The health mission unpacked – with Hannah White and Jo Bibby

Jennifer Dixon:

The idea of mission-led government was first set out by Keir Starmer 2 years ago. Missions were to focus on long-term complex problems, which could have achievable results. They were also an approach which stretched over two terms of government at least, requiring multiple stakeholders to join together, collaborate and achieve results. Ambitious. So Labour's election manifesto set out five missions, and one of them was on health. That was last July. Has anything happened since then? 

Well, with me to discuss all this, I'm pleased to welcome Dr Hannah White, Director of the Institute for Government, who has been studying mission approach in government, and Dr Jo Bibby who is Director of Health here at the Health Foundation. Welcome both. 

Could you remind us what is meant by mission-led government and where the idea actually came from?

Hannah White:

The idea of mission-led government is all really about the objective rather than how you get there. So instead of having a target that government sets, which has a set of things it's going to do, it thinks about a long-term complex issue that it's trying to solve, and the means of getting there has to evolve along the way. But the missions need to be clear, they need to be measurable and there needs to be a time by which you're going to get there. And the idea is, that you marshal the resources of government, the resources of people beyond government to help you reach that aim. And the idea popularised by the economist, Mariana Mazzucato, and she's talked about it in the context of government, although looking back through the history of different governments in different countries, people identify things like John F. Kennedy's mission to put the man on the moon as precursors to this sort of approach.

Jo Bibby:

When people talk about the rationale for a mission-led approach, it's often framed in terms of addressing a lot of the familiar issues that we know that stymie government's getting results. So things like over-centralisation, the emphasis on quick fixes over perhaps some of the harder or less visible action that's needed to get long-term outcomes. And of course, the whole challenge of silo government. 

When Labour set out in 2023 their mission-based approach, I think there were some really positive things that they wanted to achieve. So they talked about the focus on real-world impact. They talked about injecting more accountability. And also the thing that probably we were most interested in, was they talked about the need for a long-term preventative approach. This isn't a new idea. In fact, Rishi Sunak talked about the need for long-term decisions to build a better future in the speech he made in November, 2023. So we know these things are easier to say than do. But fundamentally, the intent is clearly what is needed to address some of the very complex challenges we have in society.

Jennifer Dixon:

Long-term policy making everyone has talked about for decades, haven't they? It's rather elusive. I guess the question then is, what is different this time that could actually make it a reality? Is it just the promise that there may be two terms of government, but then there isn't much money? Is it just that there's more higher intensity of will this time? Or is it just the nature of the challenges are so big and complex that we can't avoid this type of approach?

Hannah White:

Government always has big and complex challenges. And I think what's different, is that you do have a government that very much pitched this as core to its approach. So it wasn't just a speech or two. And the lack of money, as you say, means unless you try to do things in a way which cuts across, which brings all the different departments together and people outside government who can contribute to this, then your chances of achieving these sorts of objectives do seem remote. But as you say, the lack of money means that this is extremely challenging. And in terms of what's actually happened in government to make a reality of this, it doesn't look yet like the sort of transformation in how government has done that we were led to believe before the election.

Jo Bibby:

I think this point about the lack of money is, I mean clearly it's a challenge, but in a sense it could be a forcing function to really think about the cross-government opportunities of where spending in departments outside of health and social care can be done in a way to maximise health gain. And so that very much chimes with I think, the values of a mission-based government that you are looking not just at individual departmental objectives, you're thinking about the long-term impact and how departments pull together. And spending money in a way that gets those co-benefits is clearly going to be central.

Jennifer Dixon:

So there are five missions: economic growth, clean energy superpower, take back our streets, so about crime and increasing confidence in the police, breaking down barriers to opportunity, childcare education in particular, and health, which is framed as ‘build an NHS for the future’, etc. But then also then talks about a ‘fairer Britain where everyone lives well for longer’, so public health as well. I think it might be worthwhile talking about the wiring of government that would need to take place to even get the mission approach moving. And now I know Hannah, you've written a lot about this, what kind of government wiring would it take? Can you say a little bit about what the IfG have been saying about this? And also where you see any progress across government, [in] how they do things?

Hannah White:

There are probably three aspects to this. There's the structures, as you say, there's the culture, and then really fundamentally there's the money. So when it comes to the structures, we had anticipated from what Labour had said, that there might be some different way of approaching the structures, particularly at the centre of government intended to drive accountability around the missions in a way which would incentivize departments to work together. What we seem to have is more of a traditional cabinet committee style approach, with a committee for each mission chaired by the Secretary of State who has lead responsibility for that mission. So in the case of health it's Wes Streeting.

