The Impact of Devolution on Local Health System Financing: A Synthetic Difference-in-Differences Study of Greater Manchester, England

Moss, Charlie; Britteon, Philip; Lau, Yiu-Shing; Anselmi, Laura

doi:10.34172/ijhpm.8689

The Impact of Devolution on Local Health System Financing: A Synthetic Difference-in-Differences Study of Greater Manchester, England

Document Type : Original Article

Authors

Charlie Moss

Philip Britteon

Yiu-Shing Lau

Laura Anselmi

Health Organisation, Policy and Economics (HOPE), Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK

10.34172/ijhpm.8689

Abstract

Background
Determining the effects of devolution policies through health system financing is pivotal in understanding their impact. Few existing studies have considered total health and care system expenditure, overlooking the transfer of resources through spending in different services locally. We evaluated the impact of devolution in Greater Manchester (GM), an area in England which received devolved health and social care powers from 2016, on the whole system of local public expenditures on health and care.

Methods
Using data on public health and care spending for 149 local health systems between 2013 and 2020, we estimated synthetic difference-in-differences (DiD). We compared expenditure in total and by services for ten GM localities relative to a weighted combination of localities from the rest of England (excluding London) for four years post-devolution. We analysed expenditures in per capita terms and as a share of total expenditure. We investigated dynamic effects with an event study specification.

Results
Compared with the synthetic control (SC) group, total annual expenditure on health and care increased in GM post-devolution by an average of £66.58 per-capita (95% CI: 11.85 to 121.30). Total expenditure on public health and social care, managed by Local Authorities, increased by £36.39 (95% CI: 6.99 to 65.80) and expenditure on social care specifically increased in the third and fourth years after devolution. We detected some short-term changes in expenditure managed by the National Health Service (NHS) Clinical Commissioning Groups (CCGs), including reduced expenditure on Continuing Healthcare and increased expenditure on acute healthcare and “other” miscellaneous expenditure. We did not detect a statistically significant effect for public health, primary care, community or mental healthcare.

Conclusion
Results suggest that additional resources were used to respond to existing pressures on the health system, and that to redirect expenditure substantial increase in resources or re-organisation of services may be required alongside devolution of sufficient powers.

