‘Levelling up… is about improving living standards and growing the private sector, particularly where it is weak. It is about increasing and spreading opportunity, because while talent is evenly distributed, opportunity is not. It is about improving health, education and policing, particularly where they are not good enough. It is also about strengthening community and local leadership, restoring pride in place, and improving quality of life in ways that are not just about the economy.’
– Government briefing on the Queen’s Speech (May 2021)

‘Levelling up’ has become an earworm. What it means for government policy is still being worked out. Clues have come in the 2019 Conservative manifesto, the Treasury’s Plan for Growth published in March, and more recently in the Queen’s Speech – which featured levelling up as the main theme. The basic objective appears to be improving prosperity for people living outside of London and the South East. For decades economic performance and productivity across the UK has been severely lopsided, with the UK economy the most regionally unequal out of 26 developed countries.

The policies outlined so far focus largely on boosting prosperity and widening opportunity through improving infrastructure, skills and innovation. Yet as well as developing financial and physical infrastructure – for example through new hospitals and technology – investment in other ‘capitals’ is critical to our future prosperity (see Box 1). To the public, prosperity means the overall quality of their lives and local communities, not just their economic livelihood and local GDP or productivity growth.

We also know that health is a key part of prosperity. Good health is not just personal, but a collective national asset that improves wellbeing, productivity and the ability of individuals to contribute to their families, communities and wider society. In the areas of England with the lowest healthy life expectancy, more than a third of 25 to 64 year olds are economically inactive due to long-term sickness or disability. Aside from the human toll, much of this is very costly and avoidable.

Since 2010, improvements in life expectancy in England have slowed more than in any other European country. The gap in the number of years people can expect to live in good health (healthy life expectancy) has also widened between rich and poor. In Hartlepool boys born today can expect to live 57 years in good health; in Richmond-upon-Thames, 71 years. A person’s life expectancy and healthy life expectancy are closely correlated with their income and wealth, with poorer health limiting the opportunity for good-quality, stable employment, and poverty in turn associated with worse health outcomes. Improving the nation’s health and narrowing the health gap across different areas of the country, and between different groups, are a logical focus of government efforts to level up.

The government’s levelling up strategy is still under construction. A white paper is promised later this year, overseen by a new dedicated team of civil servants working across Number 10 and the Cabinet Office, and its delivery will be a focus of a resurrected Prime Minister’s Delivery Unit. There are signs the government recognises that improving health is key to increasing prosperity, as referenced in the Queen’s Speech. Matt Hancock, former Secretary of State for Health and Social Care, also stated that ‘improving the disparities in healthy life expectancy is absolutely at the core of our levelling up agenda.’

But will the government’s plan really include health at its core? And what might be the most impactful approach to level up health? In this briefing we explore what a strategy to level up should contain, examine the approach taken by the government so far, and assess whether better health is likely to be supported. We conclude by outlining some key elements that should feature in the forthcoming white paper.

As the government’s strategy for levelling up is still developing, there is an opportunity to achieve a more balanced approach to improving prosperity. In the forthcoming white paper, all ‘four capitals’ should be invested in, with a strategy to improve health as a core component and attention paid to populations with the poorest health.

There are already sizeable investments earmarked to help with levelling up. Yet at present, the approach is partial and funding pots are fragmented in their conception, criteria for distribution, and management. An intelligent strategy will need to reach across most government departments to join up policy, and ensure that improved health and wellbeing is prioritised as part of economic recovery with a mix of short and longer term objectives. The value of existing funding and of any new investment could be maximised by making health improvement a core objective, ensuring that investment is not spread too thinly around the country to make a difference, and developing investment objectives that are linked with existing initiatives and spend across government to maximise impact.

Given the scale of funding pledged, and with the fund’s precise scope still to be defined, there is a particular opportunity for the UKSPF to be used strategically from 2022 as a vehicle for a more broad-based and coherent government approach. Without this, the impact of new and existing investment will not be maximised, and the stalling health improvements seen over the past 10 years will continue, acting as a brake on post-pandemic prosperity and opportunity.

In any strategy to level up health, three interlinked elements should be developed:

• a strategy to improve health and reduce inequalities, genuinely aligning priorities and investment across different government departments
• real partnership between national and local government
• a greater role for the NHS in population health.

