Devolution: different paths, similar obstacles
Tue 29 Nov 2016
MiP Conference 2016: Devolution within the NHS increasingly allows countries and regions to go their own way. MiP brought together NHS leaders from Wales, Scotland and England to discuss the opportunities and threats from this trend.
Wales, with its population of three million, saw a major reconfiguration of its services in 2009. Andrew Goodall, the chief executive of NHS Wales, said the move had brought greater accountability and a very strong ethos of partnership working.
The small size of Wales – with just 10 chief executives – helped, he added. He was both chief executive of NHS Wales and a civil servant within the Welsh government with access to ministers and the first minister.
“At its best it gives us an opportunity to have action and momentum in place,” he said. But it could be difficult when organisations went head to head. “We joke in Wales that everyone does know each other!”
There was also a lot of public scrutiny which could translate into a very visible focus on managers’ actions, he added.
Wales restated the NHS’s values this summer with an emphasis effective partnership working. “That seems to have been very important but it does take time to consolidate these relationships.” He said he was very aware that health is determined by so much more than the NHS.
Moving forward, he was looking to focus on getting clinical staff to work “at the top of their licences” and spread quality improvement methodologies through organisations.
Malcolm Summers, head of staff governance at NHS Scotland, said Scotland had had an opportunity to tailor some approaches while also being part of a wider NHS system covering, for example, education and training.
“There has been a great recognition in Scotland that we cannot continue to do the same,” he said. Change would involve the majority of care being provided locally but with centres of excellence for complex care, he explained.
“There is a focus on safe staffing and putting that on a statutory basis,” he said. Scotland was producing a workforce vision which had been co-produced with staff – and working with trade unions in partnership was seen as the way ahead. Each of the health boards had an employee director and there was a focus on staff engagement.
“It is about recognising that we are all under pressure but there is a lot that we can do collectively,” he said. ‘We need to support and motivate our staff to do the best job they can.’
Finally, NHS Confederation chair and former health secretary Stephen Dorrell gave his perspective on the changes afoot in England. He suggested Greater Manchester council leader Sir Howard Bernstein was the person who had thought most about health devolution in the UK but said STPs should not be thought of as “doing” a Greater Manchester everywhere.
The Greater Manchester vision did not start with thinking about restructuring the NHS, said Dorrell. Its starting point was the need to build sustainable communities where people could live in decent housing and live meaningful and fulfilling lives.
But to play its part in that the NHS needed to “come down off the hill”, he said, and see itself as part of a patchwork of public services that are part of the experience of people living in these communities. Defending the NHS might be at the expense of some of these other services.
“If you look over the last decade health service spending in England is up 25% in real terms; social care is flat, but acute hospital spending is up 31%,” he said.
“The real challenge around developing a vision for public services is to take the rhetoric and challenge ourselves how we can make it real. Why is it that we still think there is something different between primary and community health services? If we can’t join those up, then we really are lost.”
Dorrell said that when he was chair of the Birmingham and Solihull STP he found that it was the first time some of the partners had met.
He urged a more holistic view of the impact of other public services on health: cutting library services, for example, could lead to some people feeling isolated and developing mental health problems with cost implications for the NHS.
And he suggested that local authorities needed to be more fully part of the accountability system for the health service.
Conference reporting by Alison Moore.