The transfer of responsibility for public health to local government is widely seen as one of the more successful elements of the controversial 2012 health reforms.
It recognised that local government is best placed to address the causes of the causes of poor health – the wider determinants – like housing, access to green spaces and employment that drive health outcomes. The COVID-19 pandemic showed the value of local leaders who are trusted by their local communities, businesses and partners.
But the transfer of power to local government has not been without its challenges. The reforms coincided with austerity and local government budgets being cut or frozen.
Unfortunately, this is an example of a persistent trend with Government saying it wants to support place-based action, without giving local authorities the tools, freedoms and flexibilities to make a real difference in their communities. It is time for Government to go further and really walk-the-walk to unlock and empower this kind of local leadership.
Cuts to both core funding and the public health grant have happened at a time when demand has increased. Health Foundation analysis has shown that rates of obesity, alcohol specific death rates and drug related deaths have all increased over recent years and there are early signs that the pandemic may have further exacerbated inequalities in these areas.
Dealing with these pressures in the context of reduced funding has been a huge barrier to local areas focusing on prevention and early intervention support. Local government is also hampered by a complex and fragmented funding landscape, and a culture where a huge proportion of interaction with central government is in applying for small, short-term grants.
This is often at the expense of discussions about what would really make a difference to local areas and can favour those with the best bid writers, not necessarily the greatest need. Perhaps because addressing health inequalities is now seen as the responsibility of local government, taking action has not been high on Whitehall's to-do list since 2012. This is a naïve approach and it has led to missed opportunities to make the systemic changes that are needed.
The COVID-19 pandemic demonstrated the inextricable link between wealth and health. We know that good health improves wellbeing, economic participation and the ability of individuals to contribute to their families, communities and wider society. The CBI estimates that poor health costs the UK an eye-watering £300bn a year in lost output, excluding health costs.
Health secretary Sajid Javid has acknowledged that ‘we can only level up economically if we level up in terms of health too' but we are still waiting to see if the link between health and prosperity will be at the heart of the Government's levelling up proposals – or if it will even feature at all.
Despite efforts over many years to get Government departments to work more closely together, departmental siloes are still a huge feature of Whitehall. The difficulty in breaking down these siloes thwarts the ability of local areas to deliver joined-up, place-based agendas.
The Health Foundation, working with the Local Government Association, is currently funding five partnerships between local government and local partners to understand how to take a system-wide action on the wider determinants of health, with learnings for local and central government. The local partnerships will address the topics that matter to them: food security, mental health, and fear of violence and crime in their communities.
The Health Foundation is also funding four partnerships in the UK to integrate economic development activity with work to improve health through our Economies for Healthier Lives programme.
So, what's needed for Government to follow through on its rhetoric and really provide the conditions in which local government can take radical, innovative action to improve health?
As we've argued in our recent briefing, improving health will require a truly ‘whole government' approach and Government needs to provide sufficient and sustainable funding for all local government activities.
More discretion is also needed over how money is spent, potentially through more place-based budgeting. Giving local areas greater flexibility in this way, as has been the case in combined authorities, would make it easier for local partners to work together on shared priorities.
There are, finally, some signs that Government is starting to see improving health as a task that requires actors beyond just the Department of Health and Social Care.
The new Health Promotion Taskforce, the promised levelling up white paper and one on disparities, will be the products of cross-departmental working.
This may even see Government catching up with the health in all policies approach exemplified in many local areas. But will the white paper truly seize the opportunity to put health at the centre of efforts to level up? And will local leaders really be given more power to shape their communities?
So, as we await the latest Government pronouncements, we'll be looking out for a recognition of the absolutely vital role local government plays in improving health and a commitment to really follow through and enable local authorities to lead efforts in their areas to level up health.
The Health Foundation is sponsoring The MJ Award category: Place based approaches to improving health and health equity. This category invites entries from local authorities which can display a whole place strategy and tangible improvements in creating fair opportunities to improve health and reduce inequalities.