A cross-government strategy to improve health and reduce inequalities

(i) Boosting action on the wider determinants of health

Health can only be improved over the long term by prioritising the root causes of ill health and inequality. There is no simple solution to this: action across a range of areas is required that are well beyond the span of the Department of Health and Social Care, or the ability of the NHS, to influence.

One key area of focus should be economic regeneration, with efforts made to boost local employment and income, in turn helping to improve population health. Another should be bolstering public services in ways designed to improve people’s health and wellbeing, thereby maximising their potential and ability to contribute to society. This might include, for example, making good-quality childcare available; supporting children in their early years and at transitions in their late teenage years; subsidising transport for young people; reducing low-quality jobs; boosting the social security system to ensure adequate support for families; ensuring access to green spaces and clean air; and facilitating more active travel. These are all areas where action can be taken centrally and locally to support people to live healthier lives, and there is already enough evidence on what works to make significant progress.

The need for a more coordinated cross-government approach is increasingly being recognised., The government has already set out a number of relevant commitments that can be developed into an ambitious strategy. Most notable in relation to population health is the ‘grand challenge’ – reiterated in the 2019 Conservative manifesto – to ensure people are able to live an extra 5 years of healthy life by 2035, while ‘narrowing the gap between the experience of the richest and poorest’.

Following the abolition of Public Health England, a new ‘Office for Health Promotion’ and cross-ministerial board is also being established this year with the promise it will ‘help inform a new cross-government agenda’ to drive improvements in the nation’s health. To be more effective than previous efforts, a truly cross-cutting approach would be better owned and driven by the very centre of government to secure and sustain action over the longer term. A cross-ministerial board with teeth should be formed: for example, reporting directly to the Prime Minister, attended by secretaries of state and with a secretariat provided by the Cabinet Office to act as a broker across government. The programme should be firmly linked to the wider levelling up agenda.

Binding targets, as well as new mechanisms and institutions, should also be considered to drive sustained improvements in the nation’s health. There is a lot to learn from the attempts of previous governments, such as the health inequalities strategy in operation in England from 1997–2010. Models such as the Future Generations Commissioner established in Wales, or New Zealand’s Wellbeing Budget, are also examples of mechanisms that could aid progress.

(ii) Taking a population-level approach to preventing risk factors for ill health

Ambitious action on the leading modifiable risk factors underlying ill health – poor diet, lack of physical activity, smoking, alcohol and drug misuse – and the conditions leading to the most prevalent disability (such as mental ill health), should be a key element of a cross-government strategy. Given that most risk factors are strongly modified by wider socioeconomic circumstances, any strategy to level up health must go beyond the emphasis adopted by DHSC in recent years of identifying personal risks to ill health, influencing individual behaviours and rolling out new technology.

Evidence shows that population-level interventions will have more impact on increasing healthy life expectancy than relying on individual agency to bring about change., A range of policy levers are known to work, and more should be explored to create healthier environments – including taxation, regulation, increased spending on local public health interventions, and actions designed to alter the availability and marketing of harmful products. Working on these ‘commercial determinants of health’ will require a variety of approaches – from regulatory changes to working with key relevant businesses to modify their products or advertising. Consideration of how government could work with large investors to nudge businesses to do more to improve population health, is another area ripe for development. There is already a precedent for this, with growing action by investors to persuade companies to reduce their carbon emissions in support of net zero targets, increase sales of healthier food, and improve conditions for the lowest paid workers.,,

(iii) Supporting the care workforce

Work has been shown to have a profound influence on health, with low-quality work potentially worse for health than unemployment. Support for those in the lowest paid jobs with poor terms and conditions, including in the care sector, should also be core to a strategy to level up health. As mentioned previously, however, the Queen’s Speech was notable for the absence of an employment bill and its lack of provisions to protect those who are low paid and in insecure work.

While public sector workers already have basic protections in their employment contracts, there are many workers who are not directly employed but still provide vital public sector services without those same protections. Many of those people work in social care. Care work is also disproportionately undertaken by those who are already more socioeconomically disadvantaged, including women (who make up 82% of the workforce) and people from minority ethnic backgrounds. By improving the health and wellbeing of essential workers, boosting their spending power and helping to stabilise a social care system that is under pressure, multiple aspects of the government’s agenda could be supported. Despite some of the most ill and vulnerable in society depending on social care services, a quarter of care workers are employed on zero hours contracts, increasing numbers are paid at or close to the National Living Wage, there are over 100,000 vacancies across England, and turnover is high.

