6. In it for the long term: embedding health as a shared value across the whole of government and be


Key points

  • A range of measures and structures are needed to ensure that health and addressing health inequalities are embedded as shared values across the whole of government, with action taken across the wider determinants and a renewed focus on preventative activity that stops people from becoming ill in the first place.
  • There needs to be a fundamental shift in the way governments measure success. This needs to go beyond narrow measures of GDP and encompass wider outcomes including health and wellbeing.
  • The cycle of short-term decision-making that currently prevails is undermining efforts to improve people’s health over the long term. There needs to be stronger legislative frameworks and cross-government bodies in order to encourage and facilitate long-term decision-making.
  • Investment across government needs to be rebalanced towards health-creating areas of spending such as children’s services, housing and social security.
  • While the role of government is pivotal in creating the conditions for long-term investment in strategies to maintain and improve people’s health, reductions in health inequalities will not be possible unless there is genuine and effective involvement of communities and place-based approaches.

6.1 Change the way success is measured

Good health is a country’s greatest asset but is not considered a primary measure of successful government. There needs to be new ways of measuring policy success, moving beyond traditional economic indicators such as GDP and encompassing wider metrics of population wellbeing and health equity. This would enable policies to be evaluated in terms of their contribution to health and wellbeing as well as their economic impacts, and would incentivise all areas of government to put health and wellbeing at the heart of policy.

A leading example of this approach comes from New Zealand which, in 2019, became the first country to commit to setting budgets on the basis of wellbeing rather than economic growth (see Case Study 3). The prevention green paper recently released by the government committed to developing and launching a new ‘Composite Health Index’, a policy that was originally recommended by the former Chief Medical Officer for England in her 2018 Annual Report. This could be a useful tool for embedding health as a shared value, but will only have the necessary impact if it is based on meaningful measurement of people’s wellbeing and health. If it is used in policy evaluation right across government, it could help to embed an approach that views health as one of the nation’s primary assets. Further research has also found that public health expenditure is three to four times as productive at the margin than health care expenditure, adding to the case for greater investment in public health.

Case Study 3: Using non-GDP measures to embed health in all policies

New Zealand’s Wellbeing Budget

In 2019, the New Zealand government published its first Wellbeing Budget, in which priorities are explicitly structured around intergenerational wellbeing. This is part of a strategy to put current and future generations’ wellbeing at the heart of government decision-making.

‘We’re starting from a position where the received wisdom – that creating economic wealth makes everyone better off by creating bigger and better businesses, higher employment, more savings and spending, an increased tax take and a greater ability for government to support those who are vulnerable or in poverty, ill health or deprivation – is no longer seen as a guaranteed ticket to a better place.’

David Lovatt, 2018

The budget has five priority areas: taking mental health seriously; improving child wellbeing; supporting Maori and Pasifika aspirations; building a productive nation; and transforming the economy. These priorities were selected using expert advice and data from New Zealand’s Living Standards Framework (LSF) Dashboard. The LSF Dashboard comprises a range of indicators and analysis for assessing the wellbeing impacts of policies and proposals across generations.

For the first time, government ministers were required to show how their bids would achieve the wellbeing priorities, which resulted in many innovative, cross-departmental programmes being developed. Budget allocations were based on a wellbeing analysis, taking into account the impact that initiatives would have on economic, social, environmental and cultural outcomes for current and future generations.

This is thought to be the first attempt by any country to integrate wellbeing formally into its national budget-setting processes. This has the potential to fundamentally change the way government decisions are made, opening the door for health and wellbeing to be considered a key measure of national success and a contributor to other forms of development.

6.2 Embed long-term health considerations in legislation and policy for the whole of government

A long-term, cross-government approach is critical to improving health and reducing health inequalities nationally. However, short-term political cycles act against this. As outlined in the Health Foundation’s report, Shaping Health Futures, governments in the UK have often found it difficult to plan and prepare for the future – for health and social care as well as on infrastructure, tax and other policy areas. Legislative frameworks are increasingly being used in other parts of the UK to help public bodies break out of short-term decision-making cycles and take a long-term approach to improving health and wellbeing. For example, in 2015 the Welsh government enacted the Well-being of Future Generations (Wales) Act, which placed a duty on public bodies to work towards improving the health and wellbeing of both current and future generations. Case Study 4 illustrates how public bodies in Wales are working differently since the introduction of the Act, and what can be learned from their experiences.

