‘Levelling up’ has become an earworm. It featured highly in the Conservative manifesto in 2019, which was referring to improving infrastructure, skills, productivity and economic growth across the country. The idea is to make the UK economy less lop-sided, and less focused on London and the South East.

The aim of ‘levelling up’ has gained even more potency because of the pandemic. For those working in health, policies to level up might also help tackle avoidable inequalities set out by Marmot and others, caused by factors injuring health like poor housing, low quality work, and low skills. In short, poverty and deprivation.

But the government’s levelling up strategy is still under construction. The recently announced Levelling Up Fund is mainly focused on basic infrastructure like transport, not health.

So is levelling up a real and serious aspiration? What would a strategy look like that might also help reduce health inequalities?

In the latest episode of our podcast, our Chief Executive Dr Jennifer Dixon discusses these issues with two expert guests:

  • Professor Diane Coyle is an economist and the Bennett Professor of Public Policy at the University of Cambridge. Diane has many other distinguished roles, including advising the government on economic policy during the pandemic, and leading an independent review for Greater Manchester, which shaped its industrial strategy
  • Sir Howard Bernstein was the Chief Executive of Manchester City Council from 1998 to 2017 and is honorary chair in politics at University of Manchester. He led the devolution of power and budgets to Greater Manchester – the ‘DevoManc’ deal signed between the Government and Greater Manchester Combined Authority in November 2014. He is also a member of a new taskforce set up by the government to advise on the regeneration and development of town and city centres in the wake of COVID-19.

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Dr Jennifer Dixon: Levelling up has become a bit of an air one. It featured highly in the Conservative Manifesto in 2019, which was referring to improving infrastructure skills, productivity, and economic growth across the country. The idea is to make the UK economy less lopsided and less focused on London and the Southeast. The aim of levelling up has gained even more potency because of the pandemic. For those of us working in health, policies to level up might also help tackle avoidable inequalities set up by Michael Marmot and others caused by factors injuring health, like poor housing, low quality work, low skills, in short poverty and deprivation.

The government's levelling up strategy is still under construction. The recently announced Levelling Up Fund is mainly focused on basic infrastructure like transport and not health. The Cabinet Office is working with government departments to put flesh on the bones of a strategy. Meantime, we're waiting for long-promised devolution and recovery white paper, which might spell out whether more powers can be devolved within England to local authorities, city regions, and metro-mayors. Is levelling up a real and serious aspiration, or is it just plain old pork barrel politics to spruce up a few highly selected towns before the next general election?

What would a serious strategy really look like that might also help to narrow the health gap? With me today to discuss this, I'm delighted to welcome Professor Diane Coyle and Sir Howard Bernstein. Diane is an economist who is the Bennett Professor of Public Policy at the University of Cambridge. Diane has many other distinguished roles, including advising the government on economic policy during the pandemic and leading an independent review for Greater Manchester, which shaped its industrial strategy, which leads me to my second guest.

Sir Howard Bernstein, who as many of, was the chief executive of Manchester City Council from 1998 to 2017 and is currently honorary chair in politics at the University of Manchester. Howard led the devolution of power and budgets to Greater Manchester. The 'DevoManc' deal signed between the government and Greater Manchester combined authority in November 2014. He's also a member of the new task force set up by the government to advise on the regeneration and development of town and city centres in the wake of COVID. Welcome to you both.

Sir Howard Bernstein: Good morning.

Professor Diane Coyle: Hello.

Jennifer: What I thought we'd do first is maybe just kick off and just think about this term, which is rather vague. What does it mean levelling up? What do you think the current government means by it and what should it mean?

Diane: It's a process rather than a well-defined destination, I think, and a recognition that there are parts of our country that have not been doing at all well. We know that it could have been better because the former East Germany has overtaken parts of this country to become better off than they are. The interventions that Germany made then show that something can be done about this. It isn't an impossible feature of nature. We're not destined to live with it. Of course, there are the political imperatives that got reflected in the upsets at the last election. Having said that, I don't think there's a very clear definition or understanding of what levelling up will comprise.

