Manchester lights the way

The devolution deal that placed about £6bn of health and social care funding in the hands of organisations based in Greater Manchester is often held up as the precursor – or even blueprint – for sustainability and transformation partnerships (STPs). But while it is clearly well advanced in some areas, it readily admits that some STPs are further forward in others.

It is perhaps a sign of the scale and scope of the work programme faced by STPs that change in Greater Manchester is only now beginning to bite – 18 months on from devolution. Finance is one area where progress has been made, buoyed by taking control of £6bn of annual funding. 

Speaking at the HFMA Chair, Non-executive Director and Lay Member forum in Manchester last month, Steve Wilson (pictured), executive lead, finance and investment Greater Manchester Health and Social Care Partnership, explained that the funding is an aggregate of all the region’s health and social care funding. 

He has been in the job just over a year and believes relationships between the sectors are stronger in Greater Manchester than elsewhere in the NHS. A key difference with other parts of the country is the availability of the £450m NHS transformation funding given to the region up front as part of the devolution deal. 

‘This has bound everybody in,’ Mr Wilson told the forum.  ‘It’s no more than our fair share of the total transformation funding, but it comes to us front loaded and entirely within our discretion, within reason. For example, Greater Manchester still has to meet constitutional standards and the objectives set out in the Five-year forward view.

‘We are in a privileged position and sometimes we forget that. The problem with having money is that it is never enough, but we have an opportunity that others don’t have and we need to make sure we take advantage of it.’

Mr Wilson said all applications for the transformation fund are assessed against strict criteria to demonstrate value for money, strategic fit and robustness. Each application is then independently reviewed by consultancy BDO to ensure the process has been applied correctly. The fund is also governed by a performance management framework, which includes an assessment of delivery against a range of health and social care outcomes.

Mr Wilson said the consolidation of the financial data across the organisations involved is one of the tests of delivery for the Greater Manchester Partnership. 

The partnership has developed an integrated place-based finance report that shows provider, commissioner and social care positions. These include provider cost improvement plans, CCG risks and local authority budgets, including use of reserves. Effectively, this operates as a shared control total for each of the 10 Greater Manchester localities, with delivery against this measured through the transformation fund investment agreement. It will form part of the quarterly monitoring of delivery of the investment agreement.

Accessing capital

Access to capital is a big issue for STPs, with some estimates claiming £9bn is needed across England. In Greater Manchester, the partnership is looking at different ways of accessing capital, particularly via local government, which can access prudential borrowing from the Public Works Loan Board. 

‘If we do it right, the local authority can secure a recurrent income stream from the NHS so they can invest without reducing their overall borrowing ability,’ Mr Wilson said. ‘This would often represent better value for money for the NHS and would be particularly appropriate for developing the integrated neighbourhood hubs that are critical to the delivery of the Greater Manchester strategy.’

The partnership wrote its sustainability and transformation plan a year before the other parts of the country and initially its funding gap was £2bn. Since then, however, the government has announced additional funding, extra money in the Better Care Fund, and the social care precept, which has reduced the gap to £1.2bn.

‘The significant area is the social care gap within that,’ Mr Wilson said. ‘The social care gap has been in every version of our strategic financial plan but we’ve not solved it. We have to integrate to deliver services better, but there is an unsolved financial issue.’

The strategic plan includes five themes, common to many STPs: 

• Focusing on population health
• Transforming community-based care and support
• Standardising acute hospital care
• Standardising clinical support and back office services
• Enabling better care.

Picking out two of these – transforming community-based care and support, and standardising acute hospital care – Mr Wilson explained that transformation was focused on 10 localities. These were based on local authority areas, with CCGs broadly coterminous with each council, and an additional ‘locality’ covering what can be done at Greater Manchester level.

To support the transformation of community care, support services and acute care, a commissioning review was completed, which led to the planned creation of 10 integrated health and social care commissioning functions. They will follow a population-based commissioning model.

Local care model

Some commissioning will be devolved to further organisations, known as local care organisations (LCOs), which are similar to accountable care organisations. Where it makes sense, the commissioning of high-volume services will be at the Greater Manchester level, either through a lead CCG or a single Greater Manchester commissioning hub. 

The LCOs will foster integrated health and social care provision and will include primary, community and social care, together with urgent care and some acute services. They could be in a number of forms – a single provider, a lead provider or an alliance. 

In the new model, payments by the strategic commissioning functions are likely to be based on a capitation basis rather than the payment by results tariffs. Population outcomes measures will be the key indicators and risk and gain share arrangements with providers. 

Local care organisations may then use a variety of incentives to drive the appropriate models of care within each locality – for example, incentivising self-care and early intervention.

Mr Wilson said the shift to LCOs meant close alignment with the Greater Manchester acute strategy was ‘crucially important’. ‘If the LCOs move care out of hospitals, for example, we need to understand, and where appropriate mitigate, the impact on stranded estate.’

Devolution was not just about driving economic growth, but also to drive the integration of public services to maximise the contribution they make and the value they deliver. Although Greater Manchester has a strong, growing economy, the area also has pockets of deep deprivation. 

Collaborative roots

To an extent, the agreement to devolve decisions about health and social care to Manchester was an acknowledgement of what was already happening in the city. The 10 local authorities had worked together for a number of years – on their joint ownership of the city’s airport and the establishment of the Greater Manchester Combined Authority, for example.

Greater Manchester is taking a place-based approach to the commissioning of services, which naturally leads to the integration of public sector services, Mr Wilson said. 

NHS England has defined a range of devolution, starting with: ‘a seat at the table’, which allows flexibilities within current legislation; co-commissioning; delegated commissioning arrangements; and finally the full transfer of the commissioning functions (such as in Scotland and Wales). 

‘The reality is that Greater Manchester is more delegation than devolution, but I don’t think that matters at this stage,’ said Mr Wilson. ‘It’s something that will evolve over the years. All the CCGs are co-commissioning primary care, for example, but CCGs across the country are allowed to do that.’

While acknowledging that some would call the partnership’s governance structure burdensome, he insisted it had been useful in bringing together what were originally 37 local authority and NHS organisations. 

The Greater Manchester Partnership works closely with NHS Improvement and a director sits on the partnership’s management team, Mr Wilson added, but the organisations are not fully integrated. The representative reports into the NHS Improvement management structure. Local integration between NHS Improvement and NHS England may be further forward in other parts of the country.

The Greater Manchester Health and Social Care Partnership may be different to STPs in several ways – the transformation fund being available up front, for example – but it has much in common with them, including the scale of the challenge.