AS THE dust clears a week after George Osborne’s bombshell announcement that £6 billion in health and social care spending is to be “devolved” to the emerging Greater Manchester Combined Authority (GMCA), it is still unclear exactly what is being proposed.Early interpretations of the scheme have been discarded and revised in different accounts, leaving little in the way of unambiguous fact.
Is the NHS budget — and even major NHS and foundation trusts — to be handed over lock, stock and barrel to control by local government, or not? Is an elected mayor, who will not be elected until 2017, but replaced in the interim by an appointee, to have control, as some say, or not?
Will it become, as the enthusiasts of the Socialist Health Association claim, a new MHS — a Manchester Health Service, separate from the NHS and somehow belatedly sprouting some form of democratic accountability?
Or will it, as Manchester City Council leader Sir Richard Leese told Channel 4 News, remain part of the NHS? Will the new bodies controlling Greater Manchester’s health budget really be able to make changes in the terms and conditions of NHS staff — as the memorandum claimed? Or will national agreements remain?
For many the bizarre intervention of Osborne negotiating the shape of healthcare services in a single English region, and working with NHS England boss Simon Stevens to sideline his Tory colleague, Health Secretary Jeremy Hunt, was puzzling enough: the subsequent confusion and contradictory statements are even more baffling.
Of course Osborne is one of a rare breed of Tories who have managed to hang on to northern seats, and has been eagerly beavering away at constructing what he describes as a “northern powerhouse,” to be showered with government patronage.
The GMCA had already been given control of transport, housing and the skills budget — but the £6bn for health and social care is a much bigger prize, eagerly accepted by the eight Labour leaders and by leaders of the other two Greater Manchester councils as well as local clinical commissioning groups (CCGs), none of them troubling even to enquire as to the views of those they supposedly represent, still less the population of Greater Manchester.
While the local bigwigs, no doubt eyeing up positions of power that would by no means leave them out of pocket, were happy to ignore trivial questions like the views of their electorate, Osborne in turn seems to have gone beyond his legal powers in carving out such an attractive slice of budgetary cake.
The memorandum of understanding’s footnotes openly admit that “some of the areas described in the MoU go beyond the statutory powers of NHS England and CCGs, and are often commissioned nationally.”
An earlier footnote also admits: “There will need to be an agreement as to the precise scope and extent of the commissioning functions that can lawfully be delegated.”
But hey, why let a few legal questions and technicalities get in the way of a £6bn deal?
Cautionary notes sounded by shadow health secretary Andy Burnham — warning of the implications of a “two-tier health service,” and a “Swiss-cheese effect in the NHS whereby cities are opting out” — were brushed aside equally by careerist Labour councillors and many of his Manchester Labour MP colleagues. But it seems Burnham’s response was much closer to the popular view on the ground. This is not so much devolution as abdication of responsibility and passing the buck.
Burnham will also have spoken for many in other parts of England when he warned that no deal should be offered to one area of the NHS that could not work everywhere and also be offered to other areas. “If I was health secretary I would not be offering this deal,” he said.
Wigan Labour MP Lisa Nandy, writing in the New Statesman, has also warned strongly over the complete lack of a democratic base for the whirlwind changes being imposed top-downwards on the “city region.”
She writes: “Ministers have confirmed to me that no thought has yet been given to public scrutiny or involvement,” adding that the three-week consultation on the impact of the changes had only 12 responses — 10 of them from local authority leaders who brokered the deal in the first place.
“The consultation didn’t even mention the NHS once, let alone the transfer of responsibility and billions of pounds of NHS funding that was announced and signed by George Osborne today, just weeks ahead of the general election”.
Her view is shared by the Greater Manchester Association of Trades Union Councils, which is mounting a protest at the whole stitch-up. Both Unite and Unison in Manchester have up to now opposed a single elected mayor for fear whoever takes office would resort to wholesale privatisation and cuts in business tax.
The timing and the choice of Labour Manchester for the first experiment is clearly designed to wrong-foot Labour and boost Tory hopes.
