From legislation to delivery: will devolution improve health outcomes?

At a time when the UK’s health is deteriorating, the case for stronger local leadership has rarely been clearer. 

Our new analysis shows that average healthy life expectancy in the UK has fallen by around 2 years over a decade to just over 60 years. In most parts of the country, people will now reach retirement age in poor health, with a gap of nearly 20 years between the richest and poorest areas. 

This is more than a public health concern, it is an economic one. Poor health is acting as a drag on local economies, driving rising economic inactivity and constraining productivity. This should be a ‘watershed moment’ for how we think about health and a spur to act on the social and economic drivers of these trends. 

It is in this context that the English Devolution and Community Empowerment Act has become law. Taken together, the measures in the act, alongside a new statutory duty to improve health and reduce health inequalities and the ability for mayors to appoint a health commissioner, mark a shift in expectations. Strategic authorities are increasingly recognised as holding many of the levers over what drives health. 

System convenors

Around 80% of health outcomes are shaped not by health care but by the building blocks of health – good jobs, safe and affordable housing, transport and access to green space. This creates an opportunity for strategic authorities to play a more active role in shaping these conditions. In practice, this means acting as system convenors, bringing together local government, the NHS, employers and others to align action across health, growth and public service reform.

The opportunity now is how far this can be built on consistently across the country. The legislation moves things forward but leaves significant room for interpretation.

Through the Mayoral Regions Programme, funded by the Health Foundation and led by the West Midlands Combined Authority in partnership with nine other mayoral strategic regions in England, there are early signs of what this could look like in practice. In some areas, strategic authorities are working with councils, the NHS and others to link economic strategy with health outcomes, whether that’s tackling economic inactivity, improving access to good work or embedding health into spatial planning.

In the West Midlands, this approach is taking shape through a ‘health in all policies’ model that brings together transport, housing, employment and innovation. For example, work on active travel and the Outdoor Region for Everyone initiative links investment in infrastructure to increased physical activity, supporting both health outcomes and economic participation.

Approaches such as health in all policies, including those set out in the Mayoral Regions Programme toolkit, provide a practical framework for aligning action across sectors and could support more consistent, place-based approaches over time.

However, progress remains uneven. In some places, roles, relationships and capacity are still evolving, reflecting different stages of maturity. A key challenge will be how strategic authorities step into a stronger convening role while working alongside existing responsibilities held by local government, the NHS and others. The act does not fully resolve how these roles fit together in practice, and clarity on who does what will need to be worked through locally.

Capacity and resource

There are also practical questions about capacity and resources. Many strategic authorities are continuing to build their analytical capability, relationships with system partners and their ability to act at scale. The new duty is not matched by dedicated funding, although expectations are high that strategic authorities maintain capacity and expertise to deliver it. What happens next will be critical. 

From the Mayoral Regions Programme, one consistent theme is that progress has depended less on formal powers and more on how effectively places bring partners together around a shared agenda linking health and growth.

That includes closer working between strategic authorities and councils, stronger alignment with integrated care systems and a clearer narrative about how improving health underpins economic and social outcomes. The Health Foundation and partners will continue to support this shift through the Mayoral Regions Programme and wider work.

The decline in healthy life expectancy is not inevitable. But reversing it will require action well beyond health care, using the levers that sit at regional and local levels.  

The act creates a significant opportunity. Realising its full potential will depend on how strategic authorities and their partners continue to build on this momentum and act together.

Katherine Merrifield is the Deputy Director for Health and Inequalities at the Health Foundation. Mubasshir Ajaz is the Head of Health and Communities at West Midlands Combined Authority.

This article was first published by Local Government Chronicle on 14 May 2026.