tag:theconversation.com,2011:/uk/topics/devo-manc-16895/articlesDevo Manc – The Conversation2016-02-25T17:33:27Ztag:theconversation.com,2011:article/470682016-02-25T17:33:27Z2016-02-25T17:33:27ZFrom Medieval kings to modern politics: the origins of England’s North-South divide<figure><img src="https://images.theconversation.com/files/94803/original/image-20150915-16968-yvqxnb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/stopherjones/9956052273/sizes/o/">stopherjones/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>The medieval world has a powerful hold over our modern imaginations. We continually revisit this murky period of history in fictional frolics such as Game of Thrones, and stirring series including The Last Kingdom. Echoes of the so-called “dark ages” even carry as far as today’s politics – particularly when it comes to <a href="http://www.bbc.co.uk/news/magazine-27731725">discussions about devolution</a>. </p>
<p>Indeed, as Westminster <a href="https://theconversation.com/the-northern-powerhouse-what-actually-is-it-50927">begins to relinquish political powers</a> to England’s newly-formed city regions, <a href="http://www.independent.co.uk/news/uk/home-news/campaigners-want-to-ditch-george-osbornes-yorkshire-devolution-plans-and-create-northern-powerhouse-10473615.html">some have claimed that</a> these territories should be defined by historical precedent, rather than <a href="http://www.citymetric.com/politics/devolution-meant-be-about-boring-practical-things-so-why-do-we-obsess-about-identity-1630">administrative practicalities</a>. </p>
<p>But how close are we to our medieval roots, and are our connections with the past really strong enough to influence modern-day decisions? To find out, we need to take a closer look at what’s left of the Celtic, Anglo-Saxon and Viking kingdoms of yore. </p>
<h2>Ancient Elmet</h2>
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<a href="https://images.theconversation.com/files/109812/original/image-20160201-32251-1mkv6n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/109812/original/image-20160201-32251-1mkv6n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/109812/original/image-20160201-32251-1mkv6n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=485&fit=crop&dpr=1 600w, https://images.theconversation.com/files/109812/original/image-20160201-32251-1mkv6n1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=485&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/109812/original/image-20160201-32251-1mkv6n1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=485&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/109812/original/image-20160201-32251-1mkv6n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=610&fit=crop&dpr=1 754w, https://images.theconversation.com/files/109812/original/image-20160201-32251-1mkv6n1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=610&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/109812/original/image-20160201-32251-1mkv6n1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=610&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The Leeds city region.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Leeds_City_Region.jpg">harkeytalk/Wikimedia commons</a></span>
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<p>Perhaps the most obvious links between past and present can be found simply by looking at the names of places on a map. Take, for example, the Leeds city region – one of the first regions to be <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/221012/Leeds-City-Region-Deal-Document-Final.pdf">granted new powers</a> over transport and skills development. </p>
<p>This region encompasses the villages, towns and cities between Harrogate in the north, Barnsley in the south, Bradford in the west and York in the east, with Leeds at its heart. But it’s not the first time Leeds has been the centre of a regional power base; it was also at the core of the early medieval kingdom of Elmet. </p>
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<a href="https://images.theconversation.com/files/94801/original/image-20150915-16993-mdw7lk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/94801/original/image-20150915-16993-mdw7lk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/94801/original/image-20150915-16993-mdw7lk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=718&fit=crop&dpr=1 600w, https://images.theconversation.com/files/94801/original/image-20150915-16993-mdw7lk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=718&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/94801/original/image-20150915-16993-mdw7lk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=718&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/94801/original/image-20150915-16993-mdw7lk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=902&fit=crop&dpr=1 754w, https://images.theconversation.com/files/94801/original/image-20150915-16993-mdw7lk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=902&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/94801/original/image-20150915-16993-mdw7lk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=902&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A map of the Old North, based on information from Celtic Culture by John Koch.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Elmet#/media/File:Yr.Hen.Ogledd.550.650.Koch.jpg">Notuncurious/Wikimedia commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>This shadowy kingdom was under the control of Celtic rulers, who spoke a language akin to Welsh. It was later <a href="http://www.thelatinlibrary.com/histbrit.html">conquered by Edwin, an Anglo-Saxon king,</a> in the 7th century and became part of his empire. Today, the kingdom is recalled in place names, and the parliamentary constituency of <a href="http://www.bbc.co.uk/news/politics/constituencies/E14000689">Elmet and Rothwell</a>.</p>
<p>Yet despite these geographical similarities, this connection is tenuous – the modern Leeds city region also encompasses parts of North Yorkshire that would not have been in Elmet. And it’s unlikely that administrators had the medieval kingdom in mind when they were drawing the boundaries. </p>
<h2>Pursuing the past</h2>
<p>To find a more convincing connection between modern politics and medieval monarchs, we need to go beyond mere borders and explore cultural, political and genetic links. For instance, the advocates of Yorkshire devolution <a href="https://yorkshiredevolution.co.uk/history-and-heritage-of-yorkshire.html">trace their heritage</a> back to medieval times – and even earlier. There’s certainly some evidence to support their longstanding connection with the region. </p>
