Andy Burnham often describes health and social care devolution in Greater Manchester as one of the most important reforms of his political career. Few politicians have invested more effort in the idea that local leaders can improve public services by bringing decisions closer to the people they serve.

Yet ten years after Greater Manchester became the first English region to take control of a devolved health and social care budget, an important question remains: has the experiment delivered the improvements its supporters promised?

Since 2016, Greater Manchester has exercised significant influence over the planning and integration of NHS and social care services. While the NHS remains a national service, Greater Manchester has enjoyed more freedom than most parts of England to coordinate healthcare, social care and wider public services.

Supporters point to genuine successes. Greater Manchester was widely praised for cooperation between councils, the NHS and other public bodies during the Covid-19 pandemic. It has also pioneered programmes designed to bring health and social care closer together and tackle the wider causes of poor health.

Burnham has consistently argued that health outcomes are shaped not only by hospitals and GP surgeries but also by housing, employment, transport and poverty. Many health experts would agree.

However, the case for devolution was never simply about improving cooperation. It was also about improving results.

Here the picture becomes more complicated.

Despite years of devolved decision-making, Greater Manchester continues to face some of the worst health inequalities in England. Life expectancy remains much lower in some communities than in others, and large gaps persist between richer and poorer parts of the city region.

NHS waiting lists also remain a major concern. Like the rest of England, Greater Manchester experienced a sharp rise in waiting times after the pandemic. While local leaders can point to national pressures, patients will often judge the system by whether they can access treatment when they need it.

The same challenge exists in social care. Burnham has frequently argued that councils have been asked to do more with less and that years of underfunding have left services under severe strain. Most council leaders, whatever their political party, would recognise that description.

Yet this raises a difficult question. If underfunding is the main reason for poor outcomes, what has devolution achieved beyond giving local leaders more influence over how shortages are managed?

This is where the debate often misses an important point. Greater Manchester has received more responsibility, but only limited control over the money needed to deliver that responsibility. Most funding still comes from central government and remains tied to national rules and spending decisions.

As a result, local leaders can often decide how services are organised, but have much less control over the resources available to improve them. Responsibility has been devolved further than financial power.

This matters because Burnham has often presented Greater Manchester as a model for national reform.

His argument is that local leaders understand local needs better than Whitehall and should have greater control over public services. There is considerable merit in that view. Liberal Democrats have long supported moving power away from Westminster.

However, real devolution requires more than transferring responsibility. It also requires fiscal devolution. If local leaders are to be held accountable for outcomes, they should have greater control over raising and retaining the revenue needed to achieve them.

Many countries with stronger local government systems give regional authorities more control over taxation and spending. England remains one of the most centralised countries in the developed world. Local leaders are often expected to solve problems without having the financial tools needed to do so.

Greater Manchester highlights this contradiction. Burnham and his colleagues can influence priorities, coordinate services and redesign programmes. But they cannot fully control the funding streams that support them.

Fiscal devolution would also strengthen accountability. Local leaders would no longer be able to blame every shortcoming on Westminster, while central government could no longer claim credit for local successes. Voters would have a clearer link between decisions, spending and results.

Many of the pressures facing the NHS and social care are national in nature. Staff shortages, rising demand, an ageing population and funding constraints affect every part of the country. Local innovation can help, but it cannot remove those pressures altogether.

This creates a tension in Burnham’s wider political message. He often argues that Greater Manchester’s progress has been limited by decisions made in Westminster. Yet if he became Prime Minister, those national constraints would become his responsibility.

For Liberal Democrats, the lesson is not that devolution has failed. Greater Manchester has shown the value of local leadership and stronger cooperation between services. The lesson is that devolution is a tool, not a solution in itself.

Andy Burnham’s NHS record reflects both the promise and the limits of local power. Greater Manchester has shown that services can work together more effectively when decisions are made closer to communities. But it has also shown that local leaders cannot overcome every challenge created by national funding pressures and rising demand.

The result is a mixed but important record. If the next stage of English devolution is to succeed, it will need to devolve money as well as power.

* Iain Donaldson is the treasurer of the Rochdale Liberal Democrats.