‘We possess all the resources and talents necessary… We have never specified long-range goals on an urgent time schedule, or managed our resources and our time so as to ensure their fulfilment.’
President John F. Kennedy

60 years ago this month, President John F. Kennedy made his famous ‘moonshot’ speech, inspiring future leaders (including Boris Johnson) to set bold, long-term ambitions to overcome monumental challenges. But he could have been describing the challenge of health inequalities in the UK today. As the country sets about rebuilding the shaky foundations of our nation’s health and economy, could this be the moment for a new national ambition for levelling up health? As part of the Health Foundation’s current consultation on a cross-government health inequalities strategy, we explore the possibilities – and pitfalls – of a target-driven approach.

The role of targets in public policy

Setting goals and targets can be a potent but risky tactic for policymakers. At its best, a well-designed ambition can express a vision of an ultimate outcome that everyone can get behind – from campaigners and voters to front-line professionals and service users. Once adopted by one government, such an ambition can create pressure on successors to maintain progress on long-term goals. For instance, carbon emissions targets are written into law, upheld by courts and overseen by an independent body. Campaigners can hold successive governments to account with objective data and project the impact of current policies.

While they can provide direction, targets also require a delivery mechanism to make them work. This includes setting milestones and measures to show how you are doing – Wales and Scotland both publish dashboards for their wellbeing goals. A combination of carrots and sticks may also be necessary to embed strong incentives, underpinned by legislation or independent oversight.

The pitfalls of target culture

Access targets have dominated debate on the performance of the NHS in England under the last five prime ministers. These targets have driven funding for hospital capacity and improved outcomes for patients. But they have also revealed the risks of target culture, on occasion driving perverse behaviour from fiddling the figures to gaming, and diverting resources from public health, primary or social care.

So targets can fail. A top-down target culture can undermine local autonomy, professional judgement and public service motivation – the opposite of the shared mission that was embodied by Kennedy’s NASA.

The potential for a target to level up health

There is recent precedent to draw on. The Labour government set its own targets on health inequalities in the noughties. The policy was imperfect – driving too much medical and short-term behavioural activity to achieve rapid gains, which didn’t always create sustainable change in the conditions needed to promote good health. But analysis suggests that as part of a comprehensive strategy, accompanied by investment, these targets did help reverse a long-term trend in widening inequality.

Although the coalition government did not refresh the national health inequalities target, in 2017 Theresa May launched a ‘grand challenge’ to increase healthy life expectancy (while closing the gap between the experience of the richest and the poorest). This was not set as a formal target, with no infrastructure to hold it to account or ensure delivery. In fact, healthy life expectancy has continued to fall and the health inequalities gap is growing. Nevertheless, this mission, reinforced as a 2019 manifesto commitment, is a foothold for health equity advocates, and an opportunity for government to strengthen and build on this ambition.

As part of our consultation on a cross-government strategy, the Health Foundation is exploring the role of a new target to inspire and deliver ‘levelling up’ in health inequalities. We want to hear your views, evidence and suggestions on the potential role – and framing – of targets, specifically:

  1. What measure of health outcomes should the government choose? Healthy life expectancy, or other measures of mortality, morbidity and wellbeing across the lifecourse? How should it measure improvement – through a single metric, a basket of national and local indicators, or a composite measure of ‘total health’ (like the new ONS Health Index for England)?
  2. Whose health should be ‘levelled up’? Instead of the national average, should government target deprived regions, towns or neighbourhoods? How would government avoid political bias and perverse incentives, so that it addressed the drivers of health between and within places – paying particular attention to intersectionality? How would allocation formulae need to be amended to ensure resources reach the communities that need them most?
  3. When should government set the timeframe for achieving a goal? How should it incentivise a balance of urgent and phased action on the wider determinants of health to achieve both immediate and future improvements?
  4. What infrastructure should be set up to drive action across government? How could government incorporate a vision and commitment in the 2021 Spending Review and the Plan for Growth, with the accountability and resources for each government department to contribute? How should government engage with devolved administrations in the three nations as well as regions, cities and towns to set their own objectives and to allocate accountability and resources?
  5. Is there a need for government to establish independent oversight and binding legislation on the net zero model, or public reporting on progress?

The UK possesses the ‘resources and the talents necessary’ to create and level up health. The pandemic has lit up health inequalities in public and political consciousness. The strategy that the Health Foundation is setting out will help government make the decisions and marshal the resources to end health inequalities. With long-range goals and an urgent time schedule, this could be the decade for the health moonshot.

To contribute to the discussion, download the interactive report and send us your views now. Our consultation will close on Friday 7 May 2021.

Joe Farrington-Douglas is a Senior Policy Fellow, Collaboration for Wellbeing and Health.

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