And then some fairly again, traditional accountability mechanisms with the prime minister, who I spoke to yesterday on our podcast actually. And he was describing the bi-monthly accountability check-ins that he chairs for each mission board, and talking about the way in which the data they use for that is intended to try to drive accountability and transparency, and so that they can see the progress which is being made towards the missions. In terms of culture, I think it's much harder to see progress which is being made on that. There's certainly a lot of chat about mission-led government in government. What difference it's making to the way in which departments relate to each other and civil servants approach their jobs is harder to see.

And then in terms of money, I think it's only really when we see the outcome of the spending review in June that we're going to know to what extent that has been a change. We know that the missions have been put up there as a guiding principle for the spending review. But I think the question is, does that just lead to the thing that always happens in the civil service, which is that everybody badges everything that they want to do as related to some mission, in order to just try to get the money that they wanted anyway, and it doesn't really change how government's working? Or does this generally generate cross-departmental working in a way that we haven't seen as much before?

Jennifer Dixon:

In terms of the structures, the mission boards have all been formed, is that right, as far as we know?

Hannah White:

As far as we know, yeah.

Jennifer Dixon:

And the priorities in each area, because the five missions as written in the manifesto are quite broad of course, do you know whether they've been crystallised, the specifics?

Hannah White:

Yeah, so that was what the plan for change was that we saw at the end of last year. This was something we'd actually called for at the Institute for Government. We said, you can have a party manifesto on which you get elected, which tends to have hundreds of different commitments, quite granular things to quite grand things, but very specific activities and things you'll do. And then you have your missions which are very broad, very long-term at the top. And we said, there's a lack of priority setting in the middle, which tells you what you're actually going to do within a foreseeable timeframe. And that was what the government's reflecting just before Christmas, Keir Starmer, setting out what he called milestones, which are things that the government has said it's going to try and do in this parliament under each mission. For example, there's the elective waiting list milestone within the health mission.

Jennifer Dixon:

If you don't have much money, cast the net wide and bring in external assets partners who can help mobilise towards this mission. The mission boards, then, are they quite diverse with respect to private sector as well as public?

Hannah White:

My understanding is that they are bringing in people from outside government, but not really to the extent that we'd been led to believe. I mean we were wondering whether for example, mission boards might be chaired by someone who is a high profile, credible external figure, who could really hold that accountability and drive things from the centre. But the decision to actually ask secretaries of state to chair those boards fell short of that, in terms of making a sort of step change, we thought.

Jennifer Dixon:

Jo, just turning specifically to the health mission, where are things at? The health mission as set out in the manifesto was pretty NHS-y focused, wasn't it? So, your perspective on the extent to which health is really getting a look in.

Jo Bibby:

As far as we know, Wes Streeting is chairing the health mission board, but in terms of visible action, the focus very much on the NHS, the 10-year plan and then now more recently, some of the structural things around the NHS. So it doesn't feel like we're getting into that live well for longer ambition. And I mean it strikes me that there maybe are some missed opportunities here, because fundamentally live well for longer is less about what department for health and social care are doing, but it's fundamentally about what's happening in terms of economic growth. It's what's happening in terms of opportunities for young people, people who are currently out of work. It's this whole range of government policy. There could be stronger articulation around some of the policies they are announcing in the growth and opportunity and safer streets areas and the benefits that that will deliver for health. Because I think those are the things that we need to stitch together as part of a broader prevention in a health and equality strategy

Jennifer Dixon:

On the need for cross-government working, do you see any of that coming into what you've seen on the mission so far, the health mission?

Jo Bibby:

Well, I suppose the area where we should feel encouraged is on the much stronger recognition that's being seen in the work and health space. And to be fair, there's been a work and health unit across Department of Work and Pensions and Department of Health and Social Care for many years now. But I think what we're seeing now, is the Department of Work and Pensions proper as it were, really making that link into health, both in terms of understanding that if they want to help more people into work, they've got to be looking at how they support people with health conditions stay and work for longer, get back into work and so on. And we're seeing the recognition that you need good quality work to support health. So the Employments Rights Bill, I think is making some of those connections between better employment conditions and healthier lives. So I think we should be positive about that. Where I think there is more to be done, is with some of the links around some of the early years, the younger people's agenda, and of course the industrial strategy.

Jennifer Dixon:

And do you think these positive signs are anything to do with the mission framing?