Better partnership between national and local government

Levelling up is far too complex a task for central government to lead alone. Much of the agency to regenerate a local area economically, as well as to act on other wider determinants of health, is the responsibility of local government. Being much closer to communities than Whitehall, local authorities are more easily able to assess where investment is likely to be most impactful. In designing a strategy to improve and level up health, local government should therefore be heavily involved and given considerable autonomy to invest in areas and communities with the greatest needs, tapping into their experience of ‘what works’. This links with the need to develop a future strategy for devolution within England, due to form part of the forthcoming levelling up white paper.

While local authorities have a core role locally, an effective strategy to level up health will need to be based on collaborating with many outside government. The Bennett Institute for Public Policy has noted there is a large ‘ecosystem’ of national and subnational stakeholders relevant to building prosperity that should be engaged. Alongside local government in all its forms (local authorities, mayoral combined authorities and non-mayoral combined authorities), other public authorities including the NHS, police and bodies such as Natural England, will need to be engaged. The third sector and local private business representatives will also need to be involved, such as the Confederation of British Industry and local Chambers of Commerce. It will be critical to draw in these different perspectives for successful design,, ownership, implementation and impact.

Plans can be developed between central and local government, and other key stakeholders, today. But it must be acknowledged that the decade after 2010 saw significant cuts to the baseline budgets of local authorities which have eroded their capacity to improve health and boost prosperity. Services that are vital for levelling up that have been cut substantially over the past decade include housing, education, early years, social care, and public health. Before the pandemic, council spending on local public services had dropped by 23% since 2009/10 – equivalent to nearly £300 per person. More deprived areas fared the worst, with an increasing reliance on council tax meaning that poorer areas – those less able to raise as much from council tax and more dependent on funding from grants and redistributed business rates – experienced bigger cuts. Despite good evidence that spend on public health is highly cost effective, the public health grant is also 24% lower on a real-terms per capita basis than it was in 2015/16 following years of cuts.

The forthcoming Spending Review should acknowledge the key role of local government in levelling up prosperity by adequately funding local authority baseline budgets, and by investing in sector-led improvement to build capacity.

A greater role for the NHS

A striking feature of the levelling up approach to date has been the lack of discussion about how the NHS itself – England’s largest ‘industry’ and a key employer based in all parts of the country – can contribute to prosperity beyond its core role in providing health services.

For the population as a whole, health care services by themselves make only a minor contribution to overall health outcomes, next to other factors such as poverty, employment, early life, and education. But the NHS is a huge organisation and taken in its entirety has an annual budget of £150bn, with 1.5 million staff directly employed. How might it do more to boost population health through action on economic regeneration and on the wider determinants of health?

(i) Boosting economic capital: prosperity and jobs

The NHS is the largest employer in the UK. On top of existing staff shortages of over 100,000, our projections of future trends in demand and supply for health care (based on pre-COVID-19 data) point to the need for over 230,000 more NHS staff by 2025/26. As part of its normal business, and provided it is given investment commensurate with need, the NHS will be able to employ and train a significant number of those seeking work in future – particularly in areas that need to be levelled up where there may be fewer opportunities.

The same is true for social care. Currently the adult social care workforce employs around 1.52 million people in 1.65 million jobs in England. If the workforce grows in proportion to the number of people aged 65 and older, then an extra half a million jobs will be needed by 2035, again in many areas needing to be levelled up.

As health care is a globally expanding industry, the NHS’s role to boost enterprise through research and development, innovation and life sciences is central. For many years the ‘innovation health and wealth’ agenda has been pursued through a variety of policies and initiatives., In the wake of the pandemic there will be renewed emphasis on this as part of attempts to drive successful enterprise for the UK globally, including through vaccine development and trials for example. Given the domestic priority of levelling up, and the increasing recognition that ‘place matters’, the obvious opportunity now is to pursue this agenda while developing current regional and local initiatives that are more explicitly designed to benefit local people through employment. This is especially the case in areas outside of the ‘golden triangle’ of research institutions in Oxford, Cambridge and London. Such activity is already happening and has accelerated due to the pandemic in areas such as Manchester, Leeds and Newcastle, with activity linked to government investment., The key will be to boost these existing efforts by linking such initiatives with new levelling up funding as part of an explicit strategy – countering the ‘spread too thinly to be effective’ argument for new investment, and adding value to existing levelling up investments.