Howard: Well, I agree with Diane. What it needs to be fundamentally is a process for tackling inequalities, which have increased, as we all know in the lights of this pandemic. Inequalities around education skills, access to housing, partners of population health homelessness, poverty have been prevalent in our society for far too long.

Jennifer Do what the state of play is in government at the moment on developing a more comprehensive strategy? We hear that the cabinet office is coordinating central government departments on this. Also, separately, Michael Gove is leading something as well, which is also about recovery.

Howard: If you are going to level up in the way I think Diane and I are describing it, it's intrinsically late to a public sector reform agenda. Parts of the analysis needs to be, how do you actually create relevant, properly designed services around people rather than around programs?

I think that is being addressed at some level. I think what we mean by creating innovation centres in places like Manchester, Leeds, Liverpool, or biggest cities I think is currently the subjects of analysis within the base department. I think there is quite a lot of this stuff going on. What we're needing, I think is greater clarity about the outcomes of that process.

Diane: There's definitely a lot of work going on across the civil service and also in local government to think about how to make levelling up real and deliver on this process. The challenge it seems to me is really quite large though, because it's public service reform across the board. It's linking up policies across departments that are traditionally very siloed so that they have this focus on place and people in a way that they haven't before.

I think it's also linked to political decisions and questions of accountability. That makes ultimately delivering on the levelling up promise really quite a complicated thing. How much more devolution of powers is there going to be? How do the English regions fit into the context of the devolved nations and all the tensions there? What about overlapping responsibilities between different LEPs and city regions, and so on. Those are really quite thorny issues and it's possible to make a lot of headway on this levelling up before you get to those but ultimately, I think those political issues are part of their story as well.

Jennifer: I think what you're describing both of you is really quite extensive and it feels almost beyond the powers of any government at the moment, given the pandemic and the fiscal hardship that we are likely to face to have the bandwidth to really do all this. Given this is such a massive agenda, how should it proceed and how could it develop something which is a long-term program?

Diane: Well, it's obviously difficult, and the financial pressures are there but it's also an opportunity because my sense is that the appetite for doing things differently is quite strong within government and among citizens also. Actually, it's creating that broader sense of levelling up that Howard was describing that it's not just about the hard economic measures, productivity, GDP per capita, but it's about quality of life, a place that you're proud to live in, environment, health, and all of those other factors, too. That makes it a complicated challenge but there's also an opportunity at the moment.

Sir Howard: The pandemic has actually underlined the significance for being able to respond to these challenges. This is not always about how you spend new money. I've made this point before. There are significant amounts of money going into our skill system, many parts of our public services, without necessarily impacting upon people and driving, then creating the incentives for change. There are some big budgets going to emerge over the next 12 months.

Research and development is a classic example of that through the science budget. It's absolutely essential that that research and development budget is spent in ways which not only deliver global Britain ambitions but also the requirement to support our biggest cities, particularly in the north of England to achieve their full potential.

Jennifer: I think everybody agrees that the economy in Britain is completely lopsided. In fact, I think the IFS showed out of 26 comparable developed countries, it was the most decentralised nation with respect to productivity in the economy. We've had industrial strategies, we've had plans before, haven't we to try to level up, although those terms probably weren't used. Why would it be different this time? Why has it been so difficult in the past?

Diane: At the moment, I don't think it's clear that it would be different. All of us who have been working in this area for some time were depressed by the abolition of the Industrial Strategy Council and the scrapping of the industrial strategy in the new plan for growth because we've had so many of them. If you've got a new one every three years, it's not a strategy. One of the things that's needed is just consistency of intent and policies over time. Or look at something like skills policies and the number of times that's been changed or the almost constant reform of the National Health Service.