Jo Bibby:

That's hard to know from the outside, since we're not really seeing a lot of the internal working of the mission approach. In the spending review, there may be some stronger pointers of that joint working being driven by the mission approach. We just don't know if these are opportunistic bits of joint policymaking or genuinely a mission-driven government.

Jennifer Dixon:

And why has it been so quiet on the process? Is there going to be a big reveal at some point? Or is it just chugging along in the background?

Hannah White:

I've spent quite a lot of time since the election thinking there might be more going to be announced, but I think maybe I'm reaching the conclusion that that's not the case. I do think the Spending Review is going to be a bit of a reveal, in terms of where things have got to, and just looking at how that spending is allocated and what we see there being bid forward jointly across departments. Because ultimately, the money is always at the root of what's driving incentives for civil servants and ministers in the system. So I don't think so at this stage. I think we've probably got the machinery that is going to be used from now on. And now they're trying to just drive that machinery to achieve.

Jennifer Dixon:

Just on the spending review. And I was reading one of the Mansion House speeches, where they were talking about the long-term investment from pension funds and trying to incentivize the pension funds to invest in UKPLC and so on. Do you think or have either of you heard a whiff of this that there is a connection between any initiative in that direction and these missions? Because that would be a clear place, wouldn't it, to invest?

Hannah White:

Well, the only positive sign I would say, is that they've made Torsten Bell, the Pensions Minister. And in his book he did advocate very strongly for this.

Jennifer Dixon:

And I suppose the other connection is, when I hear discussions about mission, it still seems a pretty national type of enterprise, whereas obviously we've got devolution going on and increasing powers to local government. How far is devo a feature in the mission type of approach?

Hannah White:

There is no getting around the fact that local and devolved governments are going to need to be part of achieving these national missions that the government has articulated. But again, we haven't really heard much. We know that particularly on the growth mission combined authorities, strategic authorities now are producing their local plans and relate to the overall missions and the overall growth mission in particular. But we've not really seen any big communications effort from the government to show how that is all connecting up.

Jo Bibby:

I think it's an interesting example that around the combined authorities doing their growth plans and then at the same time in the Devolution Bill we have a duty being proposed with strategic authorities for health improvement, but that duty isn't in place yet. It's not even defined. Yet, if the growth plans are all in place without really thinking through the opportunities to use growth plans to improve health and reduce inequalities, we're missing an opportunity. So it's a challenge, isn't it, on the timing of these things that we need to be making these connections earlier, I think.

Jennifer Dixon:

It's such a wonderful idea this, isn't it, the missions. I mean it's somewhat utopian, but it's absolutely worth trying, particularly if there isn't much money around. What examples are there around the world where this approach has been used, where there's been some positive tangible outcome that can give us some hope that it can work even in a different system?

Hannah White:

It feels very logical. The idea of missions has a inspirational vision-type element to it, which is what people say they want from government. So I think everyone is willing this approach to work. In terms of other examples, the one that Mariana Mazzucato has been most closely associated in the UK, has been Camden Council, which has been using a mission-led approach and set a series of missions. Firstly, it set up a commission to decide what its mission should be, and then it set these four missions around economic opportunity, diversity, food and creative and sustainable streets.

And the interesting thing there, is that the leader of Camden Council was Georgia Gould who then became an MP and has gone into the Cabinet Office. And although she doesn't have direct responsibility for missions within the Cabinet Office, presumably the idea of putting her there was that she would support that approach. In terms of other countries, there has never been a whole national government which has tried to take a mission approach as far as I'm aware. But there were examples of mission-led approaches within government. So for example, the Australian government's used missions through its science agency. Germany's trying to use a mission-based approach on its energy transition. But I wouldn't say there's any existing example of where it's been done and it's been done well and it's incontrovertibly been a success.

Jennifer Dixon:

And some of the missions that we want are multifaceted, they have a very big social element, as opposed to a science element or a technical element, which may lend themselves the technical. It may be easier to do moonshots or at least this type of thing with a very circumscribed, bounded, technical…

Hannah White:

…Exactly, exactly. I totally agree. And that's why I think when it comes to progress, it's the energy mission and the clean power bit of the energy mission, which it seems to be making the most visible progress in the UK, because it's got a really clear measurable target that you can really see how things add up to achieving it. And so it is definitely easiest when you have something of that nature that you are aiming at.

