Devolution, governance and equity in health and health care systems
The article below co-authored by Fuse Senior Investigator Professor David Hunter considers the implications of devolution on health policy in England.
This is one of a series of blogs aiming to promote discussion around a stream of work coordinated by the British Academy (BA) on the theme: 'Governing England: English Institutions and Identity in a Changing UK'. Here we consider the implications of more or less devolved models of governance for the organization and provision of health services and health policy in the UK. This work seeks to highlight the wider problem of how important parts of the public sector, with national as well as local objectives and responsibilities, might be affected by future changes in governance resulting in increased devolution.
The health sector covers a broad range of services which cover mental as well as physical health. One important part of its mission is to prevent illness and promote good health, as well as treating illness. This has been repeatedly emphasised in health policy documents, including the report by Derek Wanless in 2004 on Securing Good Health for the Whole Nation, and more recently in the NHS 'Five Year Forward View' with its Triple Aim focus: improved population health, patient-centred care, effective resource use.
Thus, one role of the National Health Service is providing medical care for those who are ill, through services in hospitals, clinics, GP surgeries and home care in the community. Since the inception of the National Health Service there has been a commitment in the UK to equity of provision, making most medical services free at the point of consumption to all those who need them, regardless of their ability to pay, and funding health services through national taxation rather than through individual insurance. However, the health system extends beyond medical treatment. A growing number of people (especially in the older age groups) have chronic and complex care needs, requiring combinations of medical and social support.
We are concerned here with the wider public health function of the state, not only the care of those who are ill. The health sector includes policy and practice intended to promote good health in the population and prevent people from becoming ill. Thus the 'health sector' involves action beyond health care for individuals, aiming to make our physical and social environment healthier, and involves partners in many sectors, such as housing, transport, environmental, employment, education and social inclusion. Reflected in the 'Triple Aims' cited above, is an additional responsibility of the state health sector to ensure that it makes effective use of the available resources by using resources in the most cost-effective ways.
Most medical health service functions have, historically, been operated through non-elected agencies; at the national level, NHS England has allocated NHS funds to agencies with responsibility for ensuring effective provision of the health services needed at the local level. (Most recently this has been the role of local 'Clinical Commissioning Groups' (CCGs) led by health care specialists, especially general practitioners, overseen centrally by NHS England.) These bodies use commissioning to shape the clinical services so that they improve health and prevent disease, as well as prolonging life, through provision of hospital care and community based services (GP surgeries, clinics and home care). These agencies have also been implementing Sustainability and Transformation Plans (STPs) currently being rolled out through the CCGs.
On the other hand, social service departments, which are situated administratively within elected local government authorities, have responsibility at local level for provision of social care services, and these have been funded through a combination of local taxation and subsidy from central funding (though various forms of 'rate support grants').
Historically (since 1974), Public Health was the responsibility of local Public Health Departments, sitting within the NHS administrative system. However, with the introduction of Health and Wellbeing Boards across England in 2013, responsibility for local Public Health planning and policy has become more integrated with local government. Nevertheless, parts of the public health function are still exercised centrally through Public Health England (PHE), an Executive Agency of the Department of Health. PHE also still operates regional teams to guide and support the local public health system (located within local authorities). The role of regional PHE teams[1] includes regional oversight and leadership of local public health policy and practice. For example, these regional bodies are responsible for:
Managing strategic discussions with partners (within and beyond the health care sector);
Giving professional support and leadership to the public health system;
Ensuring consistently high-quality services that address local needs and priorities and contribute to improving local health;
Ensuring the region has a national emergency planning, resilience and response strategy.
The House of Commons Health Committee report in 2015 on Public Health post 2013 raised questions about how effectively PHE is able to execute these roles. The public health function also needs to engage with a range of partners in different local government departments (such as housing and urban planning, transport, environmental quality and hygiene, economic development, education) and several these agencies relate directly to other central government agencies, not to the NHS or the Department of Health.
We see therefore that the health sector, considered broadly, is very complex, involving networks of different agencies operating at different geographical scales. Some health-related functions at local level are already the responsibility of elected local authorities, while others, particularly medical services, are managed through non-elected local agencies. Local agencies involved in different aspects of the wider health system in England also relate to a range of different government bodies operating at the national level.
It is therefore interesting to consider how alternative models of devolved governance in England relate to systems as complex and wide ranging as the health sector. Further consideration can then be given to the potential implications if more democratically devolved systems of governance, controlled through locally elected bodies, were introduced for the health system as a whole, across the country.
