TOTAL FOOTBALL is a style of play in which positions are fluid and the collective comes above the individual. Developed in the 1970s, its influence can be traced from the Netherlands to Barcelona to Manchester City, whose manager, Pep Guardiola, is a devotee of Johan Cruyff, the style’s most celebrated practitioner. Less well known is that it is also, according to Jon Rouse, the chief officer of the Greater Manchester Health and Social Care Partnership, the model for the city’s new health-care system. Just as players are given freedom to work things out on the pitch, so too are health and local-authority leaders in the conference room.
Three years ago Greater Manchester became the first region to gain control of its health spending. Mr Rouse’s organisation—which includes NHS institutions, councils and community groups—was set up and put in charge of the city’s £6bn ($8.6bn) health and social-care budget. Its role includes overseeing ten “local care organisations”, which in turn put together teams to look after areas of 30,000-50,000 people, identifying the most vulnerable and intervening early to prevent emergency admissions. Devolution of these powers created the chance for a big shift in how the health service operates.
Health leaders in Manchester believe they are taking the NHS back to its founding ideals, as set out by Aneurin Bevan, the Labour politician who established the health service in 1948. They argue that since then health care has been run according to the needs of doctors, not patients, and has come to rely on specialist intervention rather than prevention. Although talk of further devolution deals has gone quiet under Theresa May, the NHS has nevertheless followed Manchester’s lead. Its recent long-term plan announced that the country would be split into “integrated-care systems”, which will have similar aims, bringing local authorities and the NHS together to plan services.
Manchester should be a fruitful location for such an experiment. There is a long history of collaboration between local authorities, dating back to the city’s response to Margaret Thatcher’s dismantling of urban councils in the 1980s. A report in 2009 by a panel including Lord O’Neill, an economist and later a Treasury minister, argued that Manchester needed greater self-government to boost its economy. “It was a light-bulb moment for a lot of us,” says Steven Pleasant, head of Tameside council, on Greater Manchester’s eastern edge. George Osborne, chancellor from 2010 to 2016, put Manchester at the centre of his “northern powerhouse” regeneration initiative.
Combining health and social care has produced some successful tie-ups. From the basement of Dukinfield town hall in Tameside, a team of local-authority workers has long provided support to almost 4,000 elderly people, who can summon them at the touch of a button. Prior to devolution, the head of a local hospital didn’t know the service existed, says Mr Pleasant. But it has now teamed up with the NHS to beam clinicians in via Skype when tending to call-outs. Since the collaboration began, only 392 out of 3,143 responses to falls have required an ambulance or a trip to accident and emergency (A&E), when previously all would have, saving an estimated £1.5m.
Health Innovation Manchester, a research network, injects expertise into the system. At its office in the city centre, staff draw diagrams on specially painted walls to work out the details of more than 75 projects that aim to do such things as eradicate hepatitis C and reduce elderly falls. Its aim, says Ben Bridgewater, the chief executive, is to make the city the world leader in life sciences. Manchester has set up “teaching care-homes”, which play a similar role to teaching hospitals, and a city-wide stroke response system. It has also seen improvements in child development and lower rates of smoking during pregnancy.
Yet progress is far from uniform. A recent review by EY, a consultancy, criticised failures of governance that have left a new health centre with few tenants in Trafford. Mr Rouse says that of the ten local care organisations, three are where he would like them to be and four are developing quickly, leaving three unmentioned. Kieran Walshe, a professor of health policy at Manchester University, notes that it has been hard to get local authorities to share data, let alone to spend across borders, and that the central leadership has few formal powers to prod them to do so. Greater Manchester has also fallen behind the rest of the country against the headline A&E target since devolution, which has prompted intervention from a regulator.
“We’ve always said that what we’re trying here is a generational shift,” cautions Mr Rouse. He foresees a big transfer of resources to frontline services, enabling joined-up support for anyone with health problems, which should ease financial pressures on urgent care. A report last year by Mr Walshe and colleagues notes that, by seeking to redesign the whole system at once—including primary and community care, lots of acute care and mental-health services—Manchester is taking a risk. If it comes off, it will represent a revolution. If not, “it will have been a very time-consuming and expensive exercise.”
At a time when the NHS is seeking to integrate health and social care, this provides a lesson worth heeding. Greater Manchester has a lot of advantages, including a history of links between local authorities, lots of devolved powers and strong leadership. And yet even here, progress has been incremental. Integration of health and social care may well be worth pursuing. But a dose of realism about its prospects would not go amiss.