Let’s not forget, either, that the new scheme unveiled by Osborne completely ignores the structures so controversially imposed with no mandate by his Tory colleague Andrew Lansley in the Health & Social Care Act.
Once again a major change is being imposed from the top downwards with no discussion whatever with local CCGs created by the Act or the GPs who were supposedly to be put “in charge.” Instead a number of CCG chairs have signed up, irrespective of the views of the GPs they supposedly represent.
Health and wellbeing boards, the council bodies set up under the Act which are supposed to link social care with public health and wider health services, were also ignored. They are not even mentioned until page 10 of the memorandum, which simply declares: “Local HWBs will agree strategies and priorities … within their districts and in the context of the GM wide strategy and local priorities.” Many localities will
certainly find their priorities overruled by the “GM wide” bodies that are really in charge.
The GMCA has effectively taken over the role of one of the strategic health authorities that were scrapped by Lansley’s Act, but it will also have control over social care budgets and quite possibly even less democratic accountability than the old SHAs, since it seems unlikely the high-powered decision-making will take place in open session or publish board papers. They will carry on as they began.
A new “Health and Social Care Devolution Programme Board” will be set up — with three bureaucrats from the GMCA, three from Greater Manchester’s CCGs, an undisclosed number from the 15 NHS and foundation trusts serving Greater Manchester and bureaucrats from NHS England and the Department of Health.
The programme, says the memorandum, “will need to be supported by full-time resources … this will include a full-time chief officer, a full-time finance director and such other staff as the parties agree.” The bureaucracy is already growing.
Where will the money come from to pay for all this? The MoU says: “A programme and resourcing plan will be agreed with all parties by March 13 2015” — just a fortnight after the scheme was announced! It’s anything but democratic.
Even if we disregard the high-handed and undemocratic fashion of its creation, there are serious problems with handing over billions of pounds of NHS funding to local government bodies that have been slashing spending on social care, and which have developed a culture of putting almost every service out to tender for the cheapest bid.
The social care administered by councils has already seen the privatisation of almost all home care and care homes. It always differed from the NHS not just because of who was in charge, but because unlike the NHS where healthcare has always been free of charge at point of use, funded from general taxation, social care has always been subject to means-tested charges — putting it increasingly beyond the reach of many who need it most.
More recently social care has been among the pioneers of giving service users “personal budgets,” rather than services, leaving them to fend for themselves and buy their own services in a harsh and cheerless market. They will increasingly find they need to top up inadequate budgets to fund the care they need.
If the NHS budget is to be controlled by cash-strapped local government, how long before barely adequate, frozen health budgets are siphoned off to prop up social care, or the values of means-tested charges for social care begin to erode the NHS principle of services free at point of use on the basis of clinical need?
And while the council chiefs rub their hands in glee at the £6bn to be handed into their control, they might ponder whether this sum is enough to do what needs doing and how long a devolved Greater Manchester could count on receiving the £22bn each year it gets from Westminster when its taxes to the Treasury add up to just £17bn. How long before the flow of funds is cut off, leaving Manchester to slash even more services — and carry the can?
Amid all the confusion two things are clear: the Manchester “devolution” is yet another major reorganisation of the NHS and, contrary to NHS England claims, requires legislation as well as a democratic mandate.
And it follows on Andrew Lansley’s hugely controversial “reforms” which have fragmented the NHS, and parcelled up a growing number of services for competitive tenders and privatisation. In that respect “devo Manc” is consistent with the previous reform it largely ignores.
A real answer to Osborne’s stitch-up is not to go back to the post-2012 status quo, but to reinstate the NHS as a public service, the way it was before 25 years of market-style “reforms.”
That means repeal and reversal of the Health & Social Care Act, and the development from the local level upwards of new health authorities to take charge.
- John Lister is co-author with Dr Jacky Davis and Dr David Wrigley of a new campaigners’ book NHS for Sale (Merlin £10.95), available from www.keepournhspublic.com.
Reblogged via: Morning Star
