Warren Heppolette explains how devolution can help drive better-targeted and more cost-efficient public services
My journey in public service was prompted by my experience 33 years ago in Moldova, an Eastern European country struggling to be reborn as its economy collapsed under the shock of the breakup of the Soviet Union. The result for many of its citizens at the time was a raw, Hobbesian nightmare, particularly for the poor, the old and the disabled, dependent as they were on a government incapable of mediating between competing freedoms. My short time there as a teacher left me with a profound, and life-changing belief in the power and the necessity for public services, and indeed government more broadly, to support a fairer society and enhance the collective wellbeing of all its people, not just those who most need its help.
The UK, thankfully, is no Moldova. But today we face a similar crisis of trust, with a 2024 Ipsos poll reporting that 71% of the British public believe public services are failing to meet their expectations, amid widespread perceptions of declining quality, poor responsiveness and lack of accountability.
Intensifying demand and cost pressures are well documented elsewhere, but what’s not always appreciated is the growing complexity and acuteness of many social needs: growing housing insecurity, increasing specialist education and children’s social care needs, and unsustainable levels of economic inactivity affecting families. The results in many parts of the country are heartbreaking.
The good news for those seeking both to find less costly interventions and design better outcomes is the growing shift to a more preventative model for public services in the UK. This can be seen in the NHS Ten Year Plan, which includes a greater emphasis on proactive care, the support for children with special educational needs which aims to help them get the most from school and college, and the independent review by Sir Charlie Mayfield into how employers can better promote healthy and inclusive workplaces (the Keep Britain Working report).
Nobody ever disagrees with the theory that acting and investing earlier to address issues such as mental health, employment barriers and social isolation will lead to better targeted public services. But that ambition in government is consistently overwhelmed by the absence of any belief that this can be scaled up and sustained. The rest of this article will look first at the barriers to a more preventative approach, examining the progress of Greater Manchester’s National Prevention Demonstrator, and why I believe this innovative initiative is a model that the rest of the country should follow.
What’s frustrated ‘prevention’ in the past
The barriers which have undermined previous attempts to direct more resources towards prevention in public services are both systemic and practical. I see five.
- Silos and fragmentation – Traditional patterns of funding, policy and regulation often fail to acknowledge the complex relationship and interactions between different needs. Improving health, for example, requires a mix of medical intervention alongside social and behavioural actions; improving school attendance and attainment requires assisting families under pressure as well as being able to meet needs directly in school; improving people’s employability relies on measures which support their self-belief and address their health, skills and opportunity development.
- The 200-mile screwdriver – Too often, Whitehall frames policies which reach into distant neighbourhoods with solutions cultivated in a single department or associated with limited, short-term funding. These drive narrow, partial responses, divorced from local needs and wishes. Local leaders and practitioners often have no choice but to work with these programmes, especially when the alternative might be no funding at all.
- Marginal experimentation – Initiatives to encourage prevention are sometimes tacked onto an unchanged mainstream delivery model, and thereby lose their impact. Funding associated with prevention is also more often discretionary, the mainstream interventions inevitably being the more dominant. A sustained move towards prevention can certainly be ignited as a result of experimentation, but it will only become embedded when it enters the mainstream.
- Forecasting vs foresight – Resource planning and budget setting tend to be based on linear extrapolations of historic patterns of demand. But much projected demand can be addressed through preventative approaches. That doesn’t necessarily mean more services; it could, for example, involve better aligning existing support with residents and communities motivated to help themselves.
- Investment risk – By definition ‘prevention’ outcomes are uncertain and hard to measure, success often being what doesn’t happen; attribution of causes (particularly in complex, multifactoral environments) is hard to gauge. Without mechanisms for sharing risks and benefits, policymakers will be less likely to divert resources away from traditional areas of demand.
These barriers perhaps suggest why mission-based government – framing a grand objective such as establishing an inclusive economy, building health-creating neighbourhoods or creating the conditions for young people to leave formal education with a sense of hope – is so difficult to achieve in practice. It requires local actors to seize the opportunity to connect the full range of contributions to that mission.
When government over-specifies the solution, it inspires only project management. Peter Hyman has written brilliantly about this, reflecting on how the complexity of today’s problems requires thinking across the Civil Service in the same way that Da Vinci’s apprenticeship spanned arts and science and connected insights across disciplines.
Greater Manchester – demonstrating a pathway to prevention
The potential for devolved administrations to deliver mission-based policy has long been acknowledged. That’s why the Government has supported Greater Manchester Combined Authority’s initiative, announced late last year, to establish a ‘Prevention Demonstrator’ across Greater Manchester, to develop and implement public service delivery so as to prevent poor outcomes for residents and high service costs. The objective is to fix the foundations of a person’s life – such as housing, access to education and access to employment opportunities – as a means of preventing ill health from social and economic detriment, and of improving lives, as well as reducing pressure on acute services.
