Where next for health and social care devolution?

While the Spring Budget’s injection of £2 billion for social care over the next three years will be welcome, the reality is that it is not a substitute for the long-term solution to the huge pressures that services face.

PwC's research into the health and care system, Redrawing the health and social care architecture, shows that, in the long term, the balance of power needs to be shifted to local areas so that political accountability, financial responsibility and operational control are better aligned at the local level.

This was the topic of a recent roundtable we hosted together with CIPFA in our Birmingham offices, bringing together leaders from across health and local government to consider the experience of devolution in Greater Manchester and discuss where next for health and social care devolution.

The discussion highlighted a number of success factors that are critical to making health and care devolution a success, as well as the challenges that need to be overcome, with lessons for Sustainability and Transformation Plans (STPs) as well as places considering including health in their devolution plans.

Firstly, what stood out clearly was the importance of taking a place-based approach. Successful health and care devolution, or integration, depends on stakeholders placing less importance on their individual organisational interests and focus instead on their collaborative impact for people in their place.  And place doesn’t start and end at the city region: the Greater Manchester experience shows that micro-commissioning and neighbourhood approaches can also have their role to play in controlling demand and delivering a broader health and care strategy.  

However, central to taking a place-based approach is getting the geography right. While in Greater Manchester, the STP footprint follows that of the combined authority, this isn’t the case in the West Midlands or in many of the other STPs, providing challenges to health and local government aligning their efforts. Questions also remain about how financial incentives should be reshaped to support a place-based approach. These are just some aspects of a broader concern around the ‘faultline’ between health and social care that we heard strongly in our research on the health and care system architecture, where the lack of alignment in national structures, policies and funding leaves local areas struggling to paper over the cracks.

Secondly, the Greater Manchester experience highlights the importance of seeing health and care as part of the wider picture of productivity improvement and public services reform.  Given that the majority of health outcomes are determined by factors other than the care they receive, a more radical approach to population health is needed that also tackles issues of unemployment, poverty and housing, for example.  A broader approach will reap dividends: too many people are being kept out of productive work due to poor health, therefore improving health and social care services will have a wider economic impact, by contributing to economic growth as well reducing pressures on public services. In comparison, attendees reflected that, while they have a wide remit and ambitious plans, there is less evidence that STPs are addressing this broader public services reform agenda.  

A third critical success factor will be engaging the public in a meaningful way. A new deal is needed with the public, whereby the system is clear on what the public can expect and how they should use services, and citizens are empowered to take more personal responsibility for their health and wellbeing.  In Greater Manchester, public engagement is embedded in the plan, including over 6,000 meetings held to gain a greater understanding of the issues, more than 2.5 million social media engagements, and over 300 staff and community group meetings to date.  On the other hand, attendees reflected that STPs have been more introspective and in some cases lack the skills needed to deliver meaningful public engagement.

A further and related issue is that of accountability.  All health and care systems will need to address their lack of ownership for system governance.  Attendees spoke of the need to think about distributed leadership.  While even in Greater Manchester the mayor will not have formal responsibility for health and social care, it will be interesting to see what the elected mayors will bring to the table in terms of their softer powers in terms of convening and helping to build a sense of common purpose and vision.

Finally, there was recognition of the scale of transformation needed and the resulting pressures in terms of resource, workforce and culture.  Day to day pressures mean there isn’t always the time and space to invest in the organisational development needed to deliver transformation at scale. Cultural differences create barriers to joint working and attendees noted a continued animosity between health and local government leaders, in part driven by constitutional differences that are not always well understood.  Unlike the STP process, devolution has relied on local areas coming together and making the case for further powers, rather than organisations being forced to participate. In the long term, buy-in will be needed from all partners in order to make joint working successful.  

While there is no doubt that there is a challenging journey ahead for health and social care organisations, having a shared mission and sense of purpose will be critical regardless of whether they go down the devolution route. If there is anything to learn from the Greater Manchester experience it is that too many places are still waiting for permission rather than coming together, tackling public service reform and delivering better outcomes for their people and places.


Ali Breadon | Midlands Government and Public Sector Lead
Profile Email | +44(0)1509 60 4246

@alibreadonpwc | Linkedin Profile


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