Of course, you want improvement but there is a balance to be struck in not changing the policy framework, making it impossible for people to plan. I don't think in that sense, we've really tried it properly. There are other issues also, which you might come onto. One is about the scale of intervention and half past policies just spread jam too thin and not approached at the scale that they need to be successful.

The other is actually the degree of local involvement because if you don't really involve local people and local policymakers and decision-makers, and if you've got this almost combative relationship sometimes between the centre and the localities, then that's not going to work. Actually, you're going to lose really vital information not captured in the economic statistics that you need to understand to get things to work around the country.

Jennifer: Yes. Howard, in the Industrial Strategy Council's analysis of the government's plan for growth, it said four big things, I think. One is it said that there was an over-reliance on infrastructure. The second that they'd been, as Diane says, insufficient collaboration with local authorities and businesses to develop this, an over-centralised approach to funding where local authorities had to bid as opposed to money being put into the bottom line of local authorities and too many initiatives too thinly spread. What are your observations?

Howard: I recognise that analysis but for me, the single biggest failure of the industrial strategy is that it never made any linkages with people. It was very much an asset-based analysis where are we distinctively strong in this country in relation to research and development? What were the institutions that could be supported? What were the business opportunities to drive the supply chain?

Got all of that but where was the underpinning investment in equipping people to be able to access the skills and therefore their capability to make these ecosystems work? If you look at many of the peer cities around the world, which Diane would be very familiar with, they're not just very strong in innovation terms around research and development. They're also very strong with a technologically diverse business pace and also a very, very strong and productive labor force. Until we start to align this myriad of initiatives around place and in an aligned way, then I'm afraid we'll always going to be falling short of our targets.

Jennifer: The plan for growth as it is at the moment, has three big things in it. It really does major on infrastructure, doesn't it? 600 billion over 5 years. Skills is the second pillar, and it begins to talk about some of the things that you're talking about there, Howard and innovation is the third, but it does really look quite top heavy on infrastructure. Is that the right place to start?

Howard: I think it's one of the key inputs, certainly where I come from, we've seen precious little investment in infrastructure for the last 20 years. In fact, we're still talking about things which George Osborne announced several years ago about HS2, about, Northern Powerhouse Rail. Those are absolutely fundamental investments, not just to rebalance the economy, but to actually synergise labour markets but it's only part of the story. What we've also got to do, as we've discussed, is tackle inequality and drive innovation as part of a comprehensive strategy for growth.

Jennifer: Looking at it from the health side, as I did when I looked at a plan for growth, what was interesting in there is that there was very little mention of Britain's largest industry, which is the National Health Service. The main reference to the NHS was, we need to have a prosperous Britain in order to pay for the NHS. There wasn't a recognition about what the NHS as an asset could do to help generate wealth or reduce inequality, which was quite interesting.

It's £140 billion worth of industry sitting inside Britain. I don't know whether that occurred to you and whether you thought that there's more opportunity there for the NHS as an anchor institution to do more.

Howard: Well, I think it's one of the key platforms for public sector reform in the lights of the arrangements that Greater Manchester negotiated. I was privileged to play a part in that several years ago. We never saw it as an opportunity just to fix hospitals. We saw it as an opportunity to rethink the way we commission public services, particularly when we start to address. What do we mean by early how health? What do we mean by early intervention? What do we see as the new care models? What do we mean by health innovation system and its relationship, not just to growth, but meeting some of our global ambitions around science?

Diane: I completely agree. I've done a piece of work with some colleagues looking at what's happened in hospitals during the pandemic. If you look at the government's guidance about its development spending overseas, it emphasizes the importance of health as part of the social infrastructure, and so investing in health and the health population affecting what we economists call it human capital. The capability of people to lead good lives and do good work is fundamental. We need to think about it in that way and recognise the incredible shortage of resources in parts of the health service, but also integrate it across social care and education services.

Think about health procurement as a tool the government has to upskill and innovate, and the NHS's own research and what possibilities that has for our science space as Howard was just saying.

