Health investment and devolution: The Manchester model is not the answer for everyone

Public health is primarily a population health speciality. So I think it’s important to start with the question of what people want. Here in Wiltshire I know people want to see a joined-up system working for them in a seamless way. They want professionals to help and support them and aren’t so concerned with what organisation we belong too.

So how are we doing? The Wiltshire Better Care Plan has been a useful vehicle to improve health and social care for the frail elderly. We were very pleased to be told we had one of the top plans in the country. But top-down performance management can be too focused on process rather than outcome.

Reprioritising investment can be a real challenge, partly due to the bureaucracy of reporting systems and the sheer weight of trying to manage frontline services. So further devolution, as with Manchester, can be part of the answer – with public health playing a critical role in bringing prevention to the fore.

Devolution is compelling as it enables integration and shifts the focus from acute to primary and community care and, in turn, to prevention and population health. It allows the risks and rewards of investment to be shared locally. In Wiltshire, where we have good primary care, there is the opportunity for GPs to coordinate care at the neighbourhood level; and in time to move to commissioning on the basis of whole population health outcomes rather than a system which rewards increased contact.

Preventative activity should start at the beginning of life – so the impending transfer of commissioning responsibilities for 0-5yrs health from NHS England is welcome. However, devolution of other public health functions, such as screening and immunisation could be considered.

Simon Stevens, chief executive of NHS England, has the right approach and recognises that local authority leaders can be ambassadors for public health. We have embraced this in Wiltshire. Councillors have owned the principles of Joint Strategic Assessments which drive commissioning in the county. Wiltshire Council’s cabinet have received obesity, smoking and alcohol strategies – and commissioned sexual health services.

But there is still much to do. Using the 350 services provided through one council, and with strong resilient communities, the fundamental challenges of loneliness, dementia, mental health, housing and lifestyle also need prioritising.

I was pleased to hear the Manchester model was not going to be imposed across the country. What’s right for big cities will not work everywhere. The County Council Network have produced an excellent document which might be more relevant for areas like Wiltshire. We like to do things the Wiltshire way – which means doing the right thing for people living in a large county; supporting resilient communities and helping people to have a good quality of life.

Maggie Rae is corporate Director at Wiltshire. This article forms part of the Local Government Association white paper, “English Devolution: Local solutions for a successful nation” published 8 June, 2015.