<p>The <a href="http://www.nature.com/nature/journal/v519/n7543/full/nature14230.html">People of the British Isles project</a> analysed the DNA of more than 2,000 people whose grandparents came from the same rural areas. The resulting genetic groups have been compared with <a href="http://www.peopleofthebritishisles.org/nl6.pdf">7th-century kingdoms</a>, indicating some local stability in population over many centuries. What’s more, these ancestral links hold cultural and political force: a <a href="https://theconversation.com/cornwall-and-yorkshire-show-regional-identities-run-deep-in-england-too-41322">recent study</a> showed how much “Yorkshireness” is still a key element of the identity of those living in the county. </p>
<p>We can trace Yorkshire’s political identity back to the days of Edwin, a highly successful Anglo-Saxon king. Edwin belonged to the ruling dynasty of the Deirans, whose power base originally lay in eastern Yorkshire. Edwin expanded into the west of the county and overshadowed his northern Northumbrian neighbours, the Bernicians. He <a href="http://legacy.fordham.edu/halsall/basis/bede-book2.asp">also established looser control</a> over other parts of Britain. Not merely a warrior, Edwin was baptised in York and venerated as a saint. After his death, the Deirans lacked a strong champion. They were dominated by their northern neighbours and absorbed into a greater Northumbrian kingdom.</p>
<h2>The original Northern Powerhouse</h2>
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<img alt="" src="https://images.theconversation.com/files/112960/original/image-20160225-15179-1vtsnsk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/112960/original/image-20160225-15179-1vtsnsk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=741&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112960/original/image-20160225-15179-1vtsnsk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=741&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112960/original/image-20160225-15179-1vtsnsk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=741&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112960/original/image-20160225-15179-1vtsnsk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=931&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112960/original/image-20160225-15179-1vtsnsk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=931&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112960/original/image-20160225-15179-1vtsnsk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=931&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The Kingdom of Northumbria.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Kingdom_of_Northumbria_in_AD_802.jpg">Wikimedia Commons</a></span>
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<p>Bordered to the south by the River Humber, the Kingdom of Northumbria encompassed northern England and some parts of southern Scotland. Dating from the 7th century, it is said to be the first concrete instance of <a href="https://books.google.co.uk/books/about/The_North_south_Divide.html?id=LvbBAAAAIAAJ">the North-South divide</a>: the early medieval writer Bede described <a href="http://legacy.fordham.edu/halsall/basis/bede-book2.asp">separate spheres of Northumbrian and southern English politics</a>.</p>
<p>This northern Anglo-Saxon kingdom fragmented during the turbulence of the Viking Age. The core area was gradually incorporated into England, while the northern districts became part of Scotland. Nevertheless, Northumbrian identity evolved into a northern separatism that recurred in later times. This in turn generated a sense of northern cultural difference that is familiar today; “pies and prejudice”, <a href="https://www.waterstones.com/book/pies-and-prejudice/stuart-maconie/9780091910235">in Stuart Maconie’s words</a>.</p>
<p>But while large kingdoms were liable to disintegrate in turbulent times, local and regional networks have tended to remain relatively stable. They formed the building blocks of larger political units and some, like Yorkshire, went on to become modern-day counties. </p>
<p>A key question for modern politics is how the new devolution deals will complement these deeply-rooted identities. The case of Yorkshire highlights the tension between the new city regions, the old counties and an ancient northern identity. Medieval allegiances could be multi-layered, and encompass local, regional and national loyalties. The same balance is at stake in the <a href="https://www.routledge.com/products/9781472430793">modern devolution agenda</a>.</p><img src="https://counter.theconversation.com/content/47068/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fiona Edmonds does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Our expert joins the dots between the ancient kingdoms of yore and today’s Northern Powerhouse.Fiona Edmonds, Senior Lecturer in Anglo-Saxon, Norse, and Celtic, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/417822015-05-14T05:07:57Z2015-05-14T05:07:57ZFour critical NHS issues that could keep Jeremy Hunt awake at night<figure><img src="https://images.theconversation.com/files/81545/original/image-20150513-2452-1x84kcb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Is the NHS 'a wretched bowl of alphabetti spaghetti', as David Cameron put it?</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/jamarmstrong/5121476750/in/photolist-5aUv4W-8NyUBh-9SsEdC-8TJXdY-4GazBr">James</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The NHS has faced numerous struggles in its 66-year history, from the financial crisis of the late 1980s, which <a href="http://chpi.org.uk/wp-content/uploads/2014/02/At-what-cost-paying-the-price-for-the-market-in-the-English-NHS-by-Calum-Paton.pdf">prompted the Thatcher Review</a> and led to the introduction of the NHS internal market in 1991, to the more recent <a href="http://www.telegraph.co.uk/news/health/news/8550618/QandA-Andrew-Lansleys-NHS-reforms-explained.html">Lansley reforms</a> and the debacle of the 2012 Health and Social Care Act. </p>
<p>But surely none will compare with the challenges over the next five years. These include:</p>
<p><strong>1. More reconfiguration of services</strong></p>
