Greater Manchester has been designing a model that builds on the strong partnership that has already taken place at a city-region level and at pace but continues to address challenges, writes Sir Richard Leese

Making systems and services work better for people is at the heart of public service reform. As a strong advocate for devolution and place-based budgets, I am hopeful that we can go further than before in Greater Manchester.

We were the first area to become an integrated care system, indeed helping to shape the current government white paper. Our strong history of partnership working and meaningful involvement of local authorities, the NHS, the voluntary sector and others in our arrangements and achievements to date shows collaboration in practice.

You can strengthen local governance and accountability, but you can’t legislate for a collaborative culture. Leadership across the system in Greater Manchester and long-standing relationships, which we have invested in deeply in recent years, have acted as enablers really proving their mettle when our health and care system was under stress during the pandemic.

We were clear the scale of our challenges and ambitions for change when we did the devolution deal in 2015 and set out our five-year plan. Even before 2015, our approach was rooted in population health – and tackling the social determinants of poor health alongside prevention and early intervention, with a desire to design and package services around people, families and communities, rather than through one-size fits all, siloed programmes.

Greater Manchester model

With legislation expected in 2022, we have a shared and coherent view of our challenges and have been designing a Greater Manchester model, building on the strong partnership that has already taken place at a city-region level and at place, to continue addressing them.

When there is a system-wide commitment to a shared vision, which we have reaffirmed in Greater Manchester this year, and an ability to join up both the strategic vision and commissioning functions, there are better outcomes for everyone. With NHS reforms removing the internal market, joint purchasing decisions should be easier, reducing complexity and variation between places.

For me, form must follow function. We must not risk derailing progress to date nor future aspirations. Indeed, it is welcome that the proposed legislation leaves several decisions to local systems.

There has been a good, constructive debate over the formation of two boards set out in the proposals. We have had a broad membership health and care partnership since 2016, governed by a board, so the new arrangements reflect our work to date to help more people stay well and take better care of those who are ill; align the health and social care system to wider public services, such as education, skills, work, housing and justice and create a financially balanced and sustainable system.

A key system principle is subsidiarity with neighbourhoods – the fundamental building block, and it’s strengthening this local governance and removing duplicative transactional activity which will be vital. There are still some uncertainties on how the ICS NHS board and the ICS health and care partnership board will relate to one another.

We have made significant collaborative progress to develop our new operating model. We have been working to forge ahead with a common sense of purpose and secure clinical and care professional consensus to retain primacy of place and strengthen that population health approach, which is intended to help people take charge of their own health and wellbeing, remaining as independent as possible.

In detailed engagement sessions with system leaders, we’ve explored how to develop the financial flows to enable all partners to deliver regardless of size or sector, and to be accountable to the new boards and ‘holders’ of funding. Proportionately, greater investments are needed, including a proper long-term financial solution for social care, to reduce regional health inequalities. Yet more than this, funding must reflect behaviours and outcomes, not tariffs and rigid structures.

A key system principle is subsidiarity with neighbourhoods – the fundamental building block, and it’s strengthening this local governance and removing duplicative transactional activity which will be vital

Our five-year plan has seen the partnership focus on preventing ill-health and reducing inequalities. We’ve long had some of the worst health outcomes in the country, and unfortunately this is still the case, though we are turning the tide in areas like smoking cessation, school readiness, digital health, and cancer services.

The covid-19 pandemic has shown just how deep rooted and structural the challenges are in some parts of our city region, and our poor health and levels of poverty, poor work and overcrowded housing explain some of our persistent underperformance on some constitutional standards such as accident and emergency waiting times and bed occupancy.

Perhaps we were too ambitious about the pace of deliverability for our original plans and we now need to focus on where we can make the biggest gains. We must make choices that take us forward enabling true transformation.

Recovering from the impact of covid-19 will be key. Serious short-term challenges remain. Prioritising unmet health and care challenges and avoiding hidden harms with constrained resources is pressing.

Despite our hospitals looking after more people with covid than most other areas of the country, the NHS here never became a covid only service. Some planned care was able to continue throughout the covid period, for example we continued to treat patients requiring immediate medical care, including those requiring life-saving cancer surgery; we treated 9,000 people with cancer every week. Outpatients also continued largely unaffected.

We have a strong clinical leadership at the partnership and staff who are still connected to their profession, the frontline, and their communities. We’ve seen the impressive delivery of the covid-19 vaccination programme largely through primary care networks.

We must take those strengths – community connections, detailed knowledge of their populations and local insight – and ensure they are harnessed and have a stronger voice going forward to drive health improvements. Another consideration is workforce, not just numbers and retention and wellbeing of staff, but that staff and volunteers are equipped to deal with changing needs of the population

Creating the right conditions for good health and wellbeing will mean there is always work to do. Building a healthier population is a journey, not a destination. We must listen to our critics and our supporters, and learn from each. I am hopeful about the future and seeing what we can continue to do together.


Please note this piece was first published in the Health Service Journal on 20 May 2021



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