Tackling health inequalities

The missing delivery mechanisms in national health missions In recent years, both of the UK's largest political parties have sought to orientate their policy offering around missions. Both have made explicit commitments to tackle the country's geographic health inequalities. In their starkest form, health inequalities – whether based on race, class, gender, geography and so on – will mean that those at the wrong end have, on average, fewer years to live and worse health when alive. In comparison to London and the South East, a baby born in the North East will live three years fewer, while the north of England as a whole has 144 extra infant deaths a year.1 "health inequalities mean that those at the wrong end have, on average, fewer years to live and worse health when alive" It is not just that these injustices are self-evident; it is also that the economic consequences that flow from them matter. At a time of labour shortages, sluggish economic performance and underperforming cities, economic inactivity due to ill health is much higher in the north than in the South East.2 It is unsurprising but welcome that both main parties have developed ambitious missions to tackle these inequalities as part of their headline domestic policies of 'levelling up' and 'mission-driven government'. And yet, since 2010 when the Marmot review laid bare the millions of years of life lost to health inequalities, very little has changed.3 Life expectancy has stalled in England overall, it has decreased in deprived parts of the country and the gap continues to grow.4 What is missing is not ambitious political rhetoric or ambitious government objectives; the two main parties have almost identical missions on healthy life expectancy. Nor is there an absence of understanding about the causes; both parties acknowledge the wider determinants of health that underpin growing spatial health inequalities.5 The problem, we argue, is the failure to identify mechanisms of change. Over the past five years, the government has put health at the heart of its levelling-up rhetoric, defining levelling up as "people everywhere living longer and more fulfilling lives, and benefitting from sustained rises in living standards and well-being".6 The focus on longer lives and wellbeing is reflected in the levelling-up missions. Mission 7 targets improvements in healthy life expectancy and mission 8 targets people's self-reported wellbeing.7 Both also entail a commitment to reduce the geographic disparities of their respective metrics. The government has legally bound itself to these missions, enshrining them in Part 1, Section 1 of the Levelling-up and Regeneration Act 2023, which requires the government to report each year on levelling-up progress.8 Unless the Act is repealed, these same requirements will bind future governments too. There are, however, concerns with the way these missions are formulated. While there are clear targets for improving outcomes overall, such as the target for a five-year increase in healthy life expectancy by 2030, there are no specifics on the reduction in health inequalities. All that is required is for the gap between the highest- and lowest-performing areas to be smaller than it is now, a target that could be achieved without any significant improvement. Furthermore, there is a lack of openness about the trade-off that exists between improving health overall and tackling health inequalities.9 This is part of a broader trade-off between spatial rebalancing and improving outcomes overall. The unavoidable tension between 'levelling' and 'up' is fundamental. Although levelling up is not inherently contradictory, it has created a policymaking challenge beyond the delivery capacity of the current UK state. "the plan for delivery is a disjointed array of competitive funding pots, scattered unstrategically across an austerity-stricken local government system" As a result, the rhetoric on the missions dwarfs the reality of delivery. On the one hand, the 2022 Levelling Up the United Kingdom white paper10 and Levelling Up Act 2023 offer detailed analysis of existing policy problems and a meticulous mission-reporting framework. On the other hand, the plan for delivery is a disjointed array of competitive funding pots, scattered unstrategically across an austerity-stricken local government system. The various funds for delivering levelling up have faced criticisms of pork-barrel politics,11 for being only tangentially related to the levelling-up missions12 and, in some cases, for actually making geographic inequalities worse.13 It remains to be seen whether an incoming Labour government would preserve the levelling-up framework. The policy agenda and the political slogan of levelling up are closely intertwined. And yet, abolishing the levelling-up missions would not only require a significant amendment to, or repeal of, the 2023 Act, it would also represent yet another destabilising reinvention of spatial policy, compounding existing problems of policy churn.14 One of the key lessons for Labour to learn from the levelling-up agenda is the need to move beyond the short-term top-down initiatives that have characterised UK spatial policy for decades.15 The most sensible strategy would be to use levelling up as the starting point for Labour's 'mission-driven government'. Most of the 12 existing levelling-up missions fit neatly into one or another of Labour's five cross-cutting missions. For tackling health inequalities, much of the levelling-up framework can be retained in terms of the diagnosis of the existing problems and the legal requirements for setting and reporting