<p>In a health system funded out of general taxation, it is important that politicians are held accountable to the public for the £115 billion NHS budget. Promises or pledges of up to £8 billion (equivalent to a funding increase of 1.1% a year) have been in response to <a href="http://www.bbc.co.uk/news/health-29726934">a £30 billion shortfall by 2020</a>, identified by NHS England in 2014. The “missing” £22 billion <a href="https://theconversation.com/radical-proposal-to-safeguard-the-nhs-fails-to-tackle-problem-of-productivity-33389">is supposed to come from productivity improvements</a> and cost savings. </p>
<p>To achieve this, significant reconfiguration of services will be required. Although the Conservatives promised not to introduce a “top-down re-organisation” in 2010, the Health and Social Care Act introduced two years later resulted in the biggest ever NHS reorganisation (costing about £3 billion), implemented at the same time as financial cuts (for example, 35% of management costs). </p>
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<p>The debacle of the 2012 act is salutary for all parties. But the absence of pledges of further reorganisation in 2015 may also be explained by other factors. First, staff <a href="http://www.telegraph.co.uk/news/health/news/9155178/NHS-staff-overworked-survey-finds.html">workloads have increased</a>, pay <a href="http://www.bbc.co.uk/news/uk-politics-26556047">has been constrained</a>, morale <a href="https://theconversation.com/nhs-guardians-wont-help-whistleblowers-unless-theyre-protected-from-bullying-too-37543">has declined</a>, and “reform fatigue” is endemic. The consequences of these and other factors are being felt in the <a href="https://theconversation.com/uk/topics/aande-crisis">A&E crisis</a>, <a href="https://theconversation.com/fact-check-are-aande-waiting-times-in-england-the-shortest-in-the-world-40774">longer waiting times</a>, and poorer patient experience. </p>
<p><strong>2. Further devolution of health budgets</strong></p>
<p>Developments on the ground have often been moving ahead of the political debate. For example, NHS England’s <a href="http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf">Five Year Forward View</a>, published in autumn 2014, presented new models for the future organisation of primary and secondary care services, which have been broadly accepted. Also, proposals to integrate health and social care in Manchester, announced rather hastily earlier this year, have prompted much debate elsewhere in the country. </p>
<p>It remains to be seen whether this <a href="https://theconversation.com/uk/topics/devo-manc">“Devo Manc”</a> model <a href="https://theconversation.com/devo-manc-can-it-make-the-nhs-a-success-38133">will work</a> and whether its governance model is robust. Whether or not it is feasible, further integration of health and social care is desirable, not least because cuts in social care <a href="https://theconversation.com/uncertainties-over-the-nhs-will-continue-amid-further-tory-cuts-to-local-government-41582">have knock-on consequences</a> in the health sector.</p>
<p><strong>3. Competition vs integration</strong></p>
<p>The use of competition and the private sector in NHS service provision has long been contentious. The latest model of NHS commissioning – the Clinical Commissioning Groups (CCGs), a product of the 2012 act – sought to put GPs in charge of the majority of the NHS budget on the assumption that they were best placed to know the needs of their patients. However, only a minority of GPs were involved in CCG decision-making, and this clinical engagement <a href="http://www.primarycaretoday.co.uk/commissioning/gps-lack-engagement-threatens-ccg-continuity">seems to be waning</a>. With challenging decisions ahead, the weak public accountability of CCGs may become exposed. </p>
<p>However privatisation is defined, the involvement of the private sector in delivering health services <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9281493&fulltextType=RA&fileId=S0047279414000269">has increased in recent years</a>, and the potential for further incursions in the future remains. The Labour Party and others have expressed their opposition to further growth of the private sector in the NHS, although <a href="https://www.opendemocracy.net/ournhs/kailash-chand/moment-of-honesty-is-required-new-labour-began-dismantling-of-our-nhs">its record in office</a> from 1997 to 2010 did foster private companies. </p>
<p>Significantly, the public seem <a href="http://www.health.org.uk/public/cms/75/76/313/5503/Public%20attitudes%20to%20the%20NHS.pdf?realName=ivdT6t.pdf">to be more relaxed</a> about private providers delivering health services, as long as services remain free at the point of delivery. Given markets’ propensity for fragmentation, it will be challenging to continue with competition while also promoting integration. Also, it is significant that alternative organisational forms (such as social enterprises or mutuals) <a href="http://www.mhpc.com/health/shot-by-both-sides-social-enterprises-and-mutuals-in-the-nhs-and-social-care/">have been largely absent</a> from the current debate. </p>
<p><strong>4. Public and health inequality</strong></p>
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<span class="caption">What’s local government got to do with it?</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/fabiovenni/429164528/">Fabio Venni</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>Focus of debate on health services has largely overshadowed discussion about public health and health inequalities. Although the previous coalition government adopted a voluntary system of regulation – so-called <a href="https://responsibilitydeal.dh.gov.uk/">Responsibility Deals</a> – between the government and the food and drink industry, they did transfer public health functions <a href="http://www.kingsfund.org.uk/projects/verdict/has-government-delivered-new-era-public-health">from the NHS to local government</a>. This means that the end of ring-fenced public health funds in local authorities in 2016 will present a challenge to keep public health on the agenda in the face of cutbacks elsewhere in local government.</p>
<h2>Promises now made</h2>
<p>The impact of these challenges on public expectations of the NHS remains uncertain. Despite current <a href="https://theconversation.com/public-satisfaction-with-nhs-at-second-highest-level-in-30-years-but-are-we-really-happier-36859">high levels of public satisfaction</a> with the NHS, how will the public react to politicians’ pledges of extra funding if services do not appear to improve in the coming years? Individuals’ own experiences of the NHS have traditionally been positive despite being concerned about the overall system. With such a challenging environment from now until 2020 (and beyond), will the public still subscribe to the notion of a publicly funded health service by the next election? Possibly – but it’s not guaranteed.</p>
