A Timeline of Devolution

Reeta Ram, Director of Dementia Partners first became intrigued by the details of the Government’s Devolution plan when she attended a Westminster Forum Projects (WFP) conference in late 2016. WFP work now extends to policy decided in UK devolved Parliaments and Assemblies, the Oireachtas, and the European Commission and Parliament.

“The change from a centralised model to a local model is a little-known policy priority.  It is already happening. Greater Manchester and Cornwall have led the way in health and social care devolution  ”

We summarise the briefing of the King’s Fund on Devolution.  London Pilot projects are an opportunity to discuss lessons that can be drawn the London Health and Care Devolution Programme, in the areas of health and care integration, service personalisation, prevention and catering to local needs.

A key point King’s Fund makes is that what we are currently witnessing is not devolution. The models adopted in the deals so far appear to be closer to ‘delegation’ than the formal ‘devolution’ outlined in the Cities and Local Government Devolution Bill.

  • Devolution involves the transfer, concurrent exercise, or joint exercise of functional responsibilities from a public authority to a combined or local authority’ following an order from the Secretary of State, as set out in the Devolution Bill. This would be accompanied by a corresponding transfer of duties, accountabilities and resources
  • Delegation is without an order, commissioning functions and financial resources could be transferred to joint commissioning boards, but with accountability arrangements unchanged (ie, existing accountabilities would be retained by NHS England and CCGs)

A key concept for the local model is pooled budgets whereby local authorities and NHS bodies pool health and social care budgets at a local level through section 75 of the NHS Act 2006, which forms the basis for Better Care Fund arrangements

The Local Government Association tells us in their website that ‘Devolution is one of the most fundamental changes to the way decisions are made for local areas and how public services are funded. In England, devolution is the transfer of power and funding from national to local government. It is important because it ensures that decisions are made closer to the local people, communities and businesses they affect. Devolution will provide greater freedoms and flexibilities at a local level, meaning councils can work more effectively to improve public services for their area. The result will be more effective, better targeted public services, greater growth and stronger partnerships between public, private and community leaders in local areas.’

Devolving responsibilities to local areas has emerged as one of the new government’s defining policy agendas.

What’s happening and how did we get here?

A potted history of devolution and centralisation in England

Over the past 150 years, there has been a tendency for UK governments to centralise power. The result is a UK system that is one of the most centralised of all countries belonging to the Organisation for Economic Co-operation and Development (OECD); 75 per cent of tax revenues were raised centrally in 2012 (OECD 2014), and in 2014 just under 25 per cent of public expenditure was by local government (OECD 2015). By comparison, in Sweden (for example), almost half of revenues are spent at local government level (OECD 2014).

In the autumn of 2015, the Prime Minister announced that 38 submissions for a range of devolved powers had been received nationwide. Announcements on successful bids are expected alongside the Spending Review.

In December 2015, all 32 Clinical Commissioning Groups (CCGs), London Councils on behalf of the 32 London boroughs and the City of London, the Mayor of London, NHS England and Public Health England came together as ‘London Partners’, and agreed to work more closely together.

In support of this, central government and national bodies invited London to explore devolution – the transfer of powers, decision-making and resources closer to local populations – as an important tool to accelerate transformation plans and respond to the needs of Londoners more quickly.

Building blocks in health and social care

The centralised model is encapsulated in Aneurin Bevan’s famous dictum that ‘when a bed-pan is dropped on a hospital floor, its noise should resound in the Palace of Westminster’ (cited in Nairne 1984, p 34). Prior to the establishment of the NHS, however, all public health control was the responsibility of local government.

The transfer of public health from the NHS to upper-tier local authorities as part of the coalition government’s reforms reflected the recognition that much of what keeps people healthy lies beyond the remit of the NHS.

Will local democratic involvement in health make it easier to take difficult decisions?

In the absence of sustainable funding agreements and with challenges as to scale, whoever is responsible for health during this period is likely to have to make some difficult and unpopular decisions about the configuration of local services.

How will regulatory oversight operate in devolved areas?

The amendment to the Bill introduced by Lord Warner clarified that, even in areas in which functions are to be formally transferred via an order, the powers of the regulators (the CQC, Monitor and others) are to remain in place nationally. However, areas such as Greater Manchester have been clear previously that they want ‘a new set of relationships’ with the regulators, and Cornwall has described the current burden of information and assurance requirements on local systems from CQC, Monitor and the NHS Trust Development Authority as ‘overwhelming’.

Since we can expect arrangements to vary between different areas, regulators will need to understand the local context and adapt their approach accordingly, while remaining consistent with national rules. This raises the question of whether these regulatory bodies have the capacity and resources needed to tailor their approaches to local circumstances.

If combined authorities were to introduce their own local regulatory oversight, there will also need to be consideration of how national and local arrangements fit together. ‘Good-day and bad-day’ scenarios will need to be worked through, making it clear where the buck stops in the event of failure. For example, were there to be a significant lapse in quality of care, would it be the CQC accounting to the Health Select Committee for its failure to spot it, or the person responsible for local regulatory oversight, or both? 14

The regulators have recently begun to develop approaches to regulating whole health economies (rather than individual providers). This may provide a helpful starting point for regulation in devolved areas.

How different could a devolved area end up looking?

King’s Fund highlights that continued accountability of NHS England should ensure that existing standards and duties (such as those set out in the NHS Constitution) apply: however, there are still questions about how this will work in practice. For example:

  • what happens to out-of-area patients and their right to choose? How will areas that have taken on responsibility for commissioning specialised services protect the interests of people living in other parts of the country who use the services of their providers?

Despite the enthusiasm behind the devolution agenda, we need to remember that while the public are broadly supportive of localism, research shows that they are concerned about local variation and the ‘postcode lottery’ (Ipsos MORI 2015).

Where are we with Progress by 2020

Some speakers at Westminister Forums question whether the 2020 timeline for devolution will be achieved or postponed for much longer.

But just because this is not strictly devolution does not mean it’s ‘business as usual’. In Manchester and Cornwall, health has been caught up in the wider devolution agenda, creating a potentially ‘unstoppable momentum’ that has brought NHS and local authority leaders together to think about how services could be transformed to better meet the needs of their populations and overcome longstanding local barriers to change:

A key concern is whether the NHS can deliver on this agenda at the same time as it attempts to tackle mounting financial and operational pressures and progress the new care models being pioneered.

Kings Fund writer, Helen McKenna in her article Devolution – silver bullet or Swiss cheese?2015 comments on adopting a process of delegation rather than full devolution, that areas like Greater Manchester and Cornwall are being forced to innovate at the edges of existing legal boundaries. This begs many questions about how it will all work in practice. Who would ultimately stand behind provider deficits? How will regulatory oversight work? How different might local areas end up looking from one another? Her biggest concern is that this becomes such a focus that people are distracted from the central challenges facing the NHS today – finances and future sustainability. Devolution will not be a quick fix to those challenges – savings strategies often result in improved outcomes rather than lower costs, take time to deliver and require significant upfront investment – and we don’t have a lot of time to spare.

Dementia Partners will continue to be intrigued by developments on Devolution and the London Pilot, in the foreseeable future.