England’s new welfare state starts at 8.30 on Friday morning in Manchester town hall. A ceremony will transfer control of the city’s health services to its people. It ends half a century of ministers in parliament telling doctors when to see patients, what pills should be given, which operations get priority, and how long a home visit should last.
It ends an NHS whose size compares to Russia’s Red Army, and which behaves like it. It ends Nye Bevan’s demand to hear in Whitehall the noise of “every bedpan that is dropped on a hospital floor”. Such obsessive centralism has run out of steam, and out of money.
George Osborne’s Manchester devolution deal last November – so-called devo-Manc – began a process that is clearly unstoppable. It devolved to the city region £2bn of spending over housing, transport, planning and skills training. Friday’s proposal is worth three times that sum, £6bn, devolving nationalised hospitals and GPs to merge with local clinics, homes and home care services. NHS “in crisis” has become a national cliche. Big has not worked. Now is the turn of small.
The catalyst has been the gulf that has opened in care for the elderly, with GPs and hospitals under siege from NHS Direct and an ageing population, and local care services trying to pick up the pieces with ever-shrinking budgets. Past concessions to GPs and pharmaceutical companies are draining even a “ringfenced” NHS of money, while council care has been cut by a third. The result was predictable: blocked beds and jammed wards. GPs flush with cash hurling patients at hospitals, which cannot cope. Emergency services take the strain. Cost and chaos ensue.
Already, liaison is taking place locally between GP commissioning groups and frantic care departments. During the devo-Manc discussions, Osborne conceded Manchester an NHS liaison role, but the logic was merger. He faced the option of bringing all healthcare under Whitehall control, but the idea of piling yet more bureaucracy on the NHS was unthinkable. The only sensible alternative was to pass the NHS to the locality. Priorities would be locally decided and locally accountable. Postcode lottery would become postcode priority and postcode opportunity. There should be “decentralisation of blame”.
Crucial to the deal has been Osborne’s attachment to the two dominant figures of Manchester’s resurgence: council leader Richard Leese and his chief executive, Howard Bernstein. Osborne makes no secret of his admiration for their “can-do” leadership. Their marshalling of the nine surrounding districts into a Greater Manchester authority under a to-be-elected mayor put them in a class of their own among city bosses. They turned Osborne into a convinced, if geographically specific, localist. He is, after all, a local MP.
Critical too is that the reform is backed by the Labour leaders of eight of the 10 Manchester districts in the “northern powerhouse”. Ed Miliband’s attempt last year to get Leese to repudiate the powerhouse was said to have been greeted with a four-letter remark. As for Yorkshire and the West Midlands, their jealousy of Manchester drives them not back to Labour centralism but to more of the same for them. Small wonder that Labour’s health spokesman, Andy Burnham, was left floundering on Wednesday.
England is seeing a reprise of what happened in France in 1982. It was socialist city leaders, fed up with being bossed by Paris, who successfully demanded an end to prefecture centralism. The key strength of Osborne’s reform is that it is locally bipartisan.
Greater Manchester’s new “health and wellbeing” commission will not run hospital trusts. It will control the flow of money and thus GP commissioning and links between hospitals, community and residential care. This closes an institutional split created when Nye Bevan in 1948 moved doctors and hospitals into his NHS and left other care services to municipalities and charities. The split was papered over with ever more money.
The spotlight is now on Leese, Bernstein and whoever becomes elected mayor of the new city region. This is not a “reorganisation”, except at the top. On the surface, there must be some shift of spending from the former NHS sector into hard-pressed community care. There will be arguments about drug priorities, emergency waiting times, bed-blocking and the length of home visits. Accountability will mean intense scrutiny of such decisions. But the can will be carried locally.
Other cities are bound to want more. Last week Osborne appeared with London’s mayor, Boris Johnson, and offered him the devolved powers over planning, housing and training that he had already offered Manchester. He never mentioned health. Yet if ever there is a region in need of merging NHS and local services it is London. Johnson will be slacking if he does not beat a path back to Osborne’s door.
The NHS once ranked with the royal family and the British army in the pantheon of Britain’s public sector gods. Plagued with political interference and change since the 1980s, it has consumed ever more money and got in return only demoralising headlines. For it now to meet death by a hundred devolutions would be chaotic.
Osborne cannot deny other cities comparable treatment. The sensible next step is to ask others – and counties – to bid for similar powers. After decades of dependent centralism, localism is inevitably a gamble, especially where there is no reliable Bernstein or Leese in place. But local democracy must somehow grow up. People must be forced to be free.
Finally, at the end of his first government, David Cameron has found it in himself to do something truly local. But he and his chancellor have yet to answer the big question. If Mancunians can be trusted to run their health service, why should they not be trusted to raise and spend money on a better one? How can Osborne delegate the power to improve a service, yet not to raise taxes to do so? The lesson of Scottish devolution – conceded by the coalition – was that it was meaningless without tax-raising powers.
Robert Peel declared in the 1840s that “what Manchester thinks today, the world thinks tomorrow”. The same should go for what Manchester does today. A heavy responsibility now rests on that fine city, but also on Osborne to carry boldness to its logical conclusion.
