Now syndicated on the Socialist Health Association blog

This week’s big news in Manchester is that the devolution of direct responsibility for significant areas public spending to the city-region will now be augmented by the devolution of the entire NHS budget for the city region with a view to integrating this with social care.

You can now see more of the detail about the deal (interesting term that) on the AGMA website.
I have already written, separately, in the last weeks on both the DevoManc model and on the integration of health and social care. The first piece, for Steady State Manchester argued that the model is flawed on two counts: it continues the city-region’s headlong pursuit of economic growth within the context of competition within the globalised economy, which we see as incompatible with ecological safety and with economic and social justice with its fetishisation of skills as supply-side ‘solution’ to economic stagnation, and its trickle-down economic model.  The second piece, for the Socialist Health Association, based on my experience over 30 years of working at the interface of health and social care, and managing combined services, cautioned against optimistic technical fixes for reducing dependency and cutting costs.  Instead, I argued, integration has to start from a clear ethical mandate to address the problems of persistent and structural disadvantage that characterise the lived realities of people that have to rely on social care and who have associated health problems.  Furthermore it noted the risks of combining budgets under conditions of austerity and financial pressure: the raiding of one area of provision to prop up another.
Neither of these pieces suggested that the overall aims of devolving power and integrating arbitrarily separate care systems is wrong in itself.  But we should be very concerned about the plans as they stand for the following reasons.
1. The indecent haste with which they are being agreed, together with
2. The secrecy of the deal, negotiated between the Tory Chancellor of the Exchequer and Manchester’s politician-bureaucrats.  I’ve covered this in the previous piece on DevoManc so won’t repeat that here, other than to note that the NHS has a severe democratic deficit which will not be healed by this fix – as Lisa Nandy points out in a very good New Statesman article.
3. The context of extreme cuts to social care budgets in the region, following an almost inexorable trend to privatise and casualise provision.
It seems that the health and social care elements will remain distinct, organisationally and financially (although for how long?).  This makes a certain amount of sense (I previously noted the value of aligning but not pooling finances) in that it will make it harder for out and out raiding of budgets and “burden shifting” leading to a generalised race to the bottom.  So I think some of the more alarmist claims that have been made about the end of the NHS are misplaced – that’s happening anyway.
But the lopsided UK care system is going to be a very difficult thing to make work seamlessly and effectively, and tinkering with the interface between the health and social parts is a dangerous game under austerity.
4. The economic rationalism that underpins the whole DevoManc deal,together with the potential for more frenetic ‘deal-making’ with private health care and health technology companies. The Memorandum of Understanding on the Health and Social Care Devolution/Integration (MOU) explicitly cites the promotion of ‘growth’ and the opportunities with the that sector among the benefits:-

• To contribute to growth and to connect people to growth, e.g. supporting employment and early years services; and
•  To forge a partnership between the NHS, social care, universities and science and knowledge industries for the benefit of the population.

5. The shaky governance arrangements with power over the City Region being concentrated in the hands of a mayor who will dominate,  not a counter-balancing elected assembly, but a group of council leaders.  Meanwhile the NHS and social care will continue to be run by technocratic managers, the more senior of whom will cook up further schemes for cost-cutting and service reductions – which people who have to rely on social care have already seen plenty of under this government’s austerity-scam regime.  These schemes will continue to engage in fantasy about the quasi-magical reduction of dependency, along with the usual rhetoric about evidence-based policy and practice.
6. The lack of any very clear value-base – so different from the founding statements of the NHS, where a vision of meeting human need and liberation from want trumped narrow economic considerations.
Here is what the FAQ on the scheme offers for “why do it”:

GM has some of the worst health outcomes in the country and we want it to have thebest. People tell us all the time that the NHS and social care should be more joined up and this provides an opportunity to do this. We are also trying to solve the problem of decisions that directly affect GM being taken outside of GM because it’s important that decisions are taken as close to the patient as possible.

and the MOU, rather repetitively, says it is:

To improve the health and wellbeing of all of the residents of Greater Manchester (GM) from early age to the elderly, recognising that this will only be achieved with a focus on prevention of ill health and the promotion of wellbeing. We want to move from having some of the worst health outcomes to having some of the best;

To close the health inequalities gap within GM and between GM and the rest of the UK faster;

To deliver effective integrated health and social care across GM;

To continue to redress the balance of care to move it closer to home where possible;

To strengthen the focus on wellbeing, including greater focus on prevention and public health.

OK, there are some worthy aspirations here, but there is no mention of the determinants of those inequalities, and hence little hint of the theory of action for redressing them. The contrast with Bevan’s social justice agenda is striking: the technocrats in suits have taken over.
So, despite having worked for most of my career at the interface of health and social care, and indeed because of that experience, I have a four-fold problem with this deal.

1) It is not radical enough. To fix the problems of health and social inequalities, and to renew the health and care system so it works seamlessly to support people when and where they need it requires a radical re-engineering of not just those systems, but also of the socieconomic context within which they sit.  As the New Economics Foundation has explained in a new and important report, those reforms amount to a New Social Settlement, a reinvention of the Welfare State for these times.

2) But under conditions of austerity, it is a dangerous recipe, since an underfunded and lopsided system will be prone to systemic crises where (only somewhat accountable) managers end up having to make unjustifiable choices over what to cut, however they dress it up as modernisation and efficiency.

3) The utter failure to consult on and to build in any public scrutiny and significant democratic oversight into these arrangements is just appalling, a testimony to the sham democracy that characterises both Westminster and local government in the corporate State called Britain.

4) Finally, this is fundamentally a neoliberal plot. It seeks to “lever” health and social need and provision to serve the city-region-boosterist accumulation model, and as such is parasitic on a fundamentally flawed and malign economic system that impairs the health and well-being of both the Manchester people, and the ecosystem we rely on.

Mark H Burton
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