Discussion of devolution and public health seems timely since several changes have been made recently (or are proposed) which involve changes to the way that the health service is governed and managed in different parts of England. Below we summarise some key points about these changes, which are tending to give locally elected government bodies more influence over the ways that health systems operate at local levels. We suggest that these changes raise questions about how much autonomy and variability in health care provision may arise due to changes in national, regional and local governance structures.
Our blog draws in particular on discussions at the roundtable debate organized by the British Academy on 'Devolution in the North East of England', that was held in November 2016. A fundamental question considered was whether it would be possible to agree a model for devolution that can work in areas of England such as the North East and how the regional boundaries for devolved government would be drawn up. Another blog in this series exploresthe feasibility of devolution in the North East, given its complex physical/ socio-economic-political geography, including several urban centres and many settlements in rural areas.
Many of the communities in the North East of England have strong local identities. This issue of identity has caused questions to be raised as to the feasibility of the creation of a single coordinated health system for the whole of the North East, including policy and operation of services down to local level.
On the other hand, we do have past experience of regional management of several health functions, albeit for more extensive areas covering the whole of the North of England. For some aspects of health policy and practice we had more than 2 decades of experience (until the system was changed in 1996) of Regional Health Authorities with oversight of service provision across the North, covering Cleveland, County Durham, Northumberland, Tyne and Wear and also Cumbria, and some NHS functions continued to be regionally coordinated through three Strategic Health Authorities respectively responsible for the North West, North East and Yorkshire and Humberside until 2013. PHE also has a Regional Office for the North of England which covers not only the North East, but also Yorkshire and Humberside and the North West.
Furthermore, arguably, there is recent evidence of willingness to co-operate across boundaries to advance some shared objectives, including promotion of public health in the North East (for example work led by the Centre for Public Policy and Health at Durham University culminated in a workshop with Chairs/Members of Health and Wellbeing Boards in April 2016, which identified transport, economy and housing as 3 priority issues for joint work.
What are the potential implications of devolution for funding and equality of access?
New models of local governance and management of the health sector continue to emerge. In some cases, these involve greater autonomy for locally elected agencies to make key decisions about the ways that health services are provided.
To date the implementation of this kind of model in England has been limited to the Greater Manchester region, where a new administrative system has been put in place which gives local government greater autonomy over both health and social care provision. In 2014, Greater Manchester Combined Authority (GMCA) (a regional, elected government body responsible for this large urban agglomeration), agreed an innovative devolution settlement with central government. From April 2016 the entire health and social care system in Greater Manchester, including adult, primary and social care, mental health and community services and public health was devolved to local government, controlled by locally elected Councillors. This innovative arrangement is referred to colloquially as 'DevoManc'.
Recent announcements in June 2017 indicate plans in other parts of England for the creation of a new Accountable Care System (ACS) involving locally devolved powers and responsibilities for both health and social care. According to earlier assessments by Shortell and colleagues at the Kings Fund, this model for health and social care in England shows some parallels with Accountable Care Organization models used in the United States.
On 15th June 2017, it was announced that an agreement has been signed by relevant national and local partners in the NHS and by Surrey county council for a more devolved and integrated system of health and social care to be put in place in the region of Surrey Heartlands. The government document 'Next Steps on the NHS Five Year Forward View' published in March 2017 also envisaged that in other parts of England, changes in governance will be introduced whereby (to quote p35-36 of this document) "NHS organizations…often in partnership with local authorities, choose to take on clear collective responsibility for resources and population health. They provide joined up, better coordinated care. In return they get far more control and freedom over the total operations of the health system in their area; and work closely with local government and other partners to keep people healthier for longer and out of hospital."[2]
Devolving some aspects of health service management has been justified partly as a way of encouraging greater coordination. More devolved methods of health service management should, in theory, encourage better coordination across different sectors to meet local needs more effectively, including more effective linkages between health and social care provision for clients with complex needs. Northumberland in the North East has been indicated as one of several areas where this kind of system may be put in place.
What might be the impact on health inequalities of this kind of devolution, if it were to be rolled out across the whole of England? We know that inequalities in health are interlocked with economic and social inequity. Various reports, including the 'Marmot Review of Fair Society, Healthy Lives' underline this point. Advocates of devolution argue that it could enhance democratic local decision-making about health care provision, help to 'join up' services for health and social care, and tailor services to local need.