Jennifer: Yes, and how the NHS can operate with its assets to provide more than healthcare to help boost the economy in a local area by local procurements or lease of its estates and so on is coming up the charts in the NHS's lexicon too, which is quite important. Actually, if you look at NHS spending, it's actually pretty evenly distributed across the country.

Howard: What we mean by community facilities in different neighbourhoods, that is a very big agenda and huge opportunities here to create new clusters of community facilities around better and more relevant outcome models. Absolutely key to supporting communities.

Diane: I think that the physical infrastructure is really important, but the social infrastructure is as important. It needs to be considered as part of that investment framework.

Howard: Agreed.

Jennifer: Yes, very, very good. Diane, you, you just helpfully talked just about the health capital. They're various discussions, haven't there been over these four capitals. Actually, this is the better measurement of prosperity that the four capitals, the human capital, which includes health, social capital which includes communities and cultural capital, natural capital green and physical infrastructure. Looking at what we've got so far out of government, it's only early days, the emphasis is very much on the physical infrastructure it seems, and a little bit on some of the skills.

Do you think that in developing this strategy that we should have a more balanced set of measures in which health might feature a little bit more for example?

Diane: Yes. We use this asset or capital framework in our work because it embeds thinking about the long-term. It embeds sustainability. If you're thinking about it, it's like a company thinking about a balance sheet as well as a profit and loss. They're both absolutely integral to thinking about prosperity. Also, it makes you think about the links between them and taking a balanced approach.

For example, natural capital, clearly the government thinks that's important in the context of COP26 and climate change, but actually there's much more to it than that and it links to people's health and wellbeing. If you live in a place with polluted air, then you are more likely to see, at a group level, worse outcomes during the pandemic because of respiratory ill health. We know that access to green space is good for people's wellbeing, but it also makes places nice to live. That has economic consequences. The house prices are a really good indicator of the economic value that an environment drives.

If you think about natural capital alongside concrete, you don't need to spend so much on flood defences. You can plant trees upstream and leave some wetlands downstream. Thinking about these things as a portfolio, both integrates policies and makes you focus on the long-term as well as the short.

Jennifer: Howard, did you think about this in Greater Manchester thinking about more explicitly measurement of these four capitals or something beyond the usual GDP and prosperity?

Howard: We did something very similar really. We had a focus around three things: people, assets, and place. We had indicators which Diane helped us shape actually right across that spread of activity and priority. On people, examples, lots of skills, housing, health around our assets. What did that mean for our universities? What did it mean for research and development? Our transport base, our regional, our town centres. On place, what were the issues around governance?

How were we going on our functional economic geography to address planning international investment? You can do your own thing here. There is plenty of room for innovation, but fundamentally, you've got to have what I would describe as a comprehensive approach, which is actually underpinned by evidence. There absolutely is too many of these approaches in my view, which are not underpinned by the necessary evidence, but I think that was one of the distinguishing and distinctive parts at the Manchester story.

Jennifer: The Industrial Strategy Council did make an attempt, didn't it, to develop some metrics to assess levelling up or their progress of the industrial strategy, but which were quite broad. Who should do this now if the council is disbanded?

Howard: It is incredibly difficult to do this stuff nationally. You can have a broad framework. You can set broad priorities. You can link those priorities with a fiscal and economic management framework. Fundamentally, you've actually got some make this work at place level, particularly in those big city regions where we can make the most difference and where we can drive the better and bigger outcomes. The national Industrial Strategy to do was starting to link. You could say it's a bit too bureaucratic, that maybe right as well, but it started to create that local sense of identity, that local focus around place, people, and assets which I think very importantly.

It's just a shame really that at a time when were we were really driving those place-based strategies, that in a sense, this has been deferred. My personal view is that this agenda will come back. I think it will be called something else. It might be called the growth plan or the government's growth plan rather than an Industrial Strategy. I think what we've got to do is give the government a bit of space in order to be able to come to its own conclusions, which will not differ significantly from the previous strategies, certainly in terms of outcomes that we're looking for.

