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Paving a new path
lessons from devolution in Greater Manchester

Since 2016, Greater Manchester has been responsible for its own health and social care budget, organising services and support in the best way for the area. But is devolution in Greater Manchester effective? How has it changed ways of working? Stuart Cowley from Wigan Council, and Jo Chilton from the Greater Manchester Health and Social Care Partnership share their learning here.

In Greater Manchester, the number of care homes rated Good or Outstanding by the Care Quality Commission (CQC) has risen from 54% in April 2016 to 77% in June this year. Homecare agencies have improved from 62% Good or Outstanding to 88% and, at the same time, the number of homecare agencies and care homes rated Inadequate has also fallen significantly, from 28 a year ago to five now, out of more than 900 providers.

In Wigan, early deaths from cardiovascular disease and cancer have fallen faster than in England as a whole, with fewer people smoking and lower rates of physical inactivity.

The King’s Fund recently studied how this had been achieved through the ‘Wigan Deal’ and noted that the council had succeeded in controlling the growth in demand for social care, despite saving more than 40% of its budget since 2011.

We are often asked whether devolution in Greater Manchester is working. Put simply, yes, devolution is ‘working’. You can see this when you look at what it has enabled us to do. But the reason it is bringing success across a range of measures is the fundamental change we have made in the way we work.

Coming together to succeed

Greater Manchester has a long tradition of collaboration that stems from the 10 boroughs having worked together for decades to pool policy-making in areas such as planning, transport, skills and the economy.
The NHS in Greater Manchester also has almost two decades’ experience of joint working, developing new models of hospital care, joint commissioning and population health innovations. However, we recognised that the way services were provided through NHS trusts, primary care and social care was often fragmented and of inconsistent quality.

Bringing the NHS and local government elements together through the devolution agreement felt like a natural extension of a long-standing way of working, based around place and communities. We brought together clinical commissioning groups, local authority social care and public health functions into a single commissioning organisation in each of our 10 local authority areas. The budget is pooled, risk is shared, the staff work together and, in many cases, they are led by one chief officer.

Health and social care to support people to live well at home is provided through integrated local care organisations. Teams based in neighbourhoods of between 30,000 and 50,000 people – which we find is the natural size of people’s communities – are led by GPs, and include community health, mental health, social workers, independent providers and the voluntary and community sector.

Commissioners have developed partnerships with neighbourhood-based health, care and support providers and have established a Greater Manchester independent care sector network. This gives providers a stronger voice and the ability to shape policy, strategy and delivery. This in turn has improved outcomes for people.

This is an area where working together will bring innovation. For example, we are developing new ‘blended’ neighbourhood-based care roles which will support and enable care staff to undertake low-level healthcare tasks – providing better career opportunities and job enrichment for the workforce, as well as better support for the individual.

Providers are creating apprenticeship roles and are offering leadership development for existing registered care managers and those who want to develop into management roles; local authorities have established ethical commissioning frameworks to ensure a fair deal for the workforce and to prove their commitment to high-quality support.

As a result of these initiatives, wages are starting to rise, skills levels are improving and turnover in some areas is starting to fall. In terms of care given, the focus is on outcomes, rather than the time spent in a person’s home or a tick list of tasks.

Through this collaborative approach, we are also working to shape the market – understanding and researching demand, how costs can be met and the need for new models of health, care and supported housing.

What people want

Another area of focus has been on ensuring we are offering the best care for that person at that time. Too often in the past, social care and NHS staff have started with the question, ‘What’s the matter with you?’. We have turned that around to ask, ‘What matters to you?’

We ask staff to have a different conversation with people, about what people want to do and achieve and about their community.

We have numerous examples of the difference this has made, for example:

  • A man with dementia who is living in a care home is now taken to watch his football team by a volunteer from the team’s supporters’ club.
  • A woman with dementia who loved to iron before moving into a care home now irons clothes from a local charity shop and enjoys visiting her local tea room with the shop’s volunteers.
  • A man with little sight who lives in his own home and used to enjoy going to the bookmakers is now taken there by volunteers from his local veterans’ association. He says, ‘With someone on my arm I can stride out again.’
  • A woman with Chronic Obstructive Pulmonary Disease (COPD) who loved to sing has joined a community choir, which has led to new friendships and is good for her lungs too.

We find that when we turn around the conversation with people, listen to them, work out together how we can offer the best support and personalise the care based on what matters to them, we see better outcomes and better manage demand.

This actually means fewer people in social care, so we can focus on the people with the most complex needs.

The prevention goal

Prevention is often talked about in terms of avoiding illness or disease, but for us it’s also about avoiding or minimising the need for social care or NHS care by intervening early to enable people to continue living independently in their own homes.

This might be by finding suitable housing options, helping someone to become independent again following a stay in hospital, or supporting people to stay active and take part in the local community.

As part of our work on prevention, we have analysed future need for supported housing and we know we currently do not have enough. Having this knowledge means we have been able to begin working with planning and housing colleagues to achieve our ambition of providing a further 15,000 supported housing units by 2035. This will help us to meet future demand.

Having a clear strategy

Devolution has also enabled us to develop targeted strategies to ensure we are helping people as best we can. Working with self-advocates, families and specialist organisations, we have listened to people to understand what they want to see. Through this, we have co-produced a learning disability strategy with 10 areas identified, such as belonging, health and justice, employment, advocacy and workforce.

We have also developed an autism strategy that focuses on making sure public services are accessible and improving employment opportunities.

For informal carers, we have worked with partners to develop a model of best practice in how to support them. We know there are at least 280,000 unpaid carers in Greater Manchester and that without their contribution the health and care system would collapse.

We have therefore co-produced a carers’ charter and a commitment to carers which very clearly sets out their rights. It focuses on identification, an improved annual health and wellbeing check, support in employment and opportunities for young carers. A carers’ partnership ensures carers’ voices are heard and they influence policy and development.

As well as this, we have co-produced a working carers’ toolkit for employers that has been endorsed and adopted by all of Greater Manchester’s key public sector organisations as well as in the private sector. This helps organisations to identify carers and put structures and policies in place to support them, helping to ensure their wellbeing and minimising the risk of them leaving their job.

As with other policies in Greater Manchester this approach has been agreed by listening to local views, defining a standard that we all aspire to and then handing over responsibility for delivery to local areas.

Work in progress

To return to the original questions, we ask ourselves if our strategies are working by asking if our local population is being served well.

Using Wigan as an example, we have recently produced our 2030 version of the Wigan Deal, after listening to the views of more than 6,000 local residents. Healthy life expectancy has improved, 3,000 people are using community-based alternatives to traditional social care and we are best in the North West for getting people home quickly from hospital. Each Greater Manchester borough could also point to their own successes.

We are making good progress, but it takes time. However, we have glimpsed what is possible and we are determined to continue because we know it is the right thing to do.

When we have turned around the historic inequality in health and care outcomes in Greater Manchester, then we will be able to say that devolution has been a success.

Additional content
Read case studies on how services are improving in Greater Manchester, including this example of a care home turning around its CQC rating, and this homecare agency which is embedding person-centred care principles.

Stuart Cowley is Chair of the Greater Manchester and North West Association of Directors of Adult Social Services, and Director of Adult Social Services at Wigan Council. Jo Chilton is Programme Director for Adult Social Care Transformation at Greater Manchester Health and Social Care Partnership. Email: Email:

What can be learnt from Greater Manchester’s progress? Should devolution be replicated in more areas? How can it assist with the integration agenda? Let us know what you think by commenting below.

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