Devolution: A New Prescription?

Is it time for a new prescription to put the NHS back on its feet?

The decision to abolish the world’s biggest quango, NHS England, should be so much more than just another Whitehall restructuring.  At first blush, collapsing NHS England into the Department of Health and Social Care rather looks like a massive step towards centralisation but dressed up as major reform. 

It seems slightly “off” that Whitehall takes over the very body that was meant to keep ministers out of the day-to-day grind of NHS commissioning, planning, and, crucially, blaming.  What’s the story and how will it end?   The Government has a real opportunity to take a political gambit here: kill the quango, shift the culture, and reset public expectations.

In Labour’s telling, this is about “mission government”: ending a decade of short-termism with long-term, measurable outcomes. For health, that means fewer lives lost to preventable disease, fewer missed diagnoses, fewer hours lost to the waiting list purgatory. It also means, if Labour is serious and wants to win a second term, devolving real power – and cash – to the regions. Reform (the think tank, not the party) argues for precisely this: devolve the NHS’s hulking budget to regional mayors via multi-year block grants. If Dorset has more pensioners and London more child asthma, let local leaders set the terms of care. That would require the courage of a Lion.  It would also require Whitehall to do the unthinkable: let go and devolve powers over health and care away from Westminster and Whitehall and towards those who want to tackle regional health and care inequalities.

Greater Manchester is often held up as the blueprint. In 2015, the city-region secured nominal control over a £6bn health and care budget. Arguably, despite its success,  real power has never quite changed hands. The experiment - which some suggested was about devolving the failings of the NHS in Greater Manchester - is proof that Andy Burnham’s prescription is a tonic for growth.    With improved population health – life expectancy went up relative to other areas - putting  health and wellbeing front and centre of Metro Mayoral ambitions seems to be working better for the people of Greater Manchester.  But decision-making has still flowed upwards to NHS England, not outwards to voters. Local leaders were made answerable to Whitehall targets, not local ballots. Perhaps it’s time for the Government to re-write the prescription in other Metro Mayoral areas?  One where it is clearly written, “more health devolution and less centralised bureaucracy - to be taken every day!”

It is clear that for many an over-centralised approach to delivering better health and care outcomes simply is not working . On the most bread-and-butter issue – health – people want radical reform. Polling shows that over 2/3 of the public are closer to the view that “the whole healthcare system needs to be radically changed”, and only a few people think that “a few tweaks” are sufficient.

Polling also shows that Reform UK voters are the most eager for radical reform. And yet Nigel Farage’s position, espoused over many years, on the merits of private healthcare will not be a medicine his target voters will stomach - or the country can afford.

When it comes to the nation’s health and care it makes sense to redraw the map and try to make sense of who is responsible, accountable and who holds the purse strings. Of course, the ‘national’ in the NHS remains central to the Government’s mission but perhaps devolved powers to deliver ambitions which match the health and care needs of local and regional economies and populations is the vehicle to deliver real change and a healthier and more prosperous future?

I have no doubt that the NHS is safe in Labour’s hands. Wes Streeting is cutting NHS waits bed-by-bed and already we are seeing some exciting progress.  But if Mission Control is held in Westminster and Whitehall we will have more managerialism and caution.  If the polls are right and the voters want to see radical change to the NHS and care about care then surely the Government should embrace health devolution as the means for delivering better health outcomes. Improving health and wellbeing and tackling health inequalities in all parts of England requires a more devolved and less centralised approach. If done right, you will see the democratic renewal the country so desperately needs; voters will thank you at the ballot box, feel more engaged, live healthier lives and be better off - not left behind.

Scrap NHS England, sure. But don’t stop there. Give our Metro Mayors the means and powers to deliver better health outcomes when and where they are needed.  Let voters feel, maybe for the first time in a generation, that health isn’t something done to them, but for them, and by people they actually recognise. In an age of populism, that just might just be the best prescription.

The power to do things differently

In the words of Bob Dylan, “the times they are a changing”. The Devolution White Paper may not sound like a best seller but it does warrant greater public attention and applause. It lays the foundations for full fat devolution and probably heralds the biggest change in how we are governed in a generation. Whilst the detail and the HOW? Is still hard to fathom, the prospect of completing the Devo Map in the North and a fully devolved England - with 30+ Metro Mayors and strategic authorities - is now in plain sight. If there is to be a devolution revolution there needs to be an agency which will inform and shape debate, one which understands what good devolution looks like,  what it means, what it’s for and why devolution is the agency of change. That’s us!

Gordon Brown's  UK Futures Commission (December 2022) New Britain presented a new vision for decentralisation, Lords reform and a radical devo shake up. The Devolution White Paper ticks a lot of Brown’s boxes on the need for public service reform and a devolution framework to devolve powers in all parts of England.  The Devolution Bill,  expected “before the Summer” has the potential to go further and faster to unlock growth and put money in people’s pockets. 

The Devolution White Paper does not focus as much as it might on the role devolution can play in building trust and democratic renewal or why devolving power away from Westminster and Whitehall is quite simply a good thing. Regardless, it could be the game changer that Rachel Reeves and the country needs.  

Without a doubt, not everyone will welcome plans for unitaries and strategic authorities or even like it but the devolution revolution IS happening and mustn’t be slowed, derailed or disrupted. Devo Agency is on a mission to generate understanding and advocacy for devolution in all parties and across all geographies. 

Labour in power is about mission led Government and the promise of change.  We believe good devolution holds the key to unlocking growth and delivering change to the left behind people and places in all parts of England. How we are governed and how a Labour Government chooses where and how to give away powers to the regions is why we are creating Devo Agency. To date the devolution journey has been bumpy, long and successive governments have failed to get to their devo destination. Landing it is the BIG challenge for this Labour Government who promises change but preaches fiscal caution.  

The  Devo Agency believes that devolution can be the agency of change and devolution must be embraced and integral to the delivery of Labour's Growth mission. More devolution can deliver the change the country needs and build Britain's future back.  The dividends, return on investment and social value will be high if the Government fully commits, lets go, gives away powers and supports local growth plans. 

Devolution is about recognising that all local and regional economies are different. By devolving more power and control to  local and regional leaders - who are best placed to come up with strategic plans for the areas they represent - the Labour Government can be recognised as an enabler to growth and realise the UK's full potential and maximise productivity.

There is a clear need for public service reform and to make better sense of who is responsible and accountable and for what. The future relationship between local, regional and national government - and where power lies and decisions are made in the context of the Devolution White Paper - begs many questions but the framework is broadly clear. A single settlement for devolved areas, greater powers and the potential fiscal devolution raise important questions about the future collective power of Metro Mayoral and Strategic Authorities and how they will be held to account centrally and democratically? Labour needs to have a plan for public service reform and a coherent framework which works in all parts of England - not just city regions - if they are to have  any hope of delivering the change it promised on 4th July.

It is clear that there needs to be greater devo literacy - and advocacy - amongst those who are elected at local and national level if Labour’s is to complete the Devo map without delay. Understanding or signposting what devolution means and what a Metro Mayor is for - is now essential.  We need greater clarity and advocacy and a new narrative which makes sense to - and is understood and supported by - the voting public. We have had proof of concept with some great Metro Mayors  - but this is time for a sea change.  To achieve change, boost growth and productivity requires a deeper and wider national debate about how devolution will work, fiscal devolution and future accountability and governance. How devolved regional economies with a bevy of powerful Labour Mayors  - in the North or the Midlands - actually work with a Labour Government is a huge opportunity but very much work in progress. 

Devo Agency will provide thought leadership and a forum to support, shape and inform the  national debate on devolution.