In Greater Manchester, we have a plan to put prevention at the heart of the health system
8 min read
Last week, the Health Secretary announced a new drive to ease the 8am rush for a GP appointment. New money is to be made available to expand practices across the country.
Wes Streeting is right to prioritise access to primary care and I can remember announcing something similar myself when I was in the role. But, 15 years on, we have to ask: how sustainable is this approach going forward?
The big change between my time and today is that the NHS is now fully feeling the damaging effects of a 15-year-long funding squeeze on all the things that could prevent people ringing their GP in the first place.
When the first round of austerity started in 2010, the notion of “protected” departments entered the political lexicon. Ever since, health has been top of the list.
This is an increasingly problematic concept. Paying for the health service by constantly cutting investment in homes, communities, people’s incomes and living standards cannot possibly be the route to a healthier nation.
With another difficult spending review now looming, we are at real risk of locking ourselves in a cycle of spending more and more on NHS services, cutting other services to pay for it, but none of it achieving any tangible improvement in people’s health.
We can’t say we weren’t warned.
Back in 2002, the last Labour government brought in former banker Derek Wanless to advise on the funding outlook for the NHS. His report, which was the catalyst for a huge increase in NHS spending, is worth revisiting.
Wanless said his recommendations would need to be considered against three possible scenarios over a 20-year period: “solid progress”; “slow uptake”; or “fully engaged”.
The first would involve the NHS becoming quicker on the uptake of new technologies and more preventative in its approach. The third would go even further and involve individuals taking more personal responsibility for their health, and their employers doing the same. In both scenarios, the NHS would become more sustainable by 2022 in terms of spending as a percentage of GDP.
Sadly, however, we have ended up with the worst-case scenario: “slow uptake” or, in other words, business as usual. The injection of new funding did not bring a significant switch to prevention and, as Wanless predicted, increased life expectancy has only been matched by longer periods of ill health at the end of life, and little narrowing of health inequalities.
Of course, this is not all the fault of the NHS. Those cuts to council budgets, social care, housing, and benefits have made what were seasonal winter pressures in 2010 a year-round phenomenon in 2025 and removed the bandwidth to pioneer change. One thing is clear though: we can’t afford to ignore what Derek Wanless was saying for another 20 years.
So how to break out of this depressing cycle?
This is where we have more positive news. Unlike the early 2000s, at least there is a vehicle which makes delivering the fully engaged scenario a possibility.
English devolution and the rise of the mayoral combined authority model is the game-changer for prevention this country has long needed. Such is the maturity of this system in Greater Manchester that it has allowed us to put forward a major proposition to the government as part of the spending review: to become the UK’s first Prevention Demonstrator.
This April, Greater Manchester moved to an integrated budget settlement with Whitehall – a financial arrangement which allows us to build from the bottom up, break out of the constraints of siloed spending, and make a decisive move towards prevention. If the government takes the opportunity now to go further and consolidate all relevant existing spending within this pot, we could pioneer a completely different way of supporting our residents within the remainder of this Parliament. We are confident we will help more people into work and reduce pressure on the NHS.
Our core proposal is to create a structured Live Well service, delivered through trusted grassroots organisations, to provide a range of everyday support and social interventions to our residents, helping them to remove barriers and take more control of their physical and mental health.
All public services will be able to refer into Live Well, but it will be particularly beneficial for the NHS. It is estimated that around a third of calls in the 8am rush relate to a social need rather than a medical one, where people might be seeking support for issues like stress, loneliness, housing need, or financial struggles. Can you imagine if the receptionist could offer a same-day Live Well appointment instead of one with the GP? Across Greater Manchester, it could free up thousands of GP appointments every week.
This would be the fully engaged scenario in practice, allowing the government to show a marked improvement in primary care waiting times as well as a reduction in the prescribing budget. This is already beginning to happen in places like Leigh, where local charity Compassion in Action takes direct referrals from GPs across the Wigan borough via an integrated IT system into the charity’s non-clinical mental health service.
The power of Live Well is that it puts the voluntary welfare state, which has sprung up across England in the last 15 years, at the centre of the system rather than picking up the pieces at the margins and fighting for scraps. It is David Cameron’s ‘Big Society’ but with the crucial difference of core funding and supporting infrastructure.
What makes our pitch compelling is that it can be delivered through switch-spending rather than new money. Supporting people who are able to work to find a job can be crucial to improving their health and wellbeing. Currently, the UK spends billions on employment support through corporate entities, too often providing top-down, tick-box delivery – without truly helping people into work. People’s barriers to work are often linked to issues over which the DWP has very limited control, such as housing, debt, trauma, bereavement and relationships. Helping people with these challenges, and rebuilding trust, requires a whole-person approach that a combined authority can provide, working with not-for-profit local partners, but a Whitehall department never could.
English devolution and the rise of the mayoral combined authority model is the game-changer for prevention this country has long needed
We believe the spending review should set out a roadmap for routing all employment support funding through our integrated settlement, so that we can commission networks of voluntary organisations to deliver Live Well. To them this would feel like new money, and the circular benefits to our communities would be huge. In return, we are happy to be held to account by the DWP for delivering an increase in the number of people helped into work.
To stand the best chance of success, Live Well would need to be supported by new thinking on housing. Greater Manchester has adopted the Finnish “Housing First” philosophy and is developing a plan to intervene on housing supply, standards, and support. The fully engaged scenario cannot be realised without city-regions like ours being released from the grip of the housing crisis. In practice, this means a package of funding and support being agreed in the spending review which enables us, across our 10 councils, to reach the tipping point in this Parliament of building more council and social homes than we are losing. Alongside that, we need to be able to act on standards in the private-rented sector through the new Greater Manchester Good Landlord Charter, launching next month, accompanied by a new drive on enforcement.
This is the moment for the country to get serious about prevention. All areas across England are doing versions of Live Well, and our commitment as a Prevention Demonstrator would be to share and learn with other places. The big win would be to strike an agreement with the Treasury where the savings from a higher employment rate are shared, creating a revenue stream back into the pot for our councils and community and voluntary organisations. Think about the power of that – a financial incentive for prevention at the heart of England’s new place-based systems, potentially offering a path to easing the local government funding crisis.
Where is the evidence Live Well could succeed? Well, a study of health devolution in Greater Manchester in the Lancet found that, pre-pandemic, we increased life expectancy faster than expected, particularly in our more deprived communities. At the same time, the gap with the rest of England on levels of school readiness amongst children receiving free school meals was closed.
In fact, the real question is this: what is the alternative approach if it’s not this one? We have tried all other versions of public service reform over the years and none have achieved what was claimed for them. In fact, the fragmentation they brought made things worse, adding cost and complexity. The only thing left is the fully engaged scenario – a whole-person, whole-place approach to prevention – and Greater Manchester is ready to demonstrate it will work.
