Wednesday, March 04, 2015

Are you a clumper or a splitter?

The Economist reports about an experiment in the National Health Service:

On February 25th it emerged that local authorities, clinicians and George Osborne, the chancellor of the exchequer, were proposing to transfer control of the £6 billion ($9.3 billion) of public money spent on health care in Greater Manchester to local hands. They want to create a health and wellbeing board, made up of NHS and local-government representatives, to administer a single budget for the conurbation. A trial version is expected to take shape in April. 

The city region’s doctors and hospitals will still be bound by national targets for things like waiting times, and subject to national regulations and inspections, but the board is a welcome idea nonetheless. It is bottom-up, pushed by local figures rather than imposed by the government, and it advances two positive trends.

The first is the integration of health and social care. Long-term conditions like diabetes, dementia and depression are now responsible for 70% (and rising) of Britain’s state health-care spending. They require a mixture of medical and non-medical attention.  

The second positive trend is that regional conurbations are becoming more powerful. Manchester has led the way: in 2011 ten local councils in and around the city formed a “combined authority” to manage services and infrastructure jointly.

But the initiative will also test Britons’ willingness to tolerate regional variation (or “postcode lotteries”, as tabloid newspapers call it). Andy Burnham, the opposition Labour Party’s shadow health secretary, warned that Manchester’s proposals could turn the NHS into a “Swiss cheese”, with some parts more autonomous than others; taking the “national” out of the National Health Service. 

The newspaper concludes:

Public services can be nationally uniform or locally accountable. They cannot be both.

Whether you live in the UK or not, what's your take?  Is this a good approach or not?  How would you measure success? Does it matter whether we consider the short term or the long term?


massmotorist said...

When it comes to government, at least in America, in general more efficient, thoughtful, and professional government exists the higher you go:

Federal>State>County (where applicable)>Municipal

When you get down to the local level, you're way more likely to get government by personality, emotion, or (sometimes) outright corruption. The problems can be largely ameliorated if the local governments/programs are highly structured (e.g., in MA we have mandated state AG approval of local bylaws to check for conflict with state law, heavily regulated municipal finance, state testing and accountability on schools, open meeting laws, etc).

Local governance works as long as there are systems in place to prevent the locals from making poor decisions. The record is clear that if left to their own devices, many of them will - even with the best of intentions, local bodies get captured by hyperlocal interest groups, strong personalities, make decisions based on insufficient data or perspective, etc.

Emily DeVoto said...

From Facebook:

As long as they remain adequately and publicly funded and committed to holding the line against privatization (which has already had disastrous effects on quality and access), I think it's a good thing. Local authorities banding together to provide efficiencies of scale in infrastructure (I hope) seems like a good idea.

Isam Osman said...

From Facebook:

Hmmm. Mixed feelings. The idea sounds good and logical but like most things it's the execution that will tell. I still believe the private sector has some role to play. They instil certain values such as customer service , value for money and accountability that we can learn from in the NHS.

rjr said...

Having worked in a large catholic health system at the medical director level I can give a number of examples how the approach of "all changes must be system wide" has stifled innovation for efficient and more appropriate care. Requiring uniformity usually means dumbing down to the mean.