Keywords

Devolution

Decentralization

Health Expenditure

Local Government Expenditure

Health Policy

United Kingdom

Sapkota S, Dhakal A, Rushton S, et al. The impact of decentralisation on health systems: a systematic review of reviews. BMJ Glob Health. 2023;8(12):e013317. doi:1136/bmjgh-2023-013317
Saltman R, Busse R, Figueras J. Decentralization in Health Care: Strategies and Outcomes. McGraw-Hill Education (UK); 2006.
Costa-Font J, Greer SL. Federalism and Decentralization in European Health and Social Care. Basingstoke: Palgrave Macmillan; 2013.
Jiménez-Rubio D. Health system decentralization: creating as many problems than it solves? Comment on "The effects of health sector fiscal decentralisation on availability, accessibility, and utilisation of healthcare services: a panel data analysis". Int J Health Policy Manag. 2023;12:7432. doi:34172/ijhpm.2022.7432
Channa A, Faguet J-P. Decentralization of health and education in developing countries: a quality-adjusted review of the empirical literature. World Bank Res Obs. 2016;31(2):199-241. doi:1093/wbro/lkw001
Sumah AM, Baatiema L, Abimbola S. The impacts of decentralisation on health-related equity: a systematic review of the evidence. Health Policy. 2016;120(10):1183-1192. doi:1016/j.healthpol.2016.09.003
Cobos Muñoz D, Merino Amador P, Monzon Llamas L, Martinez Hernandez D, Santos Sancho JM. Decentralization of health systems in low- and middle-income countries: a systematic review. Int J Public Health. 2017;62(2):219-229. doi:1007/s00038-016-0872-2
Dwicaksono A, Fox AM. Does decentralization improve health system performance and outcomes in low- and middle-income countries? A systematic review of evidence from quantitative studies. Milbank Q. 2018;96(2):323-368. doi:1111/1468-0009.12327
Abimbola S, Baatiema L, Bigdeli M. The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. Health Policy Plan. 2019;34(8):605-617. doi:1093/heapol/czz055
Costa-Font J, Rico A. Devolution and the interregional inequalities in health and healthcare in Spain. Reg Stud. 2006;40(8):875-887. doi:1080/00343400600984346
Dougherty S, Lorenzoni L, Marino A, Murtin F. The impact of decentralisation on the performance of health care systems: a non-linear relationship. Eur J Health Econ. 2022;23(4):705-715. doi:1007/s10198-021-01390-1
Xu W, Lin J. Fiscal decentralization, public health expenditure and public health-evidence from China. Front Public Health. 2022;10:773728. doi:3389/fpubh.2022.773728
Chen C, Zheng M, Zhu J. How does fiscal decentralization affect health outcomes? Evidence from China. Risk Manag Healthc Policy. 2023;16:1893-1903. doi:2147/rmhp.S412547
Abdullah A, Stoelwinder J. Decentralization and health resource allocation: a case study at the district level in Indonesia. World Health Popul. 2007;9(4):5-16. doi:12927/whp.2007.19514
Walshe K, Coleman A, McDonald R, Lorne C, Munford L. Health and social care devolution: the Greater Manchester experiment. BMJ. 2016;352:i1495. doi:1136/bmj.i1495
Greater Manchester Combined Authority (GMCA). Taking Charge of Our Health and Social Care in Greater Manchester. GMCA; 2015. https://www.greatermanchester-ca.gov.uk/media/1120/taking-charge-of-our-health-and-social-care-plan.pdf. Published December 2015. Accessed August 15, 2022.
Britteon P, Fatimah A, Gillibrand S, et al. The impact of devolution on local health systems: evidence from Greater Manchester, England. Soc Sci Med. 2024;348:116801. doi:1016/j.socscimed.2024.116801
Walshe K, Lorne C, Coleman A, McDonald R, Turner A. Devolving Health and Social Care: Learning from Greater Manchester. Manchester: The University of Manchester; 2018. https://www.alliancembs.manchester.ac.uk/media/ambs/content-assets/documents/news/devolving-health-and-social-care-learning-from-greater-manchester.pdf. Accessed June 2, 2023.
Sandford M. Devolution to Local Government in England. House of Commons Library; 2024. https://researchbriefings.files.parliament.uk/documents/SN07029/SN07029.pdf. Accessed July 10, 2025.
Britteon P, Fatimah A, Lau YS, et al. The effect of devolution on health: a generalised synthetic control analysis of Greater Manchester, England. Lancet Public Health. 2022;7(10):e844-e852. doi:1016/s2468-2667(22)00198-0
Moss C, Anselmi L, Morciano M, Munford L, Stokes J, Sutton M. Analysing changes to the flow of public funding within local health and care systems: an adaptation of the System of Health Accounts framework to a local health system in England. Health Policy. 2023;137:104904. doi:1016/j.healthpol.2023.104904
Office for National Statistics (ONS). Healthcare Expenditure, UK Health Accounts: 2021. Office for National Statistics. ONS; 2023. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/bulletins/ukhealthaccounts/2021. Accessed September 25, 2023.
Anderson M, Pitchforth E, Edwards N, Alderwick H, McGuire A, Mossialos E. United Kingdom: health system review. Health Syst Transit. 2022;24(1):1-194.
NHS England. Fair Shares: A Guide to NHS Allocations. NHS England; 2023. https://www.england.nhs.uk/wp-content/uploads/2020/02/nhs-allocations-infographics-v3-23-24.pdf. Accessed September 19, 2025.
McDermott I, Checkland K, Coleman A, et al. In: Allen P, Checkland K, Moran V, Peckham S, eds. Commissioning Healthcare in England: Evidence, Policy and Practice. 1st ed. Bristol, UK: Policy Press; 2020:63-82. doi:51952/9781447346128.ch005
Lo C, Anselmi L, Sutton M. Horizontal equity in primary care financing: an assessment of payments to general practices in England, 2014-2022. Soc Sci Med. 2025;373:117996. doi:1016/j.socscimed.2025.117996
