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Manchester united? The road to devolution

A healthcare strategy to integrate health and social care services, as part of the Greater Manchester Devolution Agreement, is due to be finalised this year. Can local doctors be sure that their voices are being heard, and that their concerns with budgets and recruitment are being addressed?

If a week is a long time in politics, the past seven months for the local authority and clinical stakeholders involved in the groundbreaking bid for devolution of healthcare in Greater Manchester must already have seemed like a lifetime.

Since the signing of a memorandum of understanding back in February, and creation of a joint working body made up of the region’s local authorities, CCGs (clinical commissioning groups) and NHS providers, much discussion and analysis appears to have taken place.

During this year’s BMA annual representative meeting, council chair Mark Porter explained that it was vital for the BMA to be ‘in the tent’ during the negotiation and planning phase of the proposals.

However, the association’s cautiously proactive approach has been tempered with serious questions and concerns, not least around funding and budgets, impact on working conditions and the potential for devolution to be accompanied by increased privatisation.

Written evidence submitted to the consultation on the Cities and Local Government Devolution Bill — prospective legislation that seeks to enshrine the legal framework for future local devolution deals — expanded on these concerns for Manchester and for potentially devolved areas.


Bid for clarity

In an effort to make things clearer and potentially allay clinicians’ fears, the BMA hosted a Q&A panel discussion at Manchester Town Hall before an audience of members on 3 September.

Opening the discussion, Manchester consultant psychiatrist JS Bamrah explained how the BMA’s history was ‘steeped in healthcare and politics’, adding that ‘it has always had a vested interest in the NHS’.

The panel, chaired by Dr Bamrah, also included council deputy chair Kailash Chand, BMA GPs committee deputy chair Richard Vautrey and Greater Manchester local medical committees honorary chair Tracey Vell.

It also featured Manchester City Council chief executive and devolution programme board co-chair Sir Howard Bernstein, Central Manchester CCG chief officer and programme board interim chief officer Ian Williamson, and Manchester NHS and local authorities CEOs forum chair Mike Farrar.


Funding and budgets

With the NHS facing financial pressure nationwide, the issue of how to apportion and administer a combined budget estimated at £6 billion for the region’s various health and social care services, has been present from the outset of Devo Manc.

Articulating the fear held by some doctors, particularly those in general practice, Dr Vautrey outlined the potential danger of a merged budget.

He said: ‘One of the real concerns that many GPs will have is that we’ve [general practice] become a risk sink for the NHS, and potentially social care as well.

‘One of the risks of that merging of [health and social care] funding is that the limited funding that general practice has leaches out even further to support important social care work, and then general practice struggles even more to be sustainable.’ 

Addressing concerns with funding, Sir Howard said that the financial sustainability plan submitted by Greater Manchester’s local authorities would make clear to the Government what resources were needed for existing and future health needs.

He added that there was no chance that funding for one aspect of care would be used to finance other areas, and that under the devolved structure there would be a multilateral approach to spending.

He went on to say: ‘It’s absolutely clear that if we don’t get the resources we’re asking for, we won’t be able to transform the system.

‘What we’re talking about here is how the resourcing of health and social care over the next four years can actually be better aligned in order to deliver better outcomes for the people of Greater Manchester. 


No change

‘There is no change in any local authorities’ statutory responsibilities, there is no change in CCG responsibilities, there is no change in the secretary of state’s responsibilities.

‘We are creating the platform for taking decisions on how we spend that money on a unified leadership basis.’

Mr Williamson insisted that there would be no attempts to strip funding for specialist care services in order to plug gaps in funding elsewhere.

He added: ‘We have some of the best specialist services in the country in Greater Manchester … we want to support and continue to allow them to thrive. 

He added that a key component of the sustainability strategy was to devise a way of squaring the circle between preserving specialised services while shifting to a preventative approach to healthcare.

He said: ‘We have to have that debate, we have to try to shift care upstream … and we have to manage that in a controlled and careful way so that we preserve and make sure we have high-quality services in hospitals when people need them.’


A voice for doctors

The prospect of integrated health and social care services supporting more than two million people has understandably seen the BMA seek assurances that doctors will be part of the decision-making process.