Local leaders believe Greater Manchester’s potential rests on its high level of existing devolution and integrated funding; the coterminous boundaries between health and local government, a relationship deepened with the Deputy Mayor for Health soon to be accountable both to the Secretary of State for Health and to Greater Manchester through the Mayor; strong innovation and digital capability; Greater Manchester’s established place-based model (Live Well) which has a track record of collaborating across boundaries to deliver person-centred care via neighbourhood teams; and strong cross-system leadership, with shared institutional commitment to integrated delivery.
The Demonstrator’s focus will be on tackling economic inactivity linked to ill health, social complexity and demand-side pressure across health, housing and local government. It will explore opportunities to pool budgets and reprofile public service spending towards prevention and highly decentralised governance models.
Early results
The Prevention Demonstrator should be seen in the wider context of the Greater Manchester Strategy 2025-2035, launched by the Mayor last summer, which aims to create a thriving city region where everyone can live a good life. The strategy reflects a collective vision for the next decade, emphasising the importance of prevention and community engagement to achieve these goals. It aims to address poverty, worklessness, poor health, trauma and insecure housing, challenges that are driving demand in every public service but the rising cost of which is avoidable.
Live Well, Greater Manchester’s delivery model for Public Service Reform, is another radical approach that reflects the reality that wellbeing, independence and good health are created in and by communities themselves, not by services. Services should be organised around people, families and communities in ways which make sense to them, removing the silos of Whitehall departments and providing support earlier in their lives.
The model aims to demonstrate that prevention offers financial benefits in the shape of reduced pressure on hospitals and emergency services, improved labour market participation, better value for public spending over time and strengthened accountability and trust.
It’s still early days for all these initiatives but Greater Manchester has been on a journey for many years which has already resulted in the sort of changes which a more preventative approach will deliver. Positive developments include:
- The effect of devolution on healthy life expectancy. This has been evaluated by the Health Foundation and the University of Manchester, which concluded that “Greater Manchester had better life expectancy than expected after devolution. The benefits of devolution were apparent in the areas with the highest income deprivation and lowest life expectancy, suggesting a narrowing of inequalities. Improvements were likely to be due to a coordinated devolution across sectors, affecting wider determinants of health and the organisation of care services.”
- Community-led approaches to prevention. Wigan now has the highest proportion in England of young adults with a learning disability supported in their own home and 9% fewer people in long-term care compared to similar populations; it is the Care Quality Commission’s highest-rated social service authority in England. At the same time it is the lowest spender on long-term care relative to its population in the North West of England.
- A pan-Greater Manchester programme to support GP practices actively seeking to identify and support patients with the most unmet health needs. As a result, every GP practice in Greater Manchester now reviews patients with the highest risk of heart disease and diabetes. By targeting 135,000 at-risk cardiovascular disease patients and delivering 73,000 enhanced reviews, it is estimated that the region has avoided 200 strokes and 180 heart attacks, generating £6.7m of gross fiscal savings in the first year.
- Working Well programmes. These have supported more than 70,000 Greater Manchester residents to date, unpicking a wide range of barriers to work through relational approaches. By July 2023 more than 25,000 people had found employment, many of whom would otherwise not have been likely to move into work without specialist intervention.
- Strengths-based approaches to reablement. Manchester’s Better Outcomes Better Lives – working with people earlier and encouraging greater independence – has achieved savings of more than £39m per year.
A national blueprint
Greater Manchester’s ambition is not only to reduce the current pressure on public services in the region but to create a national blueprint for reform. To help roll this out, we will be developing playbooks and delivery tools.
We will be building on existing civic data assets so as to strengthen the ability to predict, target and track the moment and effectiveness of preventative action.
We will build an economic model for prevention which identifies preventative spending and assesses whether it is sufficient to meet current and future demand. We are already working with the Scottish Government and Public Health Scotland to utilise and further develop tools (such as those developed by CIPFA) to measure and track prevention expenditure.
Finally, we will develop a blueprint of what components are required for a successful mission-led approach, and an evaluation framework which tracks progress in near real-time, assesses value for money and captures the experience of both residents and front-line practitioners on how it feels to work together.
The key insights so far are: one, that collaboration is the force multiplier for the prevention demonstrator; two, that public services cannot change without re-establishing trust between citizens and the state; and three, that community is the first line of defence against rising risk.
The depth of collaboration between communities and frontline teams now required will have to go beyond what has previously been seen in pursuit of shared missions and that will test the limits of existing devolution. The aim is not simply to stop bad things from happening, but ultimately to unlock community power and human potential. If we replenish the public’s belief in the power of government to do good, so much the better.
Warren Heppolette is Director of the Prevention Demonstrator, Greater Manchester Combined Authority.
