Editorial Thursday 27 February 2015: Four questions about the Greater Manchester SHA structural solutioneering

The revelation by the Manchester Evening News that there is to be a Greater Manchester health and care authority, to which the region's entire £6bn annual budget will be devolved, is a spectacular one.

It involves the creation of a new statutory body by April 2016 to assume the budget, sitting above a supervisory commissioning body formed of the area's councils, CCGs and NHS England.

This is clearly in no way adding new bureaucracy and complexity into the NHS system.

(If they are casting around for a name for the new body, 'Greater Manchester Strategic Health Authority' is as good as any. You're welcome.)

The memorandum of understanding seen by MEN states that the new body will work on the “principle of subsidiarity…ensuring that decisions are made at the lowest level possible”.

Mmmmmm. That was how the brilliantly-successful GP practice-based commissioning was meant to work in World-Class Commissioning. And of course we got world-class commissioning as a result.

(Stop giggling.)

CCGs and local councils are to pool their budgets, which can also be called 'deficits' locally.

A new layer of regulation. Phew!
Excitingly, the memorandum also proposes that this new bureaucracy "should lead the regulation of its provider community, with support from Monitor, the NHS Trust Development Authority and the Care Quality Commission”.

The NHS has been crying out for another level of regulation, and it is a huge relief to see that this plan aims to address this crying need.

Structural solutioneering and four questions
So here we go again: it's another piece of structural solutioneering. It's unfair to point out that they haven't yet made up the governance and risk-sharing arrangements, so I won't. There are various key questions, however.

The first is what has been learned from the Manchester provider reconfiguration plan Healthier Together, and the divisions and dissent that ensured?

The second is the Tony Benn question who's in charge: i.e. who can over-rule, veto or sack whom? What is the source of the new body's democratic legitimacy. Elections for health commissioners? Will party hacks be allowed to stand?

The third is who will get surcharged, fined, banned or imprisoned if and when the new body's decisions result in patients being harmed or killed.

The fourth is about the new body's rationing, revenue-raising or target-varying powers. The NHS does not have the money to meet current demand: this is why provider deficits are growing. So this new bureaucracy will face stark options: explicitly ration care; raise additional revenue through local taxation; or vary the waiting time targets.

Those would be meaningfully devolved powers. Will it get them?