Jennifer: Yes, Diane, what do you think about having a more balanced assessment of progress at a national or indeed a local level using a balance of indicators? Obviously, Industrial Strategy Council have had a go, haven't they? The INS have come up with a wellbeing index, which has some elements too. How should we proceed?

Diane: There's a lot of work at the moment in thinking about broader frames of measuring what's going on in the economy and society. I think that's incredibly healthy, so we get away from a narrow focus on GDP per capita or conventional productivity measures. This does need to happen both nationally and in different places because it's a very diverse country. Both what people want, and the economic strengths and the existing landscape and infrastructure differ incredibly around the country.

We need to set up, I would say, as a national asset, a data platform, which has the national figures and the figures that people can go into at different levels of geography to find what they need to know, to develop local priorities and align in a very positive way at national government and subnational governments.

Jennifer: Yes. As far as we're concerned at The Health Foundation, obviously we're interested in health metrics and particularly with the demise of Public Health England, how that is then going to be measured. If you remember the Marmot inquiry, we actually funded the 10 years on inquiry published last year, and then the Build Back Fairer Report, we funded the team as well. We're an independent foundation. I think in a sense we need a constant monitoring of this because if we don't do it, who will do that and how will that be linked to progress on this sort of prosperity agenda?

Howard: I agree. Just up to this as well. The requirement for some form of national observatory, I think is absolutely right. That point has been made by a number of us over the past few months. I think there's also a requirement about the actual impacts of the pandemic. We're seeing lots of analysis, aren't we, and we'll see a lot more I'm sure over the coming months about how the pandemic has really impacted on communities and on people and on places. There is still so much uncertainty about the impacts on place, around structural shifts and the economy, how certain things will come back, how they won't.

You can't expect individual places to have access to that data and that intelligence. It is, in my view, a national requirement that we start to put together an intelligence space, which properly informs, not just national policies, but local policies too.

Diane: I'd go a bit further and say we need to have a national resource of analysts that people around the country, local authorities could draw on when they needed help understanding that data.

Howard: Agreed.

Jennifer: Yes. In a sense, we've got the OBR for economics, haven't we? Do we need something similar for some of the other major capitals that we talked about, is the question, isn't it, I guess?

Howard: Yes.

Jennifer: I think both of you have quite rightly mentioned the heterogeneity of the country and the importance of local place and indeed local government. I wanted to just ask a bit more now, probe a bit more about devolution and where we are with that. Howard, your front and centre, aren't you, given your experience in Manchester. Has the government gone cold on devolution and what's happened to the devolution and recovery white paper? What do you expect to be in it?

Howard: Well, I hope there'll be a recovery. The white paper will be astonishing if there isn't. I think it’s fair to say the momentum around devolution has been lost. I don't see much evidence of a government that's really actively promoting that agenda, which is a surprise really, having regard to the Prime Minister's personal commitment to that agenda. Certainly, when it comes to the values, he’s one of the most passionate advocates of devolution. Perhaps devolution isn't the right way of describing it at the moment.

There is a requirement to build mutual trust, respect, start to rewire the constitutional working relationships almost between local and central government. Perhaps we need to start thinking about what we mean by co-design, by place-based settlements, which is more of a partnership between local places and central government. The role local places can actually fulfil in delivering national priorities. How do you align local and national investment programs? The concepts of place deals, placed-based settlements I think is more likely to be fertile ground for exploitation in the future.

Of course, if we got ourselves into that position and we can demonstrate they work and there are challenges on both sides, of course, in that respect, then you can actually move on to a much wider, more radical discussion and debates about devolution generally.