While central government can and should act on these issues, reforms in the NHS Long Term Plan, and in the recently published Health and Care Bill, aim to boost collaboration between NHS bodies and other local stakeholders, such as local authorities, within and across integrated care systems (ICSs). ICSs – like the Greater Manchester Health Partnership – boost critical mass and skills, helping local agencies make faster progress on economic regeneration while improving health and care. Again, there should be strategic join-up between a national levelling up agenda (and a new partnership with local government) alongside these developments on the ground – to multiply the impact of the public funds invested.

(ii) The NHS as an anchor institution

First developed in the US, the term ‘anchor institution’ refers to large, typically non-profit, public sector organisations whose long-term sustainability is tied to the wellbeing of the populations they serve. Anchors get their name because they are unlikely to relocate (for example as a business might do in the event of an economic downturn), and have a significant influence on the health and wellbeing of communities.

The NHS can act in a national role and locally as an anchor in several ways.

Nationally

The NHS exists to provide universal access to health care based on need, not the ability to pay. Due to funding formulae that has explicitly taken into account health need since the 1970s, tax funds for the NHS per head of population are now distributed more evenly across the country (England) than other public services.

But while overall resource allocation (funding per capita) might reflect need, where NHS facilities are located (where staff are employed, care is delivered, supplies are procured from) may do so to a lesser extent. For example, the past 20 years have seen a large number of closures or mergers of hospitals, and beds managed by community trusts reduced, many affecting small towns. In 2019, 19 NHS trusts were earmarked for closure. These plans are likely to have been made to improve the quality of care (the NHS’s core objective) and boost efficiency, rather than to support the local community through maintaining employment (which would in turn help to improve health). The past two decades have also seen relatively low investment in primary care relative to hospital care and a persistence of the ‘inverse care law’ in general practice, with more deprived populations served less well than wealthier ones.

The impact of major reconfiguration decisions (such as facility closures) on local social capital and employment opportunities could be a greater factor in decision making, particularly for those facilities serving more deprived communities and in areas with little industry. The NHS is under huge pressure to improve the quality of care and to operate as efficiently as possible within a given budget. Decisions that also account for wider public value to a community may need to attract extra central subsidy to achieve that objective; for example, from levelling up investment funds. The Public Services (Social Value) Act 2012 already requires NHS commissioners to consider broader social, economic and environmental benefits to their local populations when making commissioning decisions. But the extent to which this is happening, or is impactful, is unclear. While this will be boosted by provisions in the recently published Health and Care Bill, the incentives for the NHS to achieve greater value for money will strongly act against these wider considerations.

Procurement is an obvious area where the incentives may also work against the goal of improving social value locally. Sourcing supplies locally in the NHS may be inefficient, not least because of the time and administration involved, but also because the NHS may not then maximise its more collective purchasing power to drive up quality and drive down cost. In the wake of the pandemic for example, the Department of Health and Social Care is looking again at how technology can be effectively supplied to the NHS.

The NHS can make the most of its role as a major employer by incentivising recruitment and retention in areas with chronic shortages, setting fair national pay rates for staff, continuing to improve health and wellbeing at work (a particularly pressing task given the high stress levels reported in NHS staff surveys) and working to address unfairness and discrimination in all its forms. Recent policies have paid attention to these issues. For example, the system of terms and conditions for NHS staff (‘Agenda for Change’) has focused on improving pay rates for the lowest paid. There are policies to develop staff and their wellbeing through the NHS People Plan, and there is a Workforce Race Equality Standard (WRES) requirement for NHS commissioners and NHS health care providers in the standard NHS contract. Further progress is still needed.

