacDouell is a professor at @FanshaweCollege in London, Ontario, and a senior community fellow at @TheGoodCityCo, a civic organisation that creates projects to help citizens take greater ownership over the places they call home. Steve also writes posts on community formation, place and neighbourliness. This post originally appeared on Steve’s own blog.