The challenges of using upstream policy instruments to reduce health inequalities: a qualitative study in the UK

Background In the UK, local government public health departments have responsibilities for health inequalities in their populations. Addressing these is an enduring challenge, given that the determinants of health equity lie in other sectors. A central government programme, Levelling Up, provided funds for action related to determinants of health. This study aimed to explore how these national policy instruments were used at local level to address health determinants. Methods To identify how Levelling Up funds had been used locally, we undertook a content analysis of 107 documents from 15 English local authorities, sampled for diversity of geographic location and authority type across areas of high disadvantage. To understand how local policy actors navigated policy instruments for health equity, we conducted a thematic content analysis of data from five workshops ( N = 60 participants) with local public health actors from four English regions. Results Levelling Up was widely described as an incoherent policy programme, misaligned with local framings of action on, and priorities for, health equity. However, central signaling of the necessity of intersectoral action was reported as useful, and local authorities had pragmatically engaged with Levelling Up to access funds for a diverse range of initiatives. Reported challenges were the high transaction costs of bidding for funding; opaque selection criteria; tensions between actions addressing national inequalities (which prompted regeneration in under-served places) and local inequalities (where new infrastructure was rarely a priority); and lack of congruence between funding arrangements (with one government department responsible) and local government organization, where leadership for Levelling Up was typically dispersed across the authority. Conclusions Leveraging intersectoral work for health equity will always be challenging; analysis of local actors’ perspectives suggests that this is particularly acute where there are tensions between actions needed to address inequalities between areas and those within local areas. To better support local public health actors, policy instruments such as central funding could be devolved more fully to the local implementation level, to ensure better alignment with democratically identified local priorities, and to minimize heavy (and inequitable) transaction costs.