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.
