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Look north

24 April 2015

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All eyes are on Greater Manchester following the devolution of funds for health and social care. What does it mean for practices?

Manchester is a great example of a place that can handle change. When the industrial revolution took hold of what was once a town, turning it into a bustling city with surrounding areas booming as well, it subsequently thrived beyond anybody’s expectations.

The same is hoped for Greater Manchester as it takes control of the combined health and social care budget of £6 billion in the historic deal that is, to use the vernacular, Devo Manc.

The new management of the billion pound budget was agreed by NHS England after a memorandum was finalised and signed by the chancellor, George Osborne and the secretary of state for health, Jeremy Hunt.

The historic agreement came after Greater Manchester’s 12 clinical commissioning groups (CCGs), 15 NHS providers, 10 local authorities and NHS England worked together to develop a business plan for the integration of health and social care across Greater Manchester. They will jointly decide on integrated care to support physical, mental and social wellbeing for its population.

The approved memorandum of understanding will give local people the right to make decisions regarding the health of the local population in primary care settings, therefore, it is hoped to ease the pressure of A&E resources.

The changes came into effect on 1 April with the full devolution being brought into place by April 2016.

The devolution follows the NHS’s Five Year Forward View that argues “for a more engaged relationship with patients, carers and citizens so that we can promote well-being and prevent ill-health”.

Simon Stevens, chief executive of NHS England, said: “[The] landmark agreement between NHS England, the local NHS and local government leaders charts a path to the greatest integration and devolution of care funding since the creation of the NHS in 1948.

“… Greater Manchester now has a unique opportunity for innovation and improvement in health and wellbeing. The eyes of the country will now be on what this new partnership can deliver.”

The delivery
The devolution to Greater Manchester has received a mixed reception. While most see its benefits some fear the unknown. Colin Tate, practice director of the Range Medical Centre, Manchester city, raises concerns about the problems that may be encountered when in practice. He says: “I’ve obviously got some concerns over how financially it will stack up.

“But I’m looking forward to the budget being managed locally because we are not going to have national pressure on us. It means we can look at the needs of Greater Manchester and will apply the funds accordingly.

“I’m sceptical about the governance behind the project rather than the actual principle of it.”

The concerns are understandable, but considering the health of people in Greater Manchester is generally worse than the average in England it is a step that many feel will help its population.

At this stage it is unclear as to how the change will unfold and the delivery is a key element of the devolution. Dr Ranjit Gill, chief clinical officer of NHS Stockport CCG, believes the new system will “turn the model of care upside down”.

He says: “NHS care as an organisation has been around the needs of hospitals and the care and services they provide first, so we have had to bend the needs of the patients to the needs of the system.

“What we are going to do to change that is build a new model of care based on the needs of the patients built from prevention, proactive predictive care and then integrating tightly with primary care, community, mental health and social care.”

One of the aims of the devolution has always been to interact with the people of Greater Manchester on a closer level. “We want to work with the public to find the latest ways of preventing ill health and treating conditions much earlier on,” said Gill.

The general feeling among the profession is that it is a positive step for the NHS and patients.

The outcomes in Greater Manchester will be closely watched by other local authorities, CCGs and councils in England. Nadim Fazlani, chair of Liverpool CCG, says: “I don’t have a crystal ball to see what the memorandum of understanding is going to be like in practice, but I think the principal that we are moving away from a very centrally controlled NHS to an NHS where standards are set nationally but then allocated locally, where we have far more say on how we spend it, makes sense for our populations.”

Fazlani continues: “I don’t think anybody is advocating depending on where you live you get a different form or standard of health care.
“I think there should be a balance between what should be nationally determined and what should be locally determined. And this is a conversation that we needed to have with or without the devolution.”

A united front?
The response from NHS England and Greater Manchester is that it is very much a move that will see Greater Manchester’s CCGs, local authorities and NHS providers unite.

Currently across Manchester there is a project called One Team that involves the pulling together of secondary and primary care services to create a ‘one team solution’ to manage a patient. Although Tate raises concerns over the devolution, he feels it may have a positive effect on this.

Mike Dixon, chairman of the NHS Alliance and a GP at College Surgery in Cullompton, Devon, is intrigued by the devolution. He says: “In terms of the concept I think it’s actually quite a good idea. In terms of its execution I absolutely feel that this needs to be a coming together of equals with local GPs (as providers) and also the local GPs (as commissioners) having an equal place at the table, and if that’s not so then it’s not satisfactory.” This is where some concerns have been raised.

Some frontline workers feel they were not consulted on the devolution and are uncertain about the change.

Tate says: “We never had the opportunity to get involved in the consultation and we wanted to.

“I think it’s a feeling among many practices. From our practice’s perspective, if we had been consulted, we would have asked about the clarity on the governance on how this is going to work.” And with a total of 527 general practices across Greater Manchester, according to NHS Choices in April 2015, there are many who could have been involved. (Technically they were involved as they are members of CCGs.)

Many feel it is too early to make any similar moves elsewhere in England until results start to appear.

And there is a sense of hesitation from some who feel there is a chance that Greater Manchester will not be able to deliver.

Tate says: “I wonder whether we’ll have the skills in the locality to make it work quickly.”

There’s no way of seeing into the future, but based on how Manchester has handled its evolution in the past, it is perhaps a model that many others will adopt.