One of the criticisms often thrown at the NHS is that it’s a postcode lottery. Your access to healthcare, the treatment you receive and the likeliness that you will make it to old age depend on where you live. So surely devolving complete control of the NHS budget to a local area – as is happening in Manchester this week – is a further damaging spin of the lotto wheel of fortune?
Certainly that’s the view of many who work in health, a plethora of campaigning groups and some politicians (particularly those on the left). In the year since George Osborne’s momentous northern powerhouse announcement, these groups have queued up to express concerns about the devolution agenda. However, while there are undoubtedly risks involved, the arguments made by detractors are not entirely convincing.
For example, even a cursory glance at England’s health statistics show that the postcode lottery is already alive and well: there is a 20-year gap in life expectancy between rich and poor areas. This is something that centralisation has not only failed to prevent, but may even have helped create by not allowing policy to respond to local needs. Manchester is completely different from Cornwall, London or Oxford, so why pretend there is a one-size-fits-all solution?
Another criticism is that this is simply a political agenda – all that is really being devolved is the blame for Osborne’s public sector cuts (Jeremy Corbyn recently called the northern powerhouse a “cruel deception”). But this misses the point. The problem with cuts in public spending are the cuts themselves, not devolution.
Given that austerity is happening regardless, local councils might as well have the freedom to choose where cuts fall, thereby giving them the ability to soften the blow for those least able to deal with them. Moreover, if this is political, Manchester’s local politicians might well be on the winning side. They have already secured an additional £450m to help reform their local services and now have the opportunity to demonstrate a distinct alternative to the governments beleaguered reform agenda. The question is what might such an alternative look like?
To answer this we must look at some of the potential opportunities involved in health devolution. The biggest of these is the possibility for local leaders to align health spending with spending on all the other things that determine our health. There is now a mass of evidence that ill health stems from the level of skills and education we have to the type of jobs we do, from the conditions in which we live to what we eat and how much exercise we do (estimates suggest social and environmental factors account for up to 80% of variation in health outcomes).
Historically, policy decisions on these areas have been separated from each other and from health, meaning policy has failed to deal with the complexities of sickness and social deprivation. However, as the devolution agenda gathers pace, powers over these policy areas are increasingly being passed down to combined authorities alongside health. For example, Greater Manchester has just taken on more responsibility over the criminal justice system (as called for by IPPR), local transportation and welfare policy, as well as holding existing powers over public health, social care and housing policy. This gives local leaders the opportunity to address the causes of ill health in their communities, as well as reduce the financial pressures on the NHS through better prevention.
Seen in this context, the devo-health agenda still contains risks, but it also offers the potential to drive the fundamental reform of our public services needed in order to address a plethora of social problems that have stubbornly persisted throughout Labour’s top-down New Public Management reform agenda and the coalition’s Health and Social Care Act. The challenge for newly emboldened local leaders such as Sir Howard Bernstein is, therefore, to unlock these benefits and demonstrate that they really can do a better job than Jeremy Hunt and George Osborne.
Harry Quilter-Pinner leads the health programme at the Institute for Public Policy Research (IPPR). The IPPR is launching a new programme of research on devo-health chaired by former health secretary Alan Milburn on 21 April in Manchester town hall.
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