A legislative framework of this kind would need to consider health and wellbeing in the widest sense, including the social, environmental, commercial and economic conditions people live in. It could be designed to ensure that government investments are evaluated in a way that recognises the long-term value of health and wellbeing to society as a whole. While more could be done to ensure that existing legislation – such as the Public Services (Social Value) Act 2012 – is used to its full effect, more wide-ranging legislation could be a powerful tool to drive change.

Case Study 4: Long-term planning for future generations

The Well-being of Future Generations (Wales) Act 2015

In 2015, Wales passed the Well-being of Future Generations (Wales) Act, enshrining in legislation a vision to create a Wales that people want to live in now and in the future through improving its social, economic, environmental and cultural wellbeing.

While a legal duty to promote sustainable development had existed since devolution in 1999, the Act strengthened the responsibilities of Welsh government and public bodies to work together to make it a reality. The Welsh people provided a strong mandate for change, demonstrating in ‘The Wales We Want’ national conversation their support for improving wellbeing and planning for the future.

Working jointly and differently

Public Services Boards were set up in each local authority area to deliver the Act’s wellbeing goals. The Boards have fostered cross-sector collaboration and developed plans for how they will work together to achieve the goals in their local areas. For example, the Carmarthenshire Board is reforming local procurement systems to drive the procurement of locally grown food. By supporting local producers, supply chains and businesses, this work will contribute to wellbeing in a range of ways, including promoting a low-carbon economy and creating local growth.

Organisations have embraced the principles in the Act and have led by example. Public Health Wales demonstrated its commitment when it moved to new, sustainable offices equipped with recycled furniture, employing a local social enterprise to fit recycled carpets and working with accessibility experts to ensure that the building is fully accessible. This highlighted how every person and organisation across Wales can play a role in sustainability.

National leadership

The Future Generations Commissioner has raised the profile of the Act and promoted action across Wales. Through maintaining a focus on the wellbeing of current and future generations, the Commissioner has shifted the debate on issues such as air pollution, housing and adverse childhood experiences. For example, the Commissioner is influencing the Welsh government Housing Innovation Grant to ensure that the Act’s wellbeing goals are embedded in its programmes.

With the third sector and Welsh government, the Commissioner is also agreeing a definition of ‘prevention’ to be used in budget setting.

Developing future generations

The Act has provided a stimulus for equipping young people in Wales with the skills they will need for the future. For example, the award-winning Rethinking Business for a Changing World initiative at University of Wales Trinity Saint David is offering students the knowledge and skills to lead sustainable, ethical and responsible businesses aligned with the Act’s wellbeing goals.

Unlike policy approaches that had gone before, the Act has been a powerful way of embedding long-term prioritisation of economic, social, environmental and cultural wellbeing across the public sector and beyond.

Legislation on its own, however, is unlikely to be sufficient unless structures are put in place to support its implementation. For example, it would be helpful to establish a high-level cross-government working group or committee, ideally with Cabinet-level accountability, with responsibility for overseeing the implementation of a whole-government approach to keeping people healthy and reducing health inequalities.

Similarly, embedding long-term decision-making at the heart of government could be aided by an independent public body, which is able to scrutinise government policy and provide independent, expert analysis. Examples of such bodies include the Future Generations Commissioner in Wales, the Children’s Commissioner for England and the Office for Budget Responsibility for the UK. Case Study 5 gives further analysis of what can be learned for existing bodies of this kind. Establishing a commissioner to provide independent analysis of trends in the nation’s health and advise on the actions required to address health inequalities could be an important way of embedding health creation across the whole of government.

Case Study 5: Providing expert analysis and advocacy through an independent public body or commissioner

A number of independent and semi-independent public bodies and commissioner roles have been established within the UK to support a longer term approach to analysis and policy decision-making that is unconstrained by more immediate short-term needs and opportunities. Examples include the creation of the Children’s Commissioner for England role in 2004, the establishment of an Office for Budget Responsibility in 2011, the Low Pay Commission set up in 1997, and the Social Mobility Commission established in 2010.