Indeed there have been calls for more integrated service provision, at the level of the North East Region, that might facilitate better outcomes in terms of promoting good health and greater health equality. This has been discussed in detail, for example, in a report produced by a Commission led by Duncan Selbie.
However, local decision making may result in geographically variable provision of health services for people with similar needs, which may increase the problem of a 'post code lottery' in access to care across England. This has long been resisted in principle by advocates for equality of access to the NHS. Giving local managers greater discretion in how to use available resources could exacerbate the issue of lack of resources to promote health and wellbeing in poorer parts of the country.
One reason for concern about the risk of such growing inequality in health service provision is that some of the most deprived populations in England, with the worst health, live in major urban areas. In the past, NHS resources, coming from general taxation, have been distributed by central government and weighted for factors like socio-economic deprivation, which tend to lead to worse health and greater need for health care. Major urban regions, even those which are relatively successful economically, do not generate sufficient funds from local taxation and the local economy to meet all of their health care needs. Therefore, although responsibility for the management of health care services might be devolved more completely to regions, it is less clear how these devolved arrangements could be financially independent of central government and how devolved management may interact with centralised funding.
NHS budgets are being severely squeezed during the current period of austerity. Under a devolved health service system across England, run by local government in more independent regions, similar to the model taking root in Greater Manchester, questions might arise about how local decisions are made and about what to fund with public money. Would democratic processes ensure that decisions were made to ensure social equity in health service expenditure and provision for the needs of different groups in the population? Would the nature of devolution within England allow those regional areas with autonomy to abandon the use of commissioning as the only tool to develop and manage services, and go back to the direct management still practised in the other parts of the UK?
There may be alternative models of governance not currently on the table for consideration in England. The question must be posed as to whether any governance model exists that allows maximum flexibility on a 'subsidiarity principle', with decisions being made at as local a level as possible, but retains the potential to plan policy and services at a regional or national scale where appropriate. Would Federal principles provide helpful models? Germany, France, Sweden, Italy, Canada, and the USA all employ varying models of devolution and federalism. At the roundtable discussion organized by the British Academy in North East England, it was suggested that perhaps more could be learnt from these other countries, and indeed from Scotland, Wales and Northern Ireland, to help inform any future devolution to English regions involving services such as public health and health care.
Where should we go next with this debate?
Discussion of devolution quickly leads beyond governance arrangements. The questions raised here about how devolution might affect the health care system in England illustrate how discussion about governing England extends quite quickly into some more profound issues about social justice, the ways that representation and participation operate in democratic systems, and how government structures affect the lives of people in different social groups and in different parts of the country.
It is important to consider whether, by devolving responsibility for governance of certain key public services, such as health systems, to different parts of England, it will be possible to more effectively pursue goals for national equity and a standardised quality of healthcare and service access or provision.
There are also some important questions to be asked about how communities work to achieve shared goals and how the geographical and administrative structures in place can affect these ways of working either through enabling collaboration across services and geographical areas or by hindering such efforts.
We can learn a lot from 'on the ground' lived experience of those involved as service planners and providers, or as service users and their elected representatives, and the BA Governing England programme is drawing out some valuable lessons through discussion with these different groups. There is also considerable scope for academic researchers to contribute their knowledge and experience of these different governance systems in England or elsewhere, including familiarity with national and international debates about ways of approaching fundamental issues of governance and justice.
Our comments are based on our combined experience in academic research on health policy and practice and work within the public health sector, especially in the North East of England. Readers from other regions are very welcome to comment and add their thoughts on the issues we identify, regarding their own situations.
We hope that this blog, and the others published by the BA, will provoke responses from a wider audience that will help us to draw together knowledge and ideas to help inform future debate on these important questions relating to how best to govern England.
Professor Sarah Curtis, FBA, Professor Emeritus, Durham University
Dr Alyson Learmonth, Honorary Fellow, Centre for Public Policy and Health, Durham University
Professor David Hunter Professor of Health Policy and Management, Director, Centre for Public Policy and Health, Durham University
Professor Ray Hudson, FBA, Professor Emeritus, Durham University
[1] see https://www.gov.uk/guidance/contacts-phe-regions-and-local-centres for details
[2] https://www.england.nhs.uk/wp-co ntent/uploads/2017/03/NEXT-STEPS-ON-THE-...
Adapted with thanks to the British Academy