Dr Vautrey emphasised the need for ‘developing relationships’ between different branches of practice and providers, and ‘getting people who feel as if they’re part of the team’ was just as crucial to future success as funding, he said.

The question is an important one. For his part, Sir Howard was clear that he wanted to see BMA membership particularly involved on a local level to ensure that plans were deliverable.

The early days of Devo Manc were somewhat marred by a lack of consultation among general practice within Greater Manchester before the announcement of the devolution deal.

Dr Vell, one of the initial critics of the failure to engage GPs in the process, is now an LMC representative on the devolution partnership board.


Paving the way

Sitting on the Q&A panel, she noted that the arrival of devolution had been swift and that there had been ‘differences’ in how the news had been received by the various levels of health provision within Greater Manchester, notably general practice.

Dr Vell said that both sectors now had a clear voice within the devolution process, and would contribute towards stabilising the foundations of future devolution.

She said: ‘We now have, as Sir Howard says, engagement with primary care and with general practice, [where we are] able to bring a voice of the workforce into that and into the work as we develop it.

‘I really think the future can be whatever we would like it to be — because we are going first with devolution … There are going to be some difficulties along the way … We’re going to need to communicate with each other and keep in touch as a profession.

‘We’ve got a chance for some integration to be GP-led instead of secondary care-led, and we have a chance to integrate with a voice in the integration process which is not just a commissioning voice but a voice of the workforce.’


Recruitment and retention

Another concern raised during the discussion was the issue around workforce numbers — in terms of retaining existing staff and, crucially, how an integrated system would seek to recruit more desperately needed doctors.

Dr Vautrey said that, in his view, the key to this was making opportunities for training integral to general practice from day one, and for ensuring that devolution did not undermine individual doctors’ confidence in their rights and protections. 

He said: ‘If you build on the foundation of the national contract and ensure you are genuinely building on that, not undermining it, you’ll attract more people into the area [of general practice]. 

‘People will have the confidence … and the certainty they have over the GMS contract, for instance, is going to be secure in Greater Manchester, just as it might be in west Yorkshire or in London.’ 

He said that ensuring that integration between urgent and routine care services did not lead to an overstretching of services was a crucial consideration for planners.

He said: ‘We have a 24/7 urgent care service in general practice right across the UK — you have it in this area as well, but you’re already focusing on routine seven-day services.

‘You have to ensure that that is sustainable; it isn’t just people working harder to be able to deliver that for a political target. 

‘It has to be integrated with an urgent care service so that you don’t undermine one service by producing a parallel service somewhere else. 

‘If you don’t, GPs vote with their feet — they will move elsewhere and they won’t come to Greater Manchester.’


Alphabet soup

Mr Williamson said that addressing the ‘alphabet-soup’ nature of current service provision was part of the solution to the problem of attracting and retaining younger doctors to the area.

He added: ‘If you want to be seen in hours or out of hours, you can choose between a GP or a walk-in centre or the emergency care department … Frankly, that is a situation that we have to do something about. 

‘We have to be designing services and jobs that allow them [younger doctors] to work more flexibly on a part-time basis, where relevant, as well as full-time where people want to. 

'We have to think about [that] as we design our services.’

The financial sustainability plan for devolution in Greater Manchester has now been submitted, while the final strategic plan for the new health system will be published by the end of 2015.


Pioneering role

Dr Chand said that with a number of regions such as Cornwall and Birmingham now exploring plans to integrate healthcare, Manchester had been privileged to be selected as a pioneer. 

Echoing the concerns of the BMA, however, he warned that the region also had a responsibility to get things right.

He said: ‘Devo Manc could be seen as a triumph for local democracy; championing the needs of total healthcare as defined by the WHO, or as the creation of yet another false dawn, I hope it is not a false dawn.’

While the details of a new MHS have yet to be fully finalised, the concept of regional devolution has already spread across the UK while the Cities and Local Government Devolution Bill continues its march through Parliament.

For many, however, Devo Manc will one day be immortalised as the pioneering region for devolved healthcare, and all the risks and opportunities that that entails.

‘The decisions which are taken now in London,’ Sir Howard told his audience, ‘[will in future] be taken in Greater Manchester, by Greater Manchester, and that strikes me as being an important consideration.’


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