At what scale are things best organised? That is at the heart of so many of our big debates today – Scottish independence, UK independence, devolution.
And yet the debate rarely takes place with a deep look at scale and what should be done at different levels. That is not to say that there is not informed debate, even if some of that is rooted in an emotional sense of the desire to regain control in a complex world, and the perennial promises and illusions of nationalism and regionalism. But scale is something, ever since Leopold Kohr argued for the breakup of nations in the last century, that is hard to pin down.
Herman Daly, the great ecological economist, for example argues that economics has focused on the twin goals of distribution and efficiency, when it should also have focused on scale. Fritz Schumacher, the doyen of “Small is Beautiful” agreed. His argument was never that we should do everything at the local level, but that “we need freedom and order: the freedom of lots and lots of small units and the order of large-scale, possibly global, organisation.” He pointed in the 1970s to the catholic tradition of subsidiarity, or devolution as a working principle – as small as possible.
The world has moved his way. Every national politician seems to profess localism. Devolution has spread and won its spurs, changing for good the national settlement at the UK level.
The latest variant is Devo Manc. This is the proposal (albeit without the legislative basis of the nations within the UK) to devolve spending to the Greater Manchester authorities. It is recognition, on the one hand, of the centrifugal dominance of London as close to a city state, and, on the other, of the widely praised governance and leadership of Manchester.
By chance, I met with two dozen leaders in the health and social care system in Manchester on Tuesday evening, just as the rumours hit the wires of Devo Manc taking on health spending across the region, devolved from NHS England. I was just one participant in a room full of passion and expertise. One of the reasons I was there though was to talk to the potential for genuinely participatory approaches to health and care – not least the social co-operative model now emerging in Wales, which offers an ownership model fit for the concept of co-production, of a partnership between service users, carers, community and the precious teams of professionals.
None of Devo Manc (health and care) is going to happen quickly and it is right to prepare the ground and to think through very carefully what needs to be done at different scales. There are still very good reasons to have an NHS, possibly even a European Health Service, for example around negotiating with Big Pharma on product and price or around aspects of food regulation. Public health ought to be easier in a national system than in the fragmented landscape of providers in the US – we need to be careful not to lose that in a devolved system.
But the consensus from the evening was that here was an opportunity to get things right. A statement prepared for the Manchester Evening News by Martin Rathfelder of the Socialist Health Association later that evening captured the mood:
“Under the right conditions this can be an opportunity to ensure that our Manchester Health Service – MHS – brings much greater benefits to patients and communities.
MHS patients must be equal partners in decisions about their own care and of their families. The MHS should be much more democratically accountable than the NHS has been in the past. Manchester still has huge inequalities in health. The average age at death of people living in the most deprived parts of the conurbation is ten years less than among those living in the most prosperous areas. The NHS has never been able to tackle inequality on its own but the MHS will be the biggest employer in the region and with local councils must use its muscle to reduce inequality. At the same time we want to see an end to wasteful and damaging competition between hospitals.
MHS should bring much closer working between social services, citizens, patients, carers, families, communities, hospitals, family doctors, pharmacists and other clinicians, researchers and the voluntary sector. and to establish real parity of esteem between mental and physical health.”
The key to success in devolution seems to me to be one that many co-ops would recognise – you do things together only those things that are done better together, and if you prove that you can do that, you can build the mandate and collective will to do astonishing things for the common good.