Regional devolution could transform the NHS – provided there’s consent

A hospital. Image: Getty.

The Labour MP for Wigan on the need to bring democracy into NHS devolution.

In a few months time, Greater Manchester will make history by choosing its first ever directly-elected regional mayor. Devolution is necessary, long overdue, and cannot be allowed to fail. The pressures in the NHS cannot be solved from Whitehall or Westminster. They can only be solved by people closest to these problems taking charge of their own lives.

Handing powers over transport, homes, policing, skills and the NHS to an elected mayor could profoundly reshape our public services for good, putting people and communities in the driving seat when it comes to choices that affect their lives, not just in Greater Manchester, but across the country.

Greater Manchester is an ideal testing ground to pioneer these radical reforms, in part because of the good working relationships between local leaders, built over decades. But the challenges for health devolution are great. Greater Manchester is a diverse area, facing varied and complex health challenges, from my borough in Wigan with a legacy of chronic ill health from the mining industry, to the challenges of a younger, urban, diverse population in central Manchester.

A&Es are under unsustainable pressure from cuts to social care. Cancer diagnosis is exceptionally poor. There is a desperate lack of support, both financially and structurally, for mental health. And under the terms of the devolution deal, there is a £2bn funding gap. It will take every bit of energy and creativity to solve this, and it must start with the best asset we have – people.

Last week, a new report from the Fabian Society found that, although there is significant support for local leadership in the NHS, more must be done. Too many people do not know what devolution means. They want more information and transparency, especially where devolution is already underway, and protection from postcode lotteries.

More than two years after the health devolution deal was announced in Whitehall and signed behind closed doors in Manchester town hall, the people remain largely shut out of the conversation. The public consultation on these sweeping changes was not properly publicised, ran for just three weeks and received only 12 responses – 10 of them from the same council leaders that signed the deal in the first place. It didn’t even mention the NHS.

There needs to be a cultural shift in the way this process has operated so far. These major health reforms, the most radical and risky to be proposed since the NHS was founded in 1948, have been subject to just one public consultation that ran online and through 10 public meetings across the whole of Greater Manchester. The vast majority of the public are unaware that the consultation "Taking Charge Together" ever happened, only 6,000 people in a population of 2.8m have responded.

Resources should be made available to local communities to get involved in this process and help to shape it. Documents must be cleared of jargon and written in a language that most people can understand. Challenges to the system must be welcomed and embraced, and formalised through a forum that publicly holds the mayor to account. Just as select committees are properly resourced and supported, councillors should be given the skills, time, resources and independence to scrutinise decision making and highlight where decisions are failing us.

In the wake of Brexit, where communities in towns and villages across the country demanded the right to be heard, to ignore this desire for greater power would not just be wrong, but politically catastrophic. Those areas must be given a voice, and more importantly, the ability to hold the mayor to account.

Great Manchester is dominated by Labour representation, but it is essential in a healthy democracy that an individual as powerful as the mayor is scrutinised on a cross-party basis, both to ensure challenge and to give a voice to people across the region who hold different views. Civil society has not been involved or consulted. And so far, there are no plans to change this.

A model that does not have the will and support of the people will not succeed. The UK is inevitably and rightly shifting towards a federal model and getting this process right is critical. That can only mean a mayor who is accountable to and directed by the needs and lived experiences of the people they represent. Real devolution comes from public consent. Democracy cannot be an afterthought.

This article previously appeared on our sister site, The Staggers


Is Britain’s housing crisis a myth?

Council housing in Lambeth, south London. Image: Getty.

I’ve been banging on about the need for Britain to build more houses for so long that I can no longer remember how or when it started. But at some point over the last few years, the need to build more homes has become My Thing. People ask me to speak at housing events, or @ me into arguments they’re having on Twitter on a Sunday morning in the hope I’ll help them out. You can even buy a me-inspired “Build More Bloody Houses” t-shirt.

It’s thus with trepidation about the damage I’m about to do to my #personal #brand that I ask:

Does Britain actually have enough houses? Is it possible I’ve been wrong all this time?

