Local authority becomes first in England to take control of its health and social care budget, but there is widespread uncertainty

Greater Manchester is to become the first local authority in England to take control of its £6bn health and social care budget in an experiment that has been criticised as being technocratic, undemocratic and understood by almost no one.

On Friday, the residents of George Osborne’s favourite city region may not notice that there has been a fundamental shift in the way their health and social care services are run. But 10 adjoining boroughs of Greater Manchester – currently responsible for social care such as older people’s and children’s homes and homeless services – will start to collaborate with the 12 clinical commissioning groups and 15 NHS trusts and foundation trusts responsible for organising, buying and providing healthcare.

This unwieldy coalition of 37 “stakeholders” is responsible for more than 100,000 workers caring for and treating the region’s 2.7 million inhabitants. Each locality has pledged to put money for health and social care into pooled budgets to buy health, care and support services in a joined-up way without duplication. A key goal is to reduce bed-blocking, whereby patients are kept in expensive hospitals, despite being ready to receive much cheaper community care, because of inefficient care pathways.

Ann Barnes, the chief executive of Stockport NHS foundation trust, says there are plenty of opportunities to make the system more user-friendly while saving money: “As an example, currently if we have a patient who is ready to leave hospital, a hospital physiotherapist will assess their needs, teach them exercises and so forth. Then the local authority will come along and get their own physio to do their own assessment. It’s patently inefficient and it doesn’t serve the patient’s needs.”

Known locally as “devo health”, the deal was struck behind closed doors in February 2015 by the 10 local authority leaders in the second of three devolution agreements between the Greater Manchester combined authority and Osborne, who sees Manchester at the heart of his “northern powerhouse project”.

Simon Stevens, the chief executive of NHS England, heralded it as having “the potential to be the greatest act of devolution there has ever been in the history of the NHS.” But the idea struck fear into many. The then shadow health secretary, Andy Burnham, a Greater Manchester MP in Leigh, near Wigan, warned of a two-tier NHS that would run counter to the principle of a universal and comprehensive service.

In a briefing paper in the British Medical Journal last week, a group of academics questioned the “ambitious rhetoric”. However laudable the ultimate goal – to reduce health inequalities within the city region and the rest of England while preparing for an expected £2bn funding gap by 2021 – “it is not clear how this is to be done or how devolution will help to bring it about”, the paper says.

Devo health is Greater Manchester’s Schleswig-Holstein question, says Neil McInroy, chief executive of the Centre for Local Economic Strategies thinktank: “Only three people have ever understood it. One is probably dead, the other has gone mad. I spend all my time discussing public policy and I don’t bloody get it. I’ve been to seminars led by people working on it and I’m not even sure they do.”



McInroy suggests it is an “opaque and technocratic plan” that few fully understand, devised behind closed doors with little consultation with the public or frontline staff. Stephen Hall, president of Greater Manchester TUC, who is part of the Greater Manchester Referendum Campaign for Democratic Devolution, said last year that Manchester’s devolution process had made “a complete mockery of democracy”.

Others are more optimistic. Tony Lloyd, the interim mayor of Greater Manchester, believes it will allow the area to tailor services on a hyper-local level to address entrenched problems, such as the fact women in parts of the city region have the lowest life expectancy in England.

“You can’t get the whole of the country’s health and social care providers and commissioners around a table, so previously the government issued national directives, which were the same whether in Scunthorpe, Solihull or Stockport. But in Greater Manchester we can get them all around the table – it’s a big table, but it’s doable and it’s something that’s never really been done before,” he said.

Ivan Lewis, the MP for Bury South, who will fight Lloyd this summer to be selected as Labour’s candidate to be Greater Manchester’s first elected mayor, says the biggest problem with devo health is the £2bn funding gap expected to have opened up in the region by 2021: “The way that reforms have traditionally been carried out successfully has been by putting much more money into a system to help the transition. Here, we are being asked to do more with less.”

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Greater Manchester has secured £450m from NHS England’s “transformation fund” to spend over the next five years. But that is less than a quarter of the funding shortfall, says Lewis. “It’s a drop in the ocean. It goes nowhere near to plugging the gap.” He said he was still unclear of how the plan would manage the tension between the free NHS and the means-tested social care system.

Kath Checkland, a GP who is also professor of health policy and primary care at the University of Manchester, says devo health could be seen as complicating an already labyrinthine system. “The new system in Greater Manchester is adding layers of complexity to an already complex system, and could be viewed from the local boroughs and GP practices as ‘centralising’ to the GM level rather than devolving or decentralising. It requires individual organisations to cede some decision-making power to the GM level and to act in the interests of GM as a whole rather than of their individual organisations.”

She warned the plan would not be welcomed by many GPs, particularly those in wealthy areas, in Trafford and Stockport, who may fear that their practices will lose out to those in more deprived areas of Rochdale and Oldham. “At a GP level, people are bewildered. They don’t really know or understand what’s going on.”