Example: Children’s Commissioner for England

The Children’s Commissioner for England has a statutory remit that includes understanding what children and young people think about the things that affect them, and encouraging decision-makers to take these views and interests into account when making decisions about children and young people. The Commissioner also has data-gathering powers and powers of entry to talk with children and gain evidence, with the aim of supporting ‘long-term change and improvements for children’, particularly those who are most vulnerable. The role is supported by an advisory group, an audit and risk committee and children’s groups, stakeholders and specialists. Crucially, the Commissioner is treated as the ‘eyes and ears’ of children in the system and the country as a whole, and is expected to carry out their duties ‘without fear or favour’ of government, children’s agencies or the voluntary and private sectors. The Commissioner submits evidence to relevant inquiries and produces regular reports with key recommendations for government.

Form, function and status of independent or semi-independent public bodies,

An audit of 16 different public bodies was undertaken in 2017 by Emma Norris of the Institute for Government to advise the House of Lords Select Committee on the Long-Term Sustainability of the NHS about implications for a new health and social care body.

Most independent or semi-independent bodies explored within the audit were found to perform an analytical and/or advisory function, either adding new expert insight or bringing together stakeholders and data to establish consensus positions on controversial issues. Some bodies, such as the Social Mobility Commission, also play a more active advocacy role around a particular cause, with a mandate to promote that particular cause among a range of different organisations.

The importance of a clearly articulated and widely understood scope and purpose to be agreed for public bodies was identified by the audit, with a need for the remit of any new body to be carefully considered – including with regards to the functions it would perform and the permanence of the body or commissioner role. Effective leadership is also vital, with a need for the requisite expertise and credibility to establish the body, build strong stakeholder relationships and ensure independence. Such bodies should also have a sufficiently well-resourced analytical capability in order to inform decision-making, and attention should be paid to reporting arrangements with respect to the frequency, initiation, time horizon and purpose of reports.

Certain forms of organisation and the status of the independent body can also guard against political interference. While it does not entirely remove the risk of political interference, giving independent bodies statutory powers means that ministers must pass primary legislation to abolish or substantially change a body.

6.3 Invest in people’s health as one of the nation’s primary assets

Government should explicitly acknowledge good health as one of the country’s greatest assets and prioritise long-term investment in health across the whole of the public sector. Investment across government needs to be rebalanced towards health-creating areas of spending such as children’s services, housing and social security. In order to counteract past and (planned) future trends away from spending that keeps people healthy (outlined in Section 5), mechanisms are needed to review the balance of health-promoting versus reactive spending across and within different areas of government. One specific area of investment that should be addressed is the public health grant (see Section 5.3).

However, changing the circumstances in which people live is not simply a question of government spending. Other levers, such as social protection through regulation and taxation, can be used to promote a general shift towards creating health, with particular attention given to those strategies that most effectively support communities experiencing the greatest deprivation. Specific areas of focus could include:

  • action to improve the quality of housing by enforcing health-informed minimum housing standards and addressing the quality of homes built outside of the usual planning system through ‘permitted development’
  • extending ‘polluter pays’ regulation and taxation of health-harming commercial products. This could include extending the Soft Drinks Industry Levy to other products with negative impacts on people’s health
  • supporting early years development including through measures to address child poverty and re-invest in local early years services, which have seen major funding cuts in recent years
  • proposing amendments to the UK Corporate Governance Code to require businesses to report on their impact on the health and wellbeing of employees, customers and communities.

6.4 Enable the NHS to take a stronger role in prevention

A whole-government approach to creating health also needs to include the NHS. The role of the NHS is explored in detail in Section 4.4, but key principles for ensuring that health creation (as opposed to health care) is embedded in the way the NHS works include:

  • ensuring that prevention and population health are at the centre of moves towards greater integration of health and social care
  • encouraging or requiring NHS organisations to work in collaboration with local government and the wider public sector to support a place-based approach to prevention
  • supporting the development and use of linked data that could be integrated into local planning systems, to enable better monitoring of people’s health and enhanced understanding of the relationship between health outcomes and wider determinants
  • systematically implementing preventative interventions that are known to be cost-effective but are not currently used consistently across the NHS (for example, smoking cessation services)
  • promoting the role of the NHS as an anchor in communities. NHS organisations should act as a role model and advocate for the improved health and wellbeing of their staff and communities, working alongside other anchor institutions including local authorities, universities and housing associations.

