Back in October we set out our hope that health would be embedded at the heart of the levelling up white paper. It had to be, given the role that good health plays in improving wellbeing, economic participation and the ability of individuals to contribute to their families, communities and wider society. How could the levelling up agenda succeed without including health?
Fast forward 4 months and the levelling up white paper is finally out. It has the necessary focus on reducing inequalities and improving quality of life for people across the country. This might be the beginning of a new policy effort to support the most deprived parts of the country, but the lack of detail, money or coherency does not bode well.
The white paper misses a significant trick: despite recognising the scale of health inequalities and their importance to the economy and quality of life, there is no sign of the new measures needed to make significant progress. Health Foundation analysis shows that with only the measures currently in place, it would take 75 years to get an additional 5 years of healthy life. This clearly takes us way beyond 2035, which is the commitment that government reaffirmed in the levelling up white paper.
But there is a glimmer of hope – a new white paper on health disparities, due in the spring and led by Sajid Javid, who is clearly engaged in this agenda. The government has the opportunity to set out more detailed plans and clarify how they will deliver 5 additional years of healthy life by 2035. Hopefully this will be the place where policy and investment come together to tackle the different health outcomes experienced by different people and places.
So what should this new health disparities white paper include? Here we set out five tests to make it as ambitious and impactful as possible.
1. Tackle the wider determinants of health head on
The risk of the white paper being led by the Department of Health and Social Care is that the vital role that the whole of government plays in improving health is overlooked. The white paper must go beyond the work of the NHS and public health teams to address the drivers of health, such as a decent home, a good education, a stable job, green spaces and clean air.
On this, we are apprehensive: the framing in the levelling up white paper implies that the main focus will be the behaviours that these determinants shape, such as obesity and smoking, and that this will be coupled with tackling the NHS backlog in diagnostic testing. In addition, it appears likely that the focus will be on targeting the individual, instead of population-level measures that impact everyone, which are demonstrated to be the most effective and equitable.
2. A new, whole-government approach to improving health
The importance of tackling the wider determinants of health means that all policy and investment decisions need to take account of health equity considerations. There is a risk that the levelling up agenda prioritises short-term economic gains at a cost to long-term economic resilience (eg focusing on regeneration through hospitality – an industry that has a low proportion of high-quality work, which is linked to better health).
The white paper will need to set out how the new Health Promotion Taskforce will hold all departments to account for the action they are taking to address health inequalities, and detail how levelling up governance structures are being used to support its agenda. As we have argued previously, thought needs to be given both to what policies the government adopts and how it organises itself to deliver them.
3. Policy ideas backed with immediate investment
The lack of new money in the levelling up white paper is a chronic barrier to action. If the same is seen in the health disparities white paper, the government will not get out of the starting blocks. Hopefully this will not be the case: the financing of public health – and the wider determinants – need to be a clear focus for the Office for Health Improvement and Disparities. Here cuts have led to a focus on acute need and not long-term preventative action. The public health grant has been cut by 24% on a real-terms per capita basis since 2015/16. And funding for council spending on local public services – which includes housing, early years and social care – dropped by 23% per person in real terms between 2009/10 and 2019/20. Worse still, the most deprived areas have tended to experience the highest level of cuts. Local areas cannot adequately invest in good health in this context. Without new money, we won’t see the shift to funding prevention that is the only way to really improve health.
4. Meaningfully measuring success
The white paper needs to set out what it is trying to achieve and how it will measure both progress and success. There needs to be a more granular assessment of progress, guided by the domains in the ONS Health Index. Holding departments and other partners accountable for their actions to improve health will also be important. The Health Promotion Taskforce will play a key role here, but mechanisms like the annual report to parliament on progress set out in the levelling up white paper should also be considered.
5. Learning from the past
Boris Johnson’s government is not the first to attempt to tackle health inequalities. A range of approaches have been tried, from targeted geographic interventions to improve overall health outcomes (the New Labour Health Inequalities Strategy) to specific regulatory activity to address risk factors (eg the sugar tax) and specific focus on particular determinants of health (via the joint Work and Health Unit, for instance). The white paper should draw on the lessons learned from these initiatives, including the need to take a long-term approach. It must recognise that the most effective and equitable measures are likely to be population-level ones that impact everyone and do not require high levels of personal resources to benefit.
Since the announcement of a government focus on levelling up in 2019, there have been calls to prioritise good health. All things come to those who wait: let’s hope this wait ends with the disparities white paper.