<p>So, the NHS will face unprecedented challenges over the next five years. And it is certain that Jeremy Hunt, who keeps his brief as secretary of state for health, will have a full agenda.</p><img src="https://counter.theconversation.com/content/41782/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Exworthy has previously received funding from the Department of Health, Joseph Rowntree Foundation, and the Commonwealth Fund of New York
</span></em></p>The paradox of competition and integration other key challenges facing the re-appointed health secretary.Mark Exworthy, Professor of Health Policy and Management, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/416432015-05-12T13:33:39Z2015-05-12T13:33:39ZIs Devo Manc a good model for English devolution? Almost …<figure><img src="https://images.theconversation.com/files/81386/original/image-20150512-22563-19fly38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sprawling powers. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/dnisbet/3294546589/sizes/l">dnisbet/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>A metropolitan area formed in 1974 covering about 500 square miles; a population of more than 2.5m; an economy bigger than Wales or Northern Ireland – that’s Greater Manchester. Last year, Chancellor George Osborne <a href="http://www.legislation.gov.uk/ukpga/1985/51/contents">unveiled proposals</a> for a package of powers to be devolved to the Greater Manchester Combined Authority. The deal – which has come to be known as “Devo Manc” – represents the most significant package of powers to be devolved to a city-region in England. </p>
<p>It includes control over more than £1 billion of public expenditure and new powers over areas including housing, planning, welfare to work programmes, and local transport. And in February this year, <a href="http://www.bbc.co.uk/news/health-31661416">it was announced</a> that around £1.5 billion currently spent by NHS England would be transferred to <a href="http://www.publicfinance.co.uk/2015/03/what-devo-manc-could-mean-for-health-social-care-and-wellbeing-in-greater-manchester">a new Greater Manchester health body</a>.</p>
<p>Devo Manc has emerged because of a coincidence of interests. Manchester’s leaders have long sought greater autonomy from Whitehall. Osborne, meanwhile, was motivated by a combination of political economy and party politics. The chancellor had become convinced by <a href="http://www.citygrowthcommission.com/publications/">leading economists, think tanks, and advisers</a> that considerable economic potential could be unleashed through the devolution of powers to England’s cities and city regions. In addition, <a href="http://www.bbc.co.uk/news/events/vote2014/england-council-election-results">the fortunes of the Conservative party</a> in the north of England troubled Osborne deeply, especially after the May 2014 council elections.</p>
<p>The chancellor has driven this agreement through Whitehall, often at odds with his cabinet colleagues. The hard negotiations were conducted in Whitehall over the summer of 2014, with the Scottish referendum acting as a catalyst. Manchester’s leaders were surprised at the extensive package of powers offered. It is a reminder that, for devolution to be delivered, leadership is a vital ingredient.</p>
<h2>Why Manchester?</h2>
<p>Greater Manchester was always going to be the guinea pig. Following Thatcher’s <a href="http://www.legislation.gov.uk/ukpga/1985/51/contents">Local Government Act 1985</a>, which abolished the metropolitan county councils, the governance of Greater Manchester was fragmented across ten authorities. But those authorities continued to cooperate and coordinate with each other, <a href="https://theconversation.com/ed-balls-pledges-30-billion-to-english-regions-and-thats-not-all-37138">establishing various institutions</a> and creating dependencies. This proven capacity to cooperate over time is another crucial component of Devo Manc.</p>
<p>In 2011, the area was awarded city region status by the UK government. At the same time, the Greater Manchester Combined Authority (GMCA) – an umbrella body, which coordinates policy and governance across the ten authorities in the area – was formed. These factors all contributed to making Greater Manchester the leading candidate for any experiment with city-region devolution. </p>
<p>And between Osborne’s political desire to make the Conservatives credible in the north, the broader political discussions about breaking London control, and the impact of the Scottish referendum on debates about governing England, 2014 served as the critical juncture, which allowed rapid progress to be made.</p>
<h2>Unanswered questions</h2>
<p>Local political leaders in the ten authorities understand the weight of responsibility they now carry, seeing themselves as trailblazers for a new form of governance, which they are confident they can deliver. They understand that if Devo Manc fails to work as planned, it could scupper similar deals. While the package of powers to be devolved is sensible and has been crafted with the issue of scale in mind, there remain unanswered questions of governance and public engagement.</p>
<p>As part of the deal, Osborne has insisted on a directly elected mayor for Greater Manchester. Despite local political opposition, there will be a mayor from 2017 (with an <a href="http://www.bbc.co.uk/news/uk-england-manchester-32332399">interim mayor</a> to be appointed very shortly). That individual will chair the GMCA, serving as the 11th member, alongside the ten authority leaders. Part of my research involved speaking to local leaders in Manchester, and they will tell you the mayor will be controlled, and far from a dominant, centralising executive position. Each of the ten authorities will hold a veto over strategic planning issues, and the mayor can be outvoted by two-thirds of the ten leaders, who collectively will form the mayor’s cabinet.</p>
<p>But there remains a lot to work out. Given that the mayor will take over the powers currently held by the Police and Crime Commissioner, that various agencies and public bodies may be brought under the framework of a mayor’s office, and that the mayor will have responsibility for a broad set of policy areas, it is easy to see how a strong, centralising structure could emerge. It is also unclear how the leaders of the authorities will be held accountable in their role as the mayor’s cabinet, with no GMCA-wide scrutiny body.</p>