This question has been niggling away at me for some time. As far back as 2015, certain right-wing economists were publishing blogs claiming that the housing crisis was actually a myth. Generally the people who wrote those have taken similarly reality-resistant positions on all sorts of other things, so I wasn’t too worried.

But then, similar arguments started to appear from more credible sources. And today, the Financial Times published an excellent essay on the subject under the headline: “Hammond’s housebuilding budget fix will not repair market”.

All these articles draw on the data to make similar arguments: that the number of new homes built has consistently been larger than the number of new households; that focusing on new home numbers alone is misleading, and we should look at net supply; and that the real villain of the piece is the financialisation of housing, in which the old and rich have poured capital into housing for investment reasons, thus bidding up prices.

In other words, the data seems to suggest we don’t need to build vast numbers of houses at all. Have I been living a lie?

Well, the people who’ve been making this argument are by and large very clever economists trawling through the data, whereas I, by contrast, am a jumped-up internet troll with a blog. And I’m not dismissing the argument that the housing crisis is not entirely about supply of homes, but also about supply of money: it feels pretty clear to me that financialisation is a big factor in getting us into this mess.

Nonetheless, for three reasons, I stand by my belief that there is housing crisis, that it is in large part one of supply, and consequently that building more houses is still a big part of the solution.

Firstly I’m not sold on some of the data – or rather, on the interpretation of it. “There is no housing crisis!” takes tend to go big on household formation figures, and the fact they’ve consistently run behind dwelling numbers. Well, they would, wouldn’t they? By definition you can’t form a household if you don’t have a house.

So “a household” is not a useful measure. It doesn’t tell you if everyone can afford their own space, or whether they are being forced to bunk up with friends or family. In the latter situation, there is still a housing crisis, whatever the household formation figures say. And there is plenty of anecdotal evidence to suggest that’s the one we’re living in.

In the same way I’m not quite convinced that average rents is a useful number. Sure, it’s reassuring – and surprising – to know they have grown slower than general prices (although not in London). But all that figure tells you is the price being paid: it doesn’t tell you what is being purchased for that payment. A world in which renters each have their own property may have higher rents than one in which everyone gets one room in an over-crowded shared flat. It’s still the latter which better fits the label “housing crisis”.

Secondly, I’m entirely prepared to believe we’ve been building enough homes in this country to meet housing demand in the aggregate: there are parts of the country where housing is still strikingly affordable.

But that’s no use, because we don’t live in an aggregate UK: we live and work in specific places. Housing demand from one city can be met by building in another, because commuting is a thing – but that’s not always great for quality of life, and more to the point there are limits on how far we can realistically take it. It’s little comfort that Barnsley is building more than enough homes, when the shortage is most acute in Oxford.

So: perhaps there is no national housing crisis. That doesn’t mean there is not a housing crisis, in the sense that large numbers of people cannot access affordable housing in a place convenient for their place of work. National targets are not always helpful.

Thirdly, at risk of going all “anecdote trumps data”, the argument that there is no housing crisis – that, even if young people are priced out of buying by low interest rates, we have enough homes, and rents are reasonable – just doesn’t seem to fit with the lived experience reported by basically every millennial I’ve ever met. Witness the gentrification of previously unfashionable areas, or the gradual takeover of council estates by private renters in their 20s. 

A growing share of the population aren’t just whining about being priced out of ownership: they actively feel that housing costs are crushing them. Perhaps that’s because rents have risen relative to wages; perhaps it’s because there’s something that the data isn’t capturing. But either way, that, to me, sounds like a housing crisis.

To come back to our original question – will building more houses make this better?

Well, it depends where. National targets met by building vast numbers of homes in cities that don’t need them probably won’t make a dent in the places where the crisis is felt. But I still struggle to see how building more homes in, say, Oxford wouldn’t improve the lot of those at the sharp end there: either bringing rents down, or meaning you get more for your money.

There is a housing crisis. It is not a myth. Building more houses may not be sufficient to solve it – but that doesn’t meant it isn’t necessary.

Jonn Elledge is the editor of CityMetric. He is on Twitter as @jonnelledge and also has a Facebook page now for some reason. 

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