Jennifer Dixon:

Absolutely connected to the Climate Change Committee and the work of climate change. Because all the net zero, it is a kind of mission, isn't it? And some of the elements of mission-led government are definitely in that example. We at the foundation, Jo, your work has suggested some of those elements to move forwards on health, particularly for example, an independent commission with reporting to parliament on progress.

Jo Bibby:

It seems to me there's something about where do governments manage to take public opinion with them and how do they do that? Ultimately, you can set out a mission approach, but if only lasts for your term of parliament, and then the new government comes in and changes it all around again, then it hasn't really had the impact you want. And so the real question I think, is how do you take the public with government on this journey of recognising that we need more long-term approaches that span multiple parliaments. And there's some areas where you see that happening and some areas where you don't. So the last Labour government did try and make a binding target around child poverty, but the legislation was changed and that didn't stick.

But on climate, clearly what government has been trying to do has also been driven by shifts in public attitudes and public values and what they want to see. So there's a much more synergy between how government is working and what the public wants. And so then I think creating these structures like the Climate Change Committee and having the independent accountability and targets and so on, they can stick because you've got the public support broadly with those mechanisms. There's other mechanisms where we've seen changes, like the independence of the Bank of England, the creation of the OBR, and they've all stuck through several parliaments, because there's clearly been some kind of wider consensus that those things work and add value.

So I think thinking particularly in terms of our interests around health and inequalities, the big challenge really is how you take the public with you on the case for some of these longer term policies and strategies. For instance, things like Sure Start; for instance, changes that we need to pollutants that we have through our food systems. So it's never going to work just with government changing the wiring. There is a big, big need to take the public with them on this narrative and journey.

Hannah White:

I totally agree with that, Jo, but a couple of notes of caution. I think up until the last couple of years that's been exactly right and the committee on climate change has been a really important mechanism. But I do think on climate change we are starting to see a political divide opening up. And to some extent part of the problem being identified is that some of these decisions on how we should get to it and what the target should be, having been outsourced to an independent body has now started to make some politicians feel uncomfortable, because in fact, parliament didn't pay enough attention to... Just nodded these reports through. They're now saying, was there actually enough democratic engagement with these things being set by technocrats? And that being unwound a little bit.

And the other point I would just make is that it's very easy to blame politicians for saying, Oh, the electoral cycle is driving their priorities. They tend to waver away from long-term preventative approaches because they feel the need to demonstrate change quickly… But actually, I think that that is an increasing tendency also of the public. The public are driving that. It's not just the electoral system, the parliamentary system, the public seem to be more primed now to want things to happen quickly. And that is then quite a vicious interaction between what the politicians feel they have to prove, however much they might aspire to the long term, and as we've said, really positive that the government came in saying a lot about that, but they might just feel that actually, well, if we don't deliver and show that we can deliver some of these things fast, then even though the public notionally is bought into things like intergenerational fairness, wanting their children to have opportunities and so on, in practice when they go to the voting booth, they want to reward or at least punish people who don't provide changes quickly enough.

Jennifer Dixon:

Is that more of an issue now, do you think, Hannah? Are you saying that there's a trend?

Hannah White:

I think it is a trend, and I think it is hard to say the cause and effect, but some of the tendency for our politicians to want to tell the public they can have their cake and eat it, which obviously was Boris Johnson's approach, but equally all the main parties ahead of the general election saying, oh, we can have improvements in public services without putting up taxes, without borrowing more… Something that the likes of Health Foundation and the Institute of Government were saying, no, there is going to have to be more money in the system somehow to achieve what you are saying. But politicians being prepared to skate over that. I think even although the polling showed that the public didn't entirely believe politicians in that, they have been increasingly primed to think maybe there are things that can happen more quickly? And why are this lot, whoever this lot happened to be at the time, not delivering?

Jennifer Dixon:

Can't you have both? You've got surface froth where politicians have got to perform and announce things every 2 minutes, but you can still build the infrastructure for something longer, if there is the consensus there.

Hannah White:

You probably do want both. I just think, I don't know, 5, 10 years ago it might've been easier to think that actually the key was just to get the longer term mechanisms in place and everything would follow. And there are some good examples of where that has happened, but I think that it's no longer quite as straightforward as that. And there were definitely more counterweights building up in the system.

Jennifer Dixon:

And obviously we are seeing a lot of surface fireworks in the health world at the moment. But do you see public opinion-driven or consensus-driven, longer term undertow towards some of the mission, particularly on the public health side that you would want to see?