on long-term targets. The current government has laid the groundwork. Unfortunately for the next government, the missing piece of the puzzle is the piece that matters most: the mechanisms of delivery. "for the next government, the missing piece of the puzzle is the piece that matters most: the mechanisms of delivery" One important innovation of Labour's mission-driven approach is to develop a set of delivery goals as realisable stepping stones towards wider change. These goals include NHS targets (for ambulances, general practices and so on), targets for preventative diseases and issues (such as cancer, cardiovascular disease and suicide prevention) and targets for healthy life expectancy. The last of these, however, are remarkably similar in their vagueness to the existing levelling-up mission on health: Labour will seek to "improve healthy life expectancy for all and halve the gap in healthy life expectancy between different regions of England".16 The one noticeable difference is that where the levelling-up agenda offers a concrete target on overall healthy life expectancy and a vague ambition on spatial health inequalities, Labour's emphasis is the other way round. Therefore, in terms of the missions themselves, Labour has a greater emphasis on geographic health disparities as well as more concrete commitments on the NHS, but this still leaves a significant gap to bridge between the ambition and actual delivery. There is little sign that we are about to see a significant cash injection into public health from either of the two main political parties. What money that is available is likely to go into the NHS and focus on health service interventions, such as tobacco control and dietary assistance.17 In terms of tackling health inequalities, the most promising aspect of Labour's health mission is the commitment to a 'prevention-first revolution'. This will depend on policies to support what the party calls "the essential building blocks of a healthy life": "secure jobs, fair pay, adequate housing, safe streets, clean air, and accessible transport".18 However, these 'essential building blocks' – more commonly known as the 'wider determinants of health' – are not prominent in Labour's health plans to date. The framing of Labour's health mission to "get the NHS back on its feet" implies a focus on short-term fixes that, while needed, will do little to tackle health inequalities in the years to come. The party's Child Health Plan includes two preventative proposals – on breakfast clubs and restricting junk food advertising – but there is nothing on the wider determinants of health. Without dedicated policies and funding, it is likely that Labour's 'prevention-first revolution' will not be revolutionary at all, and will instead continue the decades of unfulfilled rhetoric about preventative health. Since 2010, every manifesto of both of the main political parties has promised a rebalancing from treatment to prevention and yet, despite the rhetoric, little has changed. "Without dedicated policies and funding, it is likely that Labour's 'prevention-first revolution' will not be revolutionary at all" Prevention-first approaches and the wider determinants of health have a long history in research on health inequalities. The Marmot review of 2010 brought health inequalities and their wider determinants to the attention of policymakers and politicians. In the years since, the Greater Manchester Combined Authority and six other local authorities have named themselves 'Marmot cities', committing to prioritise health in a range of policy areas.19 Similarly, the South West of England and Gwent in Wales have promised to become 'Marmot regions'.20 At the national level, the government has recognised the importance of these wider determinants. The Public Health Outcomes Framework reports on the wider determinants of health, which are defined broadly as a "diverse range of social, economic and environmental factors which influence people's mental and physical health across the life course". Albeit, the number, the geographical breakdown and timeliness of these indicators are limited when compared to those on healthcare or health behaviours. However, despite an acknowledgement in central and local government of the importance of the wider determinants of health, life expectancy has stalled in England and spatial health inequalities have increased, so that in some areas, life expectancy is actually decreasing; these trends point towards the causal role played by the wider determinants of health.21 Urban development is a significant factor in the wider determinants of health, particularly in how the urban environment impacts non-communicable diseases, which account for 89 per cent of deaths in England.22 To really shift the dial on place-based health inequalities, urban development decisions made by a wide array of actors need to be attuned to public health outcomes.23 It is the totality of thousands of seemingly insignificant decisions about transport, housing, planning and so on that, in combination, drives the long-term national metrics on healthy life expectancy. This means that the delivery gap in the grand missions of both of the main political parties cannot be filled by a handful of central policy levers. "It is the totality of thousands of seemingly insignificant decisions … that … drives the long-term national metrics on healthy life expectancy" Instead, central government needs to focus on improving the decisions made by the various actors involved in urban development: public bodies, local government, planning authorities, developers, investors and so on. This does not mean