<p>Public engagement and involvement – or rather, the lack of it – is another major concern. Local leaders are aware that they have not done enough to engage local citizens about the plans. They argue that once an interim mayor is in place and the powers begin to be transferred, they can sell the changes to the public. But, if we are truly interested in reinvigorating local governance and participatory democracy, that is putting things the wrong way around.</p>
<p>Overall, Devo Manc is a positive development in the governance of the UK. A sensible package of powers is being devolved to a group of individuals who have proven themselves capable of working together. It has firm political support in Whitehall and Osborne himself is supplying Whitehall leadership. However, serious questions about governance and transparency remain. Only once they are solved can we genuinely say whether Devo Manc represents a good model for breaking Whitehall’s control.</p><img src="https://counter.theconversation.com/content/41643/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Kenealy receives funding from the Economic and Social Research Council.</span></em></p>An unprecedented package of powers has been welcomed by Manchester authorities, while the public is left wondering.Daniel Kenealy, Lecturer in Social Policy, Deputy Director at the Academy of Government, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/413752015-05-06T17:23:54Z2015-05-06T17:23:54ZDevo Manc: a shrewd political move that keeps Treasury control without the responsibility<figure><img src="https://images.theconversation.com/files/80681/original/image-20150506-10922-1r98h3i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">So it works like this...</span> <span class="attribution"><span class="source">altogetherfool/Flickr</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Signed by the chancellor, George Osborne, and the leaders of the Greater Manchester Combined Authority (GMCA), the latest twist in the Devo Manc agenda was the unique agreement that purported to grant residents “more control over the decisions that affect their lives”. Yet closer inspection suggests a more nuanced picture. </p>
<p>The agreement provides for <a href="http://www.bbc.co.uk/news/uk-england-manchester-31615218">the devolution of the region’s £6 billion NHS budget</a> to provide health and social care services. Alongside this budgetary devolution is the creation of a new board, bringing together NHS England, 12 clinical commissioning groups (formerly the primary care trusts), 15 NHS providers and the ten constituent local authorities of GMCA. Its main function is to distribute funding and take decisions over personnel, estates, information sharing, regulation and the commissioning of clinical services. </p>
<p>The media reaction has been one of <a href="http://www.manchestereveningnews.co.uk/news/health/devolution-now-greater-manchester-gets-8712970">surprise</a>, given the scale and scope of the devolved budget and the responsibilities. Yet should we really see this as a surprising event? It should really be viewed as part of a broader trend in public sector governance – the decision is consistent with the dominance of depoliticised governing strategies and more opaque accountability. </p>
<h2>Depoliticisation</h2>
<p>What do we mean by depoliticisation here? In essence, depoliticisation can be seen as a governing strategy that seeks to externalise accountability for particular spheres of governance. The aim is to promote an image of competence in government in the hope of bolstering electability. And responsibility for public service delivery is decentralised with the aim of shifting accountability to the local level – either local politicians or bureaucrats. Blame for policy failure – if such strategies are successful – is displaced from central government.</p>
<p>Such approaches to governing are not unique, but appear consistently under both Conservative and Labour neo-liberal governments. Previous examples include New Public Management (centralising policy-making yet decentralising delivery), value for money regulatory regimes and, more recently, the localism agenda. </p>
<p>However, while such strategies are often portrayed as pushing “power to the people”, in reality central government retains significant arms-length control. This can be problematic in terms of accountability, as the responsibility for service delivery is decentralised without true autonomy being realised. The true scope of central control is shrouded from view. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/80682/original/image-20150506-10922-10worzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/80682/original/image-20150506-10922-10worzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/80682/original/image-20150506-10922-10worzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/80682/original/image-20150506-10922-10worzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/80682/original/image-20150506-10922-10worzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/80682/original/image-20150506-10922-10worzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/80682/original/image-20150506-10922-10worzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Arms-length.</span>
<span class="attribution"><span class="source">Building by Shutterstock</span></span>
</figcaption>
</figure>
<h2>Retained control</h2>
<p>The devolution of health budgets to Manchester is a case in point. In line with the government’s fiscal consolidation agenda, the GMCA will be subject to spending reviews as and when the Treasury deems necessary. <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/369858/Greater_Manchester_Agreement_i.pdf">The agreement</a> between the Treasury and GMCA makes this point clear: “In the context of the wider fiscal-consolidation agenda, the City Region will be required to take a fair share of any reductions that are made to any of the devolved funding streams”. But this is not all.</p>
<p>Central government retains significant control beyond simply the purse strings. In a <a href="http://www.agma.gov.uk/cms_media/files/mou.pdf">memorandum of understanding</a> between the GMCA and NHS England it is clear that government has the ultimate say over the strategic direction of the NHS in Manchester. Any significant additions to the estate need to be agreed nationally and GMCA possesses little wiggle room to deviate from centrally-prescribed governance arrangements. This all seems out of kilter with Osborne’s rhetoric of local autonomy.</p>
