As the media was excited this week with news of Staffordshire plans for a £1.2bn sell-off of patient care without proper consultation, the worry that the NHS is increasingly heading towards privatisation feels very real.
However, privatisation is not the only reason some have feared that the ‘N’ in NHS is under threat. Indeed, discussions around George Osborne’s announcement of the devolution of health powers to Greater Manchester a few weeks ago seemed to have died down since, despite the considerable problems it poses.
While some have gone so far as to suggest that the plans amount to the ‘denationalisation’ of the health service, while others have described the proposals as the ‘greatest integration and devolution of care since the creation of the NHS in 1948’, details remain sketchy. Undoubtedly, specialists have long been calling for integration of NHS primary services and council-provided social care, alongside greater patient control and participation, all of which seem to be endorsed in the proposals.
The plans outline that a newly-created Greater Manchester Strategic Health and Social Care Partnership Board will gain control of its £6bn health and social care budget, covering a population of 2.7m people. While health decisions in the area are currently split between Local Authorities, Clinical Commissioning Groups and NHS England, these plans will see these functions integrated via the board, with power ultimately lying with a newly-elected Mayor. While the board will have to maintain national standards on care, patient rights and other statutory duties such as waiting times, the hope is that an integrated approach will promote better patient-centred care, as well as ensuring NHS decision-makers are accountable to the local population.
Some have accused Osborne of handing to Manchester a ‘poisoned chalice’, disguising the consequences of the NHS’s huge funding problems under a veil of devolved power, while others have celebrated the undoubted opportunities for better managing chronic illness, integrating mental and physical care, and strengthening local democratic ties. Yet the unanswered questions it throws up make the future of the NHS seem uncertain:
- Confused accountability: Who will ultimately be responsible for the use of public money in Manchester, and how much freedom will leaders have to depart from national health policies? Will ancillary aspects of the NHS budget also be devolved? Ultimately, what does ‘national’ mean in a devolved health and care system?
- Funding: Unlike primary care, within social care everyone is expected to make a financial contribution, with many paying the full cost: however, if the two systems are integrated, where does one end and the other start?
- Localism in action: Will regional clinical and council networks fit on to the new super-city scope? And are local councillors, who often lack specialist health expertise and time, best placed to make decisions?
- National vs Local: Though these shouldn’t necessarily sit in diametric opposition to one another, how will national standards be reconciled with locally targeted provision, and how will we avoid what Andy Burham has called ‘swiss-cheese’ NHS provision, and a ‘postcode’ lottery when it comes to health services and outcomes?
- Democratic accountability: Is this properly captured in introducing a mayor in Manchester, where the creation of the position was voted against in a referendum in 2012?
Quite unlike its comprehensive campaign against what it sees as the increased ‘privatisation’ of the NHS, Labour is yet to offer a detailed alternative to Osborne’s offer, which has received wide endorsement from a Labour-led Manchester council. As such, many of the crucial questions, not least how national and local accountability and decision-making can co-exist when it comes to health, remain unanswered.
As politics moves towards increasing endorsement of the ‘localism agenda’, it’s likely that demands for devolved health powers will increase: however, a one-size all model cannot work, as local governance and health needs vary nationwide. As such, politicians must start grappling with the bigger questions: what localism really means for variation in health services and outcomes, what it will look like from region to region, and, fundamentally, what it will mean for the ‘National’ in the NHS.