6.5 Enable coordinated, place-based approaches to improving health and reducing health inequalities

While there is a great deal that can be done by central government, locally-led approaches are also vital. Central government has a role to play in creating the conditions that can allow genuinely locally-led approaches to improving health and reducing health inequalities. The devolution of power and budgets to the Greater Manchester region is a leading example of this approach (see Case Study 6).

Central government needs to create the conditions for locally-led, place-based approaches to improving wellbeing and health by giving local governments the responsibility, powers and funding needed to create healthy living conditions. As outlined in Section 4.3, it is vital that communities are empowered to be part of the decision-making process and that the value of community infrastructure is recognised and given appropriate investment. This may require significant changes in the relationship between local government and residents.

The Wigan Deal is an example of an approach that has successfully engaged local people in working with the local authority through taking an asset-based approach to community engagement. The Deal is credited with boosting rates of volunteering and recycling in the borough as well as helping to ease the pressure of adult social care services. Although the council faced severe budget cuts, as part of the deal £10m was invested in the community sector to empower hundreds of community groups.

This report shows that the government’s recent short-term spending decisions over the past 8 years are already widening inequalities in health outcomes and storing up problems for the future. This position is not sustainable. It will take bold political decisions at national government level and commitment over the long term to create the conditions for good health. This is the time to set the direction for a healthier, more prosperous future.

Case Study 6: Joining up public services

The Greater Manchester Model: Unified Public Services in Greater Manchester

Greater Manchester is reforming its public services to prioritise wellbeing, prevention and early intervention. In 2019, the Greater Manchester Combined Authority set out plans to embed prevention in practice through the Greater Manchester Model, which joins up public services in neighbourhoods, streamlines commissioning and information sharing, and looks at resources and leadership across Greater Manchester.

We spoke to people working in Greater Manchester to find out what’s happening on the ground and what they’ve learned along the way.

Joint working

Each neighbourhood will have an Integrated Neighbourhood Function made up of front-line practitioners from a wide range of local services. These teams will develop new ways of supporting residents in more holistic and proactive ways. For example, in Wigan, police officers, housing staff, health and social workers, JobCentre staff and local community groups work closely together, sharing resources and information to support residents and communities. This involves working across and beyond traditional boundaries and coordinating services and key working to ensure that people can access the right support at the right time.

Cross-sector partnerships are also being established over larger geographical footprints. For example, in partnership with the Department for Work and Pensions, Greater Manchester’s Work and Health Programme supports people to find and stay in work. Through their GPs, people who are unemployed and have a health condition or disability can access a specialised package of support to find work, including talking therapies for people with mental health needs and an employment skills service to equip people with valuable skills for securing work and progressing.

Flexible funding

To overcome siloed budgets hampering cross-sector working, Greater Manchester is working to create a more flexible approach to funding to enable greater integration of services. For example, localities are moving towards single commissioning functions. Since 2016/17, Tameside and Glossop has pooled their local authority, clinical commissioning group and NHS Foundation Trust budgets in an Integrated Commissioning Fund. This enables the locality to use their resources more strategically and efficiently for working towards a shared goal of improving residents’ health and wellbeing.

Greater Manchester has pooled various budgets in a Reform Investment Fund, which is designed to be used flexibly to foster local innovation. Neighbourhoods can use funding to invest resources in activities that will help them reform services to address local needs. This may include service development, workforce training, funding new roles or creating information-sharing systems.

Information sharing

To support system-wide working, the Greater Manchester Information Board is developing governance and processes for sharing information. For example, as part of NHS England and the Local Government Association’s Health and Care Record Exemplars programme, Greater Manchester is piloting technologies that combine people’s multiple care records into a single one. This information can be accessed securely by a range of professionals, giving them a richer understanding of the person’s needs and ability to provide a more joined-up service. The pilot will initially link health and social care information, but the ambition is to expand this to a wider range of services, such as housing, employment and policing.

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