Jo Bibby:

I guess my view is that actually government can't move faster than public opinion for exactly the reasons that Hannah has articulated, because then they get voted out. And so things that have stuck have stuck because they've been with the grain of where the public and society wants to move. And the smoking ban in indoor places, it'd be very hard to imagine any government changing that, because it's just become normalised and it was clearly something that people wanted. There was opposition of course, we know that, but there was obviously a tipping point that gave government confidence to do it.

I think when you look at some of the public polling now, some of the interesting things are the extent to which there's perhaps a shift in the way the public are seeing the food system. And the more concern being articulated that we have a food system that is overly marketing, advertising, promoting food that people are I think, starting to recognise isn't good for them. And we know that these environmental factors drive our choices more than individual free will or whatever other people might want to put it down to. So I think there is a bit of a shift away from people just thinking it's all about individual choice in what we eat, to a recognition of what the food system we live within, how that shapes the choices we have. So that might be something where government could start to pick up that shift in attitude and see how it can work with it to bring in some stronger regulation. We've seen the success of the Soft Drinks Industry Levy.

Hannah White:

I'm interested in what you think about the very micro-reality of the fact that we've just had the Permanent Secretary of the Department of Health and Social Care go in to be Cabinet Secretary, and what sorts of awareness and thinking he might take from the department into the centre, which might affect the approach that this government is taking.

Jo Bibby:

There's a real opportunity there, isn't there? Because I think in my experience is that when you talk to people in policy areas outside of health care, public health, people are very receptive to opportunities that their particular policy area or area of public spending can offer to improving health. I never hear people really being resistant to that as a concept. But it's often the knowledge and the understanding of where the opportunities are. So with Chris Wormald, you have somebody who will have been able to see those opportunities in his previous roles, and now maybe has more to actually make them a reality.

Jennifer Dixon:

The biggest shove to the political class on the need for long-term focus on health has come from the pandemic, hasn't it? When you think of the lack of resilience. And that seems to be largely forgotten now. So I mean I think that's just a case in point, isn't it? That the short term is a very powerful phenomenon even in the face of something as huge for the country as the pandemic.

Hannah White:

I would just say, the fact that the COVID Inquiry is taking so long, I think is a bit of a shame, because if there'd been a sharper, snappier exercise, yes, it might not have fulfilled some of the very important elements around public catharsis, which public inquiries can generate in enabling everyone to participate. But actually, if we could have learned some of those lessons more quickly while the pandemic was very fresh in our minds, and this isn't to say that there hasn't been lesson learning exercises within departments, but I think if that hadn't been done in quite a visible national way more quickly, we might have seen more of those lessons more likely to stick.

Jennifer Dixon:

Given what you know, what are the big things that you would do now to really make this a reality, that perhaps isn't being done or is a bit murky at the moment?

Hannah White:

I think for me, the big thing would be really making reality of how government engages beyond government. I think there was ahead of the election, and immediately after the election, a lot of enthusiasm for experts, for the public, for voluntary sector, for the private sector to get behind some of these missions, because people are convinced of the severity of the problems facing the country and they do want to do their bit. And I don't feel that enough has been made of that as an opportunity. And so whether it's technical things like how you involve people in mission boards, whether it's about how you engage the public through using deliberative methods, which seem to have fallen off the agenda now, whether it's just that opening up of government… Which I think actually also ends up being really motivating for politicians when they have that regular input of expertise and a public backing for what they're trying to do. So it's a two-way process. And I think it feels as though we've slipped too easily back into the normal ways of doing government.

Jo Bibby:

One of the things we know is most of the things that benefit people are being delivered day-to-day across communities, whether by public servants or whether what local businesses and employers are doing and deciding. And so I think one of the things that we need to avoid is seeing this is something that is just delivered by the centre, and actually recognising it's that whole societal effort. But not just in terms of the expertise and knowledge, but in terms of the pairs of hands that need to be used to get the change that's needed. So I think really making sure that the centre doesn't rush ahead beyond what is happening in local communities will be an important factor.

Jennifer Dixon:

So we must leave it there. Thank you to my two guests, Hannah White and Jo Bibby for their insights today. Let's see what emerges over the next few months for the Spending Review. Just to say that Hannah has just interviewed Keir Starmer on a podcast for the Institute for Government, so take a look there. So join us next month, when we'll be turning to the impending changes at NHS England and the Department of Health. What has happened there? Will it make any difference? What's it all about? Join us then. And in the meantime, thanks again to my colleagues, Sean and Leo at the Health Foundation, to Paddy and team at Malt Productions. And it's goodbye from me, Jennifer Dixon. Until next time.