Atkins G. Local Government Funding in England. Institute for Government; 2020. https://www.instituteforgovernment.org.uk/explainers/local-government-funding-england. Accessed March 25, 2021.
Ministry of Housing, Communities & Local Government. 2019-20 Business Rates Retention Pilots – Explanatory Note. https://assets.publishing.service.gov.uk/media/5c4f2e2ce5274a492e19de9b/Explanatory_notes_on_pools_pilots_local_government_settlement.pdf. Accessed March 6, 2024.
HM Treasury. Greater Manchester Agreement: Devolution to the GMCA & Transition to a Directly Elected Mayor. HM Treasury; 2014. https://assets.publishing.service.gov.uk/media/5a7e3f29ed915d74e33f102e/Greater_Manchester_Agreement_i.pdf. Accessed July 19, 2025.
Association of Greater Manchester Authorities, Greater Manchester Association of Clinical Commissioning Groups, NHS England. Greater Manchester Health and Social Care Devolution: Memorandum of Understanding. 2015. https://www.greatermanchester-ca.gov.uk/media/1119/health-and-social-care-devolution.pdf. Accessed March 30, 2024.
Checkland K, Segar J, Voorhees J, Coleman A. ‘Like a circle in a spiral, like a wheel within a wheel’: the layers of complexity and challenge for devolution of health and social care in Greater Manchester. Representation. 2015;51(4):453-469. doi:1080/00344893.2016.1165514
Lupton R, Hughes C, Peake-Jones S, Cooper KM. City-Region Devolution in England. The London School of Economics and Political Science; 2018. https://sticerd.lse.ac.uk/dps/case/spdo/spdorp02.pdf. Accessed September 13, 2023.
Greater Manchester Combined Authority (GMCA). Five-Year Vision for Better Health and Social Care in Greater Manchester. GMCA; 2018. https://www.greatermanchester-ca.gov.uk/news/five-year-vision-for-better-health-and-social-care-in-greater-manchester/. Accessed June 2, 2023.
Dunhill L. Exclusive: Winners and losers from £3bn spent on ‘transformation’. Health Services Journal. March 2020. https://www.hsj.co.uk/preview.html?u=https%3a%2f%2fwww.hsj.co.uk%2fstory.aspx%3fstoryCode%3d7027126%26preview%3d1%26hash%3d2AAE18BCBFD2C5787155FC071C8A4DEC. Accessed March 28, 2024.
Amin-Smith N, Phillips D, Simpson P. 100% Business Rate Retention Pilots: What Can Be Learnt and at What Cost? London: Institute for Fiscal Studies; 2018. https://ifs.org.uk/sites/default/files/output_url_files/BN233.pdf. Accessed March 7, 2024.
Saltman RB, Bankauskaite V, Vrangbæk K. Decentralization in Health Care: Strategies and Outcomes. Maidenhead: McGraw-Hill, Open University Press; 2007.
Peckham S, Exworthy M, Powell M, Greener I. Decentralizing health services in the UK: a new conceptual framework. Public Adm. 2008;86(2):559-580. doi:1111/j.1467-9299.2007.00709.x
Bossert T. Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Soc Sci Med. 1998;47(10):1513-1527. doi:1016/s0277-9536(98)00234-2
Checkland K, Dam R, Hammond JO, et al. Being autonomous and having space in which to act: commissioning in the ‘New NHS’ in England. J Soc Policy. 2018;47(2):377-395. doi:1017/s0047279417000587
Department of Health and Social Care (DHSC). Public Information Leaflet: NHS Continuing Healthcare and NHS-Funded Nursing Care. DHSC; 2022. https://www.gov.uk/government/publications/nhs-continuing-healthcare-and-nhs-funded-nursing-care-public-information-leaflet/public-information-leaflet-nhs-continuing-healthcare-and-nhs-funded-nursing-care--2. Accessed January 29, 2024.
NHS England Digital. NHS Payments to General Practice. NHS England Digital; 2023. https://digital.nhs.uk/data-and-information/publications/statistical/nhs-payments-to-general-practice. Accessed January 29, 2024.
Department for Levelling Up, Housing and Communities, Ministry of Housing, Communities & Local Government. Local Authority Revenue Expenditure and Financing. UK Government; 2023. https://www.gov.uk/government/collections/local-authority-revenue-expenditure-and-financing. Accessed November 16, 2023.
Arkhangelsky D, Athey S, Hirshberg DA, Imbens GW, Wager S. Synthetic difference-in-differences. Am Econ Rev. 2021;111(12):4088-4118. doi:1257/aer.20190159
O'Neill S, Kreif N, Grieve R, Sutton M, Sekhon JS. Estimating causal effects: considering three alternatives to difference-in-differences estimation. Health Serv Outcomes Res Methodol. 2016;16:1-21. doi:1007/s10742-016-0146-8
Abadie A. Using synthetic controls: feasibility, data requirements, and methodological aspects. J Econ Lit. 2021;59(2):391-425. doi:1257/jel.20191450
HM Treasury, Department of Health & Social Care. London Health Devolution Agreement. HM Treasury, Department of Health & Social Care; 2017. https://www.gov.uk/government/publications/london-health-devolution-agreement/london-health-devolution-agreement. Accessed June 19, 2025.
Ferraro CF, Findlater L, Morbey R, et al. Describing the indirect impact of COVID-19 on healthcare utilisation using syndromic surveillance systems. BMC Public Health. 2021;21(1):2019. doi:1186/s12889-021-12117-5
Manchester City Council. Annual Statement of Accounts 2019/20. https://www.manchester.gov.uk/downloads/download/7264/unaudited_accounts_201920.
MacKinnon JG, Webb MD. Wild bootstrap inference for wildly different cluster sizes. J Appl Econ. 2017 Mar;32(2):233-254. doi:1002/jae.2508
Page B, Sugavanam T, Fitzpatrick R, Hogan H, Lalani M. Floundering or flourishing? Early insights from the inception of integrated care systems in England. Int J Integr Care. 2024;24(3):4. doi:5334/ijic.7738