The Government is devolving budgets and responsibility for health and social care in different ways in different parts of the country including Greater Manchester, Liverpool City Region, London, Cornwall and the North East Region.
Whilst this is genuine devolution from national decision-making, it may feel more like local centralisation to the many different social care and NHS commissioners and service providers who will experience new area-wide structures for spending decisions across the whole footprint of each devolved area.
These local areas are taking this high risk opportunity in the hope that the advantages of increased local budgetary control, strong local relationships and a shared commitment to outcome-driven reform outweigh the political and service risks of coping with massive reductions in funding at a time of rapidly growing demand and nationally imposed costs.
For devolution of health and social care to be successful some key questions have to be considered - will the new structures be given freedom to diverge from national systems of funding formulas and tariffs, means tests and eligibility criteria, and governance rules and protocols?
In addition, given the financial pressures, will these areas look beyond the clinical drivers of high health costs among older people to reduce demand for services through improved self-management and tackling non-clinical drivers of cost such as loneliness, anxiety, and physical inactivity; will they seek turn over the ‘care triangle’ to shift spending from expensive institutional care (hospitals and care homes) to lower cost high quality care at home; and will they invest in prevention services and for high risk groups?
To be successful these areas will need the ability to implement rigorous performance management processes in new structures across complex health and care systems to ensure that cashable savings are generated from reform; and ensure that they are spent in new ways of delivering health and care that ensure a financially sustainable system. Have they got this capacity and what reserve powers will the government have to intervene and manage a failing devolved area?
There is one further possibility – that the government will devolve responsibility for the Attendance Allowance for older people – the key question is how will local areas manage a budget that is not means tested if demand will inevitably grow and the budget is capped?
Devolution is one ingredient in the recipe for dealing with a drastically underfunded and poorly structured health and social care system. But unless the devolution deal is fair, manageable and affordable, the risks to local decision makers and their communities may outweigh the benefits.
Phil Hope, associate, GK Strategy