Jennifer: This whole business of where there are extra investments, at the moment we've got, as Diane was saying, quite a lot of central bidding pots that local authorities have to go for. Another approach would be actually to put that money in the baseline of local authorities. If you were really wanting to affect devolution more fully, why is the government holding onto the purse strings? Does it just not trust local government enough to put it in the baseline? Or does it believe that the bidding process itself has value?

Diane: It's a bit of both, there's a treasury orthodoxy about this, partly that nobody else can control public spending effectively. That's the trust element, I suppose. Of course, it's true that if you do devolve spending decisions, then some people will make mistakes. If you've got senior civil servants and ministers who fear that they will take the flack for it, nevertheless, then you can understand that dynamic. On the other hand, if you never trust people, then it's a vicious circle. It will never change.

I think there's also still a bit of belief that if you get these competing bids, it will drive quality just as if it were a market, which I think is a nonsense actually. It wastes a lot of resource and people trying to put their bids together with the one positive side effect that it does make places think about what they're going to put in the bid and what their needs are. I think it's rather a wasteful unproductive system.

Howard: I agree with Diane. Can I just add something around the whole approach to place leadership as well? I think we've reached the points again, which I thought we got over several years ago where national government is viewing everything as sort of one size fits all. Everybody's in the same boat and everybody's linked to their worst perceptions of some of the weaker places. They're not there for being deferential enough in being able to allow those places that can get on with things to get on with things.

They are not empowering those places who have got that capacity to move forward. I think that's going to become a much bigger issue over the coming months.

Jennifer: Do you think that the centre has got a reasonable fix on the capabilities of local government to make an intelligent decision about how much more it can swill money through them as opposed to hold it centrally? How much trust it can expand?

Howard: I don't know. It should do. It wouldn't be appropriate now, but we all know the places which struggle with place leadership, don't we? I think part of the analysis I think government should undertake is how do you actually support place leadership capability everywhere? Everywhere is going to be challenged over the coming months in my view given the pandemic and what's required to sustain economic recovery.

Place shaping is a creative endeavour. It is not a characterisation of everywhere. How you actually promote effective place leadership all over is an absolute prerequisite. Unless you've got place leadership, you're not going to have the level of competence, the level of confidence around local government in terms of its ability to deliver. That shouldn't mean in my view that you hold back those places particularly our big cities, which have got effective place leadership already in place because they've been doing it for years.

They've been absolutely remarkable over the last 12 months, and we've got to encourage and empower them to do more.

Diane: Just to underline the point I made about analytical capacity, you can help places develop leadership capacity as well. For that matter, why would you not make it a condition of rising in the ranks at the civil service that people spent some time based elsewhere in the country? They spent a good five-year stint in one of the cities or towns of the Southwest or the Northeast. They would learn a lot and it would help develop that local capability.

Jennifer: Just going back to my question, even if you had capability, would central government know it if they saw it? Have they got the capability to be able to spot, and therefore trust more where there is higher capability?

Howard: This is the whole idea around place-based settlements, isn't it? Because if you're actually co-investors, and government is a co-investor in places, and you're actually demonstrating the positive impacts of joint action, then you will build enough mutual confidence in government and elsewhere about your capacity to deliver.

Jennifer: We've got enough of a radar screen centrally to be able to spot that progress. That's the question.

Howard: If you've got a place-based settlement, you're saying, 'You're going to put this amount of money in to do X and you're going to deliver Y, and this is how we're going to measure it.' That was the whole point of around some of the stuff we did with the Audit Commission around devolution where we had clear, measurable indicators for being able to assess the impact.

Diane: You're never going to build the confidence if you don't talk to people too, so they just have to get on with it.

Howard: Exactly.

Jennifer: Yes, it seems irrelevant to mention one point here that I heard Michael Heseltine making recently. I'm sure you've heard him say this before, that when we're talking about leadership and strategic leadership in particular in a place, he obviously thinks there's too many local authorities as many others do. He said there were 1200 in the '70s, they were now 340. There should be 60 to get a proper strategic view over a place. What's your view about that?