<p>This undeniably would be seen as a positive move for Treasury officials, who seek to retain overall control over NHS budgets while seeking to absolve – at least in part – the Department of Health from service delivery. It is often suggested that governments decentralise at times of fiscal restraint, spreading the blame for falling standards in public services. It remains to be seen whether this strategy for the management of NHS resources is sufficiently successful to become the norm. </p>
<h2>Who gets the blame?</h2>
<p>The most interesting question to arise from this development concerns accountability and specifically, where the public see that it lies under these new arrangements? Who will be deemed at fault if failures arise? With this in mind, it is perhaps wise – at present at least – to treat this deal with caution. The NHS holds a unique position in the minds of the British electorate and remains a political hot potato. For this reason, for all the government’s rhetoric the likelihood of true local autonomy remains remote. </p>
<p>The success of these governing strategies must ultimately be judged by where voters direct their discontentment (if required, of course). It is more likely that voters will punish central government than the GMCA if things go wrong. Ultimately, in the longer term the application of such strategies to the NHS may well fail. After all, it is unlikely voters will separate this emotive policy area from the purview of central government. GMCA is the guinea pig, and we will learn much about the potential for a future roll out in coming years.</p><img src="https://counter.theconversation.com/content/41375/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The devolution of NHS budget to Manchester is part of a broader trend that allows central government enough control but without much of the responsibility for delivery or failure.Sam Warner, Doctoral Researcher in Political Science, University of BirminghamMax Lempriere, Ph.D. Researcher in Political Science, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/412602015-05-06T05:21:07Z2015-05-06T05:21:07ZThe quiet local revolution reshaping the NHS<figure><img src="https://images.theconversation.com/files/80414/original/image-20150505-8434-z6av3j.jpg?ixlib=rb-1.1.0&rect=8%2C749%2C5491%2C3507&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Clue: not London. </span> <span class="attribution"><span class="source">Manchester by Shutterstock</span></span></figcaption></figure><p>In the closing days of the election campaign, the political parties continue to slug it out over who is going to save or wreck the NHS. They seem to have forgotten the quiet revolution getting underway in the north-west of England which could prove decisive in determining the NHS’s fate. </p>
<p>Trapped in traditional command-and-control mode, the secretary of state for health is pulling levers in Whitehall hoping, often in vain, that they are attached to something. But the politicians fighting the election this week seem to have forgotten the historic event which took place earlier this year.</p>
<p>Following the Greater Manchester Health and Social Care Devolution Memorandum of Understanding, <a href="http://bit.ly/1IIYxoT">published in April</a>, the focus of much health policy is destined to shift from London to the English regions. Make no mistake, what is happening in the north-west will quickly be followed after the election by similar demands in the north-east, Yorkshire and Humberside, the south-west and other regions. The regions <a href="http://www.theguardian.com/society/2015/mar/25/super-council-north-east-durham-simon-henig">are already</a> queuing up.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/80420/original/image-20150505-10581-p3pfki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/80420/original/image-20150505-10581-p3pfki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/80420/original/image-20150505-10581-p3pfki.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/80420/original/image-20150505-10581-p3pfki.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/80420/original/image-20150505-10581-p3pfki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/80420/original/image-20150505-10581-p3pfki.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/80420/original/image-20150505-10581-p3pfki.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The regions will be queuing up.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/luiscdiaz/330340600/in/photolist-vc5KA-pPh5H-7HHHCa-XP4Qt-7hLVq7-7GdEQq-hNGJ65-9ywJev-7vXv6S-nPf5ar-93ysED-4MpKK9-fLBHyT-9xMCJe-7bmxL7-5V9pju-eYLWiH-hNGTwh-7hLVbL-7BXky4-9DpTpt-5wJc3H-4LCh5p-4CfdAj-8d1uPH-iCwy8-8yj8xW-onWrVy-2VUyZL-5T8V4m-5T4yKR-cSx6XS-7BYwFa-qgmjqB-4VcKUf-49aiWe-7gTVqP-9Gemj-8GfXLX-62TQFF-e3QYcj-59ic7u-o1uTde-8GfYK8-5xVRYa-cnNYRm-cjsZ2m-amUnXK-aLSnCF-8XJsVU">-</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Devo Manc</h2>
<p>From April 2016, <a href="https://theconversation.com/devomanc-can-it-make-the-nhs-a-success-38133">around £6 billion will be devolved</a> to the Greater Manchester Strategic Health and Social Care Partnership, covering a population of 2.8m people. And, for the first time since the NHS was created, local government will be in charge and lead the transformational changes in the way future services are delivered. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/80415/original/image-20150505-8411-1yplsod.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/80415/original/image-20150505-8411-1yplsod.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=817&fit=crop&dpr=1 600w, https://images.theconversation.com/files/80415/original/image-20150505-8411-1yplsod.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=817&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/80415/original/image-20150505-8411-1yplsod.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=817&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/80415/original/image-20150505-8411-1yplsod.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1027&fit=crop&dpr=1 754w, https://images.theconversation.com/files/80415/original/image-20150505-8411-1yplsod.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1027&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/80415/original/image-20150505-8411-1yplsod.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1027&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Aneurin Bevan foresaw local government responsibility.</span>
