With the Cities and Local Government Devolution Bill currently passing through Parliament, the King's Fund are hosting an online event to examine what devolution means for health and social care in England.

Deals have already been signed in Cornwall, Greater Manchester and London - but is devolution a route to improved population health and greater integration of health and care services?

  • Richard Humphries Assistant Director, Policy, The King’s Fund
  • Nabihah Sachedina Devolution Lead, NHS England, London

RH: Welcomes participants.

The aims of the webinar are a history of devolution, what it means for health and social care. Then we will hear from Nabihan before opening it up to you.

We are very keen to hear what is going on in different parts of the country.

We are now holding a poll to find out where you stand on devolution. We will run it again before we finish.

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We are very keen to hear what is going on in different parts of the country.

Devolution has been a lively and, at times, controversial issues. In part because it is a flagship policy of the government. Devolution so far primarily has come out of the government’s economic development agenda.

The health and social care bit came on at a later stage.

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There is a lot of concern about the effect of devolved powers on the ‘N’ in the NHS – the national bit. So crucial amendments had to be made to the Cities and Local Government Devolution Bill.

It is a key and important bit of legislation. This is the national picture as we understand it:

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Hot off the press this week is that is now more detail about budgets and responsibilities in Greater Manchester. The purse strings are still firmly held by NHS England though.

Deals so far are more akin to delegation rather than devolution, with formal accountabilities remaining with existing NHS bodies.

Deasl so far could have been delivered within existing legislation.

Greater Manchester remains the test case. And there’s a big question about how much devo deals are dependent on upfront investment. Greater Manchester got £450m upfront to help the changes.

Outstanding Questions

  • Is goodwill and collaboration enough or is more required?
  • If it is a matter of delegation what is all the fuss about?
  • Will devolution lead to more local democratic involvement in health?
  • How will regulatory oversight work in devolved areas?
  • Is devolution a means to delivering financial sustainability?
  • Ultimately how different could devolved areas end up looking?

NS: I am from the health London partnership. I am delighted to be here today because I believe devolution can help secure improvements in health and wellbeing.

I want to canter through our journey so far and some of the factors that have helped us along the way.

I was reassured to hear if devolution is the solution what is the problem you are trying to solve.

We started with the basic premise that form should follow function – we are trying to start from assessing our challenges and whether devolution can be the enabler for transformation.

In London we have the quickest-growing population in England and it is a very transient population. We know our population has a significant poverty rate – 7% higher than the rest of the country.

But we also know our population has particular health challenges, including obesity, and operation challenges, including retaining a workforce.

Alongside that is the financial sustainability point. We know we need to do thing differently to achieve sustainability in the future.

Services need to be more patient-centered and focus more on integration.

The good news is we have started the journey and we have a strong foundation for the future.

London partners view devolution as a tool to support greater collaboration and integration.

Greater integration of health and care can help push services towards a more patient-focused approach.

In December two London agreements were signed. The London Health and Care Collaboration Agreement and The London Health Devolution Agreement.

In London we have a complex and large health and care system. It is appropriate we have multi-level action. It seemed appropriate to pilot different aspects of devolution at different levels.

The devolution pilots and programme are very much underway. Part of that involves setting up the governance and establishing the devolution programme.

What is key is to work with the pilots to establish what will support them as much as possible. There needs to be local solutions for local problems but you need to aggregate up where it is desirable.

What will enable success?

  • Focusing on enablers of transformation alongside strategy
  • Grounding activities in agreed objectives and principles
  • Shared ownership of challenges and opportunieis
  • Acknowledging and mitigating the challenges of different organisational cultures and priorities
  • Broad engagement and co-development

RH: Let’s see the results of the first poll - 64% (more than 200 people) are in the devo-don’t know category. But this is surprising more than 30% are devo-philes – they have a positive view. The devo-phobes who see it as a source of risk is a very tiny percentage.

We will do this poll again at the end to see if opinion has changed.

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Q: We have had a few comments on the role of the public. How can we engage the public more?

NS: We did a lot of public engagement in London, we engaged about 14,000 Londoners through road shows, polls and evidence hearing sessions. What is clear is if we are to bring around significant change there is an absolute obligation to ensure that is co-designed with the public.

There is a difference between a green light to explore and a green light to go ahead with changing governance.

RH: The NHS has seen all sorts of changes and I don’t think there has ever been a golden age of public engagement. But the deals were put together quickly and there is no doubt public engagement is a continuing gap.

Q: Will NHS devolution using different boundaries to local government devolution cause problems integrating health and social care?

RH: This is a big issue in London because the boundaries of local authorities differ from those of hospitals and patient flows.

NS: The approach that has been taken in London has been to develop multi-borough working arrangements from a health perspective. So CCGs have, for a number of years now, been working together in strategic planning groups.

There is a very interesting question about how local government interfaces with health footprints.

There needs to be discussions between boroughs and CCGs, in the pilot areas the two groups have come together and submitted proposals for their geography.

RH: I think a lot of devolution talks brings in questions that are a lot bigger than devolution. One of the fault lines is between NHS care free at the point of use and social care which is heading rapidly in the opposite direction.

Devolution will not erase those fault lines.

Q: Is devolution a solution to austerity?

NS: Is this a fix for austerity? You have to look realistically at challenges facing health and care systems and local economies but that leads you to realising we cannot carry on in the same way.

So if you view the healthcare demand and associated costs and wider impacts then it takes you to a place where you have to think about the system more holistically and you have to really consider the financial sustainability question for the entire system.

RH: There are two camps – on the one extreme you have pessimists and cynics who say devolution is a Trojan horse for cuts but at the other end of the spectrum people take a more positive view, thinking it is better to shape as many decisions as possible about local health services.

I don’t think there’s a denial about fiscal realities but a desire to take as many decisions as possible.

Q: What savings can be achieved when working with other sectors – what outcomes are achievable by cross-sector working?

NS: there are great examples in London and beyond where you have health integrated at the Job Centre Plus. You see health issues identified much earlier and connections made to the relevant support systems.

There are a lot of opportunities for greater collaboration. That is really the excitement devolution brings.

Poll Results

RH: We have got the poll results for the second poll. We have fewer don’t knows, down to 54%. We have slightly more devo-philes and slightly more devo-phobes.

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NS: I am not terribly surprised coming into this a number people are unsure about devolution because it is a word that gets bandied around a lot. This is the start of quite a journey and at the moment it is early to tell what the impact of devolution will be.

RH: I am probably a devo-don't know to be honest. I would like to thank everyone for taking part.