centralising these decisions or seeking to coerce them through targets. Central government's role is to ensure that decision-makers in a range of contexts have the knowledge, data, time, capacity and incentives to contribute positively to healthy urban development. Based on 132 interviews with stakeholders, the Tackling Root Causes Upstream of Unhealthy Urban Development' (TRUUD) project has sought to understand the complex decision-making landscape around healthy urban development. Each set of actors has different reasons for inaction on health and thus different needs. Real-estate investors need more data to support their 'environmental, social and governance' obligations (ESG).24 Developers need a clearer understanding of their potential to act on health.25 Local planners need more guidance and support in using and enforcing health impact assessments.26 Local governments need more research support to make the right planning decisions.27 There are, however, also cross-cutting challenges that limit the capacity of all actors. There is no clear agreement on what health means, and confusion about what the wider determinants of health are. National strategies in crucial policy areas, like transport and housing, deprioritise or often ignore public health concerns.28 Data is often insufficient or not well suited to requirements. Partnerships and policy co-creation are often underdeveloped. And all actors sit within a chronically underfunded, underpowered and institutionally fragmented system of local governance in England. "actors sit within a chronically underfunded, underpowered and institutionally fragmented system of local governance" To realise ambitious missions to tackle the UK's significant and stubborn spatial health inequalities, central government needs to move away from the lever-pulling approach epitomised by the competitive funding pots of levelling up. The meaningful decisions that drive the wider determinants of health are fragmented among a wide range of different local actors. Therefore, national, devolved and local governments need to work together to understand where the mechanisms of change lie, supporting each other – and non-state actors – to embed public health in all major policy decisions. The role of central government does, of course, include strategic mission-setting, but it must also act to change the incentive structures in which a multitude of daily frontline decisions currently work against the national mission to improve public health and tackle health inequalities. Jack Newman is a research fellow in the School for Policy Studies at the University of Bristol. His research asks how the reform of political institutions can lead to more effective public policy. With a focus on spatial inequality and English devolution, he has worked on projects on local policymaking (University of Surrey), the UK constitution (University of Cambridge) and productivity (University of Manchester). Since January 2024, Jack has been a research fellow on the 'Tackling Root Causes Upstream of Unhealthy Urban Development' (TRUUD) project, a five-year, large-scale transdisciplinary project looking at changing urban development systems in the UK to help reduce non-communicable diseases and health inequalities. Within this project, Jack focuses on how healthy urban development can be embedded in political discourse and realised through devolution and cross-government working. Rachael McClatchey is a research fellow in the School for Policy Studies at the University of Bristol and a public health physician with a longstanding interest in healthy environments and working across disciplines. She has a decade of experience, having worked in local, regional and national government, acute NHS trusts and academic institutions. Rachael's broad research interests are environmental determinants of health and the prevention of non-communicable diseases. Specifically, this includes housing, planning, transport, natural environments, air quality and sustainability. Rachael is currently undertaking a PhD by Publication, exploring how to deliver healthier housing. Geoff Bates is a research fellow at the Institute for Policy Research, and lecturer and deputy director of studies on the Professional Doctorate in Policy Research & Practice, at the University of Bath. He was previously based at the National Institute for Health and Care Excellence (NICE) and the Public Health Institute at Liverpool John Moores University. Geoff's research interests are in public health and health policy. In particular, he is interested in how to tackle the wider determinants of health and health inequalities through policy and individual-level interventions, and understanding health and social behaviours as the outcomes of complex systems. Geoff currently works on the TRUUD project. He also works on research relating to drug use and drug policies, with a particular focus on substances that are used to modify physical appearance or performance. Sarah Ayres is professor of public policy and governance in the School for Policy Studies at the University of Bristol. Her work has explored the complexities of devolution and city governance by looking at the interplay between formal and informal structures, processes and outcomes. Her research has provided critical insights into how 'informal' decision-making – that is, what happens behind closed doors between political elites – has shaped devolution in the UK. Sarah has been an academic adviser on English devolution to three successive UK governments and regularly provides written and oral evidence to both government consultations and House of Commons inquiries.