<span class="attribution"><a class="source" href="http://commons.wikimedia.org/wiki/File:Aneurin_Bevan_and_his_wife_Jenny_Lee_in_Corwen_(15368872658).jpg">National Library of Wales</a></span>
</figcaption>
</figure>
<p>The handover of power is not so outlandish. Aneurin Bevan, founder of the NHS, foresaw that one day local government would take over responsibility for the NHS. Those wishing to see a return to the original pre-Lansley NHS model are unlikely to have their hopes realised. </p>
<p>But is it really as bad as <a href="http://www.theguardian.com/healthcare-network/2015/mar/24/devo-manc-five-early-lessons-for-the-nhs">many of them fear</a>?. Rather like the SNP being considered by those on the left as the only hope for bringing about an end to <a href="http://www.lrb.co.uk/v37/n04/simon-wren-lewis/the-austerity-con">deeply flawed and unnecessary austerity</a> – which they see as ideologically driven <a href="http://www.independent.co.uk/voices/comment/mr-osbornes-economic-experiment-william-keegans-new-book-10007905.html">as an excuse to shrink the state</a> – local government may be the saviour of a health system urgently in need of a makeover to render it fit for the 21st century. Who knows, it may make a better job of running the NHS than Whitehall has – for the most part, anyway. </p>
<h2>Reasserting local government</h2>
<p>The UK, and certainly England, remains the most centralised country in Europe. Perhaps this would matter less if competence in government was assured, but as <a href="http://www.theguardian.com/books/2013/sep/04/blunders-government-king-crewe-review">King and Crewe’s masterly book</a> detailing the blunders of successive government concludes, such systemic failure needs fixing. A rejuvenated local government offers hope for fixing our broken political system from the bottom up. </p>
<p>Critics of Devo Manc, many of them apparently hankering after some mythical golden age, fear that <a href="http://wrp.org.uk/news/10788">it is a fast track</a> to outsourcing and privatising services. But it might also be a way of ensuring that such a fate does not befall the NHS. It may seem counter-intuitive in the midst of the coalition government’s full-frontal assault on local government but precisely for that reason, the time is surely right to reassert the important role local government has in charting a progressive future. </p>
<p>Focusing democratic renewal on local government creates possibilities for participatory decision-making inconceivable at a national level. A combination of elected members and social movements developing policy, tackling inequalities and opening up local decision-making to scrutiny and challenge is possible and examples can be drawn from <a href="http://www.policypress.co.uk/display.asp?K=9781447308904&sf1=keyword&st1=ines+newman&m=2&dc=4">the contemporary context</a> in which local government operates. One example is the <a href="http://www.nechildpoverty.org.uk/">North East Child Poverty Commission</a>. Through lobbying, influencing and campaigning to raise awareness and build public support for giving children in the north-east equal life chances.</p>
<p>Democratic renewal may be a bold vision for local government when it is on its knees but its survival demands nothing less. A sense of renewed purpose is sorely and urgently needed. The Devo Manc experiment may be exactly what is needed to break the mould, rescue both local government from the central assault and the NHS from a similar fate, and restore faith in the public realm. </p>
<p>On a more practical level, and echoing the whole area approach to public services, known as <a href="http://webarchive.nationalarchives.gov.uk/20130129110402/http:/www.hm-treasury.gov.uk/d/total_place_report.pdf">the total place pilots</a>, which were supported by New Labour towards the end of its term of office, Devo Manc holds out the real prospect for joined up, place-based policy-making that has so far proved so elusive. </p>
<p>Devo Manc’s objectives go to the heart of what a renewal of health policy demands: a focus on prevention, public health and promoting well-being; closing the health inequalities gap both within Greater Manchester and between the region and the rest of the UK; integrating health and social care and creating healthy communities that are also economically productive ones. </p>
<p>Of course there are risks. Elected members will in some cases be seduced by neo-liberal ideas concerning the alleged superiority of markets, despite the evidence <a href="http://chpi.org.uk/wp-content/uploads/2013/07/David-Hunter-to-market-to-market.pdf">suggesting otherwise</a> in areas of public policy such as health. But it will be up to local communities to decide whether that is what they want and act accordingly. As Bevan said about the NHS at its birth in 1948: it “will last as long as there are folk left with the faith to fight for it”. Without that faith the NHS will not long survive under any form of governance. </p>
<p>If Devo Manc is to be an early implementer and a test bed for new thinking in health systems that reflects the needs of local populations, then that is surely to be welcomed.</p><img src="https://counter.theconversation.com/content/41260/count.gif" alt="The Conversation" width="1" height="1" />
<h4 class="border">Disclosure</h4><p class="fine-print"><em><span>David Hunter's article does not reflect the views of the NIHR or the Department of Health's policy research programme</span></em></p>DevoManc will see £6 billion devolved to Greater Manchester for the NHS, andDavid Hunter, Director and Professor in the Centre for Public Policy and Health, Durham UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/381332015-02-27T13:57:22Z2015-02-27T13:57:22ZDevo Manc: can it make the NHS a success?<figure><img src="https://images.theconversation.com/files/73218/original/image-20150226-1758-1h1i3ln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Manchester takes a leap.</span> <span class="attribution"><span class="source">Manchester by Shutterstock</span></span></figcaption></figure><p>Greater Manchester is in line to be the first English region <a href="http://www.bbc.co.uk/news/uk-england-manchester-31615218">to gain full control</a> of its NHS budget, which will be managed by local councils and health groups from April 2016. Under the plan, health and social care are to be better integrated, theoretically easing pressure on hospitals and improving home care services.</p>
