[Originally posted on Centre for London blog on 18 March 2015 – I realise I should have been cross-posting, not least to keep a record.]
Manchester (or rather the Greater Manchester Combined Authority, which will comprise the leaders of the ten Greater Manchester councils, plus a directly-elected mayor) is setting the standard. It will have devolved powers over transport, housing, policing and crime, skills, international promotion and – following a surprise announcement last month – NHS spending. The Chancellor’s budget added full retention of growth in business rates (other cities get 50 per cent). Other cities deals announced so far have been far more modest in scope, covering skills, specified infrastructure schemes, business support and some international promotion coordination.
And London is lagging too. The Chancellor’s speech alluded to announcements about devolved funding for skills, more planning powers and a London Land Commission, all of which were made last month when the Mayor and Chancellor launched their Long Term Economic Plan for London. But neither the Greater London Authority nor the boroughs have any control over London’s health service.
To be fair, taking on the NHS in London (which employs 200,000 people, more than the construction industry) could be seen as a poisoned chalice (eve a hospital pass), as institutions (most recently Barts Health NHS Trust) teeter on the brink of failure. But the failure to join up health and social care has become one of the NHS’ big problems, with old people whose care has been neglected ending up in A&E, and hospital beds occupied by patients who are ready for discharge, but can’t access social care services to enable them to leave. The short-term incentives are to dump costs between local government and the NHS, but both parties have an interest in tackling a problem that is leading to unnecessary suffering and huge wastes of money. This may mean some tough choices, but the past few years have certainly given London local government the experience it will need in taking tough choices.
So why can’t London look after its own health services? Other cities have been told that they can’t go ‘The Full Manc’ unless they accept a directly-elected Mayor rather the relying on a congress of council leaders (thereby opening a new front in the war of attrition over elected mayors that has been running for the best part of 20 years). But London has plenty of mayors: Boris Johnson as Mayor of (Greater) London, as well as mayors Bullock, Pipe and Wales of Lewisham, Hackney and Newham respectively.
Perhaps the two-tier local government system makes London too complex? London certainly is complicated, sometimes Byzantine, though the Greater London Authority and London councils are working quietly behind the scenes, including on a shared bid for further devolution. And in any case, the governance arrangements proposed for Manchester, which include a Greater Manchester Strategic Health and Social Care Partnership Board, and a Greater Manchester Joint Commissioning Board comprising NHS England, clinical commissioning groups and boroughs, are hardly straightforward.
Perhaps the real problem is one of government, not governance. Perhaps, as they look over the River at St Thomas’s Hospital, MPs consider that handing over the NHS in the capital to London’s elected leaders is a step too far, as is the case with the Met Police. Perhaps, as in Washington DC, some capital city services are seen as too important for local accountability.
This fear of letting go should not be determining public policy in London. But if it is, Londoners may start to wonder whether the presence of Parliament and Government is a boon to the capital, or a millstone.