Howard: No, he's been very consistent in this field over the years. I love him. My sense is those are distractions that there are good legislative provisions already in play, which enable different local authorities, smaller towns, bigger towns, urban, rural, rural to come together in a functional economic geography to actually work together and drive change. I think debates about removing local responsibilities, merging different local time just work. It can work in some places, but it can also be very, very divisive.

Diane: I agree. It's horses for courses. People need to talk to each other when there are overlapping areas of interest. The thing I would be a bit concerned about is accountability at these different levels or scopes of government. We've seen the local media really struggle. That is one element of accountability that has decreased. Then there are areas where, because of the overlapping responsibilities, there isn't accountability for different policies, and I think that needs a bit of thought.

Jennifer: There is a question also about the private sector's role, which I know is very active in many, many city regions. When you look, and I was hearing a discussion the other day about the varying strengthens strategic capability of Chambers of Commerce, the CBI, the Small Business Federation and so on. I just wondered what you thought, whether these groups could step up more strategically not just in a town or a city, but actually on a more national level. Do you think there's room for that?

Howard: The involvement of the business community in different and individual places is absolutely paramount. You can't effect the change that is required without vibrant upto private sets of leadership in different places, no doubt at all about that. Where it comes from, however is an open question. Being able to support business leaders play a full and active part in shaping place priorities. It's something that Manchester and all the big cities have been doing for a very, very long time.

We're very lucky in Greater Manchester because we've got very good and very effective Chamber of Commerce network, which is great credit to the leadership there. Not everyone is similarly blessed if I'm being frank. By actively cultivating relationships with business leaders and business leaders exist everywhere, you can encourage their emergence, their participation in charting the strategic direction of places.

Jennifer: I should have perhaps included unions on this as well, which we haven't mentioned so far. Presumably the same arguments apply, Howard?

Howard: Yes, absolutely. They're very, very active in Manchester.

Jennifer: I was looking at the Biden stimulus package, the 2 trillion that's on the table at the moment, the jobs plan. There's significant amount of money in there for initiatives to support labour unions interestingly enough, to try to help support workers, particularly the low paid workers.

Diane: Absolutely. If you're thinking about up-skilling, the unions would be key to that. Think about the so-called gig economy. One about a quarter of our workforce have zero-hours contracts or temporary jobs or part-time jobs or working in that very contingent way. Then if we're going to drive national prosperity and productivity, that sector is going to have to up-skill. That means enforcing all the labour regulations that we have to improve conditions, but also involving unions in helping deliver that process of up-skilling and creating better quality jobs. Absolutely key.

Jennifer: Yes, of course, good quality work is so important for health, as we know. Again, just going back to Biden, I noticed that one of the key aspects of the stimulus package is also to increase the pay of workers, providing care for that very reason, Diane, which is an increasing part of the labor force, as we know. Well, we're nearly out of time. Maybe we can end perhaps by just asking you both. Are you feeling optimistic despite the huge overhang of debt that we have in this country? Are you optimistic that we can make some progress on the levelling up agenda both generally for economic prosperity, but also particularly for the health side?

Howard: Well, we've got to is the short answer to that. All of us in our own way have got an obligation to continue to articulate this requirement and hold all government to account.

Diane: Yes, I'm optimistic about the opportunity and the appetite. I'm reserving judgment about what will actually happen.

Jennifer: With that, we'll have to leave it there for now. I'd like to thank our guests, Diane Coyle, and Howard Bernstein very much for a really rich discussion today and one which we're bound to return to, not least because of the links between health and wealth. Watch out for are linked to publication on levelling up, which is going to be published in May on the Health Foundations Website. Feel free to subscribe wherever you get this podcast, so you don't miss the next episode.

As ever you'll find relevant reading and other material in the show notes. Do join us next time when we'll be discussing what's really happening to the mental health of our young people and why. For now, that's all, folks, and see you next time.

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Q is an initiative connecting people with improvement expertise across the UK.

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