<p>What is proposed for Manchester is consistent with what many commentators <a href="https://theconversation.com/distinction-between-sick-frail-and-disabled-has-to-go-15735">have been arguing</a>: if we are to respond to the healthcare needs of our communities, health and social care have to be integrated so that care is holistic, makes the best possible use of resources and ensures that the right care is given in the right place. </p>
<p>The idea is that the best people to plan care are those closest to the patients – local professionals familiar with the local context. With one service, the needs of (for example) older people with a chronic illness, can be met in the community by social and health carers, rather than them being detained in hospitals unnecessarily.</p>
<p>But this revolution, devolving the £6 billion health budget to the local authority, is a big risk as well as being a big opportunity. It could mean much better care at less cost for the people of Manchester or it could mean worse care with all the additional costs of reorganisation. </p>
<h2>Creating a new culture</h2>
<p>What will make the difference is whether the leaders of the initiative – the councils and health groups – recognise that success depends on the culture of the care organisation they create. They have to ensure they create a clear vision for the organisation and everyone involved in it: a relentless determination to deliver high quality, continually improving and compassionate care to the people of Manchester. </p>
<p>That vision should be simple enough to put everyone on one page so everyone in the organisation understands, shares and works consistently with the same values and priorities. And every team, department, directorate and individual in the organisation has to have a small number of clear objectives (no more than five or six) aligned to that vision.</p>
<p>Staff will need to be managed in an effective and enlightened way – it is an indictment of the existing system that nurses <a href="http://www.hse.gov.uk/statistics/causdis/stress/stress.pdf">are the second most stressed group</a> in the UK working population. That means leaders being supportive, positive, enabling, listening and participative – involving staff in decision making, sharing information and ensuring they are engaging with staff effectively. It means ensuring good management is put in place in the form of helpful appraisals, good training and employee engagement – and that these factors are continually improving throughout the organisation. </p>
<p>A commitment to continual improvement, learning and innovation is vital. Everyone should have, as key objectives, improving the quality of what they do and developing new and improved ways of delivering patient/service user care. </p>
<p>It means (within sensible limits) seeing errors as opportunities for learning and resisting the creeping poison <a href="https://theconversation.com/nhs-guardians-wont-help-whistleblowers-unless-theyre-protected-from-bullying-too-37543">of blame cultures</a> that have damaged the NHS so much.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/73219/original/image-20150226-1780-nrde8x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/73219/original/image-20150226-1780-nrde8x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/73219/original/image-20150226-1780-nrde8x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/73219/original/image-20150226-1780-nrde8x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/73219/original/image-20150226-1780-nrde8x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/73219/original/image-20150226-1780-nrde8x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/73219/original/image-20150226-1780-nrde8x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Manchester will have to do things very differently.</span>
<span class="attribution"><span class="source">Learning by Shutterstock</span></span>
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</figure>
<h2>Moving away from command and control</h2>
<p>The new organisation must be built around effective team working, both within teams and with others. Team work <a href="http://www.dh.gov.uk/health/2011/08/nhs-staff-management/">is a key predictor</a> of patient mortality in the NHS and teams and directorates working across boundaries in a co-operative and supportive way will be fundamental the success of this organisation. Every team should have improving the effectiveness with which they work with other parts of the organisation as one of its five or six annual objectives, to ensure the delivery of high quality care.</p>
<p>The organisation must embody collective leadership. Leaders have to listen to and empower frontline staff and move away from the dysfunctional and punitive command and control approaches that have plagued both NHS and local authority organisations. </p>
<p>Fundamental, too, will be the extent to which leaders co-operate with each other across the system and make overall care of the people of Manchester <a href="https://theconversation.com/balance-your-books-then-cover-your-ass-why-nursing-leadership-needs-to-change-35626">their priority</a>, not just their individual or immediate team’s success.</p>
<p>National bodies overseeing the provision of care in Manchester must play their part too, supporting, appreciating and enabling – particularly in the early days of this bold venture. If they are too quick to interfere, too focused on intrusive inspection and too intolerant of innovation, it will create a toxic and low innovation culture. Exactly the opposite of what is needed. </p>
<p>If any of these elements are absent, the Manchester devolution revolution is likely to be a failure with real costs to the health and well-being of the people of Manchester. With them all in place, the Manchester model could become a solution to many of the problems of the National Health Service that confront the country as a whole.</p><img src="https://counter.theconversation.com/content/38133/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael West receives funding from ESRC, Department of Health,
He works for AstonOD and The King's Fund</span></em></p>The United Kingdom’s second city will finally take control of its own health, but it’s a risky venture.Michael West, Senior Fellow, The King’s Fund and Professor of Organisational Psychology, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.