Locally

Over and above providing care and joining with partners to boost employment and innovation, NHS organisations can make a further contribution to the prosperity of a place. This can include, for example, adapting the way people are employed as well as the way goods and services are purchased and buildings and spaces are used. The potential for the health service to create this type of social and environmental value in local communities is recognised in the NHS Long Term Plan, and a number of trusts, systems and other partners are aiming to make progress by participating in a UK-wide Health Anchors Learning Network, co-funded by NHS England and NHS Improvement and the Health Foundation.

Examples of local anchors work on the ground can be found in areas like Mid and South Essex NHS Foundation Trust, which has developed a number of initiatives aimed at working with and better understanding its local community, including an employment dashboard designed to support access to work and measure progress in tackling inequalities. The dashboard combines hospital data (including the roles and demography of staff and vacancies mapped to local deprivation), with council data (local demographics and the aspirations of young adults). In Newcastle, a cross-sector partnership has been set up by the NHS and other local bodies with a strong focus on targeting areas of deprivation and ensuring inclusive local recruitment.

The role of integrated care systems (ICSs)

A key thrust of the NHS Long Term Plan was to develop ICSs – partnerships between NHS organisations, local government and other agencies designed to coordinate local services and improve population health. ICSs have been created in 42 areas of England, covering populations of around 1 to 3 million. The latest reforms to the structure of the NHS in England (as outlined in the government’s Health and Care Bill) develop this agenda further, and more formal versions of ICSs are likely to be established in 2022.

ICSs offer an opportunity to strengthen the NHS’s role in preventing disease and reducing inequalities. This includes collaboration with local government and other community groups to identify and address social factors that shape health, such as food insecurity and social isolation. While the previous versions of ICSs (Sustainability and Transformation Partnerships) developed 5-year plans for improving local health and care in 2016, analysis of these plans found that their approaches to prevention and reducing inequalities were often weak. Most plans included a prevention strategy, but fewer than half specified how NHS agencies would work with local public health teams. Coverage of how these plans would meet national prevention priorities was patchy. The plans were also broadly focused on individual-level approaches to disease prevention, with few describing interventions to address the social and economic determinants of health.

Stronger engagement with local government and more systemic approaches to addressing inequalities will be needed if ICSs are to deliver on their ambitions. Rather than searching for ‘silver bullet’ solutions, local leaders are likely to have the greatest impact by focusing on reshaping the multiple factors that impact on the health of their communities. To reduce rates of obesity, for example, action will be required across health care, food, transportation and other aspects of the local environments in which people live.

England has a long history of partnership initiatives between the NHS and other sectors that have aimed to improve health and wellbeing. Yet evidence about the impact that these partnerships have had on health outcomes and health equity is limited., Communication, culture, resources, management, and other factors are likely to shape partnership success. The potential for local partnerships to have a positive impact is also fundamentally shaped by the broader political context in which they operate – including the level and distribution of funding available for public health, education, and other public policy areas. ICSs will only be able to tackle inequalities as part of a coordinated national approach, which is in turn linked to a broader levelling up strategy for investment.

Measurement

As noted by the Business, Energy and Industrial Strategy Committee in its recent report, it is not clear how the impact (as opposed to delivery) of the levelling up strategy will be assessed – particularly following the recent scrapping of the Industrial Strategy Council. As emphasised previously, at the core of a cross-government strategy to level up must be a more balanced view of the factors that shape people’s health and impact the prosperity of a local place. A broader set of metrics should be used to set targets and assess progress, including measures of health and wellbeing. These could include indicators of healthy life expectancy, mortality, morbidity and wellbeing across the life course that are already monitored by the ONS and PHE. A range of wider wellbeing and health indices and frameworks could also be drawn on. The new ONS Health Index for England, for example, tracks a broad spectrum of 58 indicators to measure the health of the nation and compare different places. These include healthy life expectancy and avoidable deaths; working conditions (including job-related training and low pay); children and young people’s education; access to green space, and access to housing.

Internationally, a number of other indices and frameworks have also been developed that could be drawn on. The World Bank has developed the Human Capital Index, the OECD uses a Framework for Measuring Well-Being and Progress, and the New Zealand Treasury uses a ‘Living Standards Framework’ based on the ‘four capitals’. The same sorts of indicators could be used to identify areas in greatest need of investment when allocating any future levelling up funding (such as via the UKSPF), to set clear targets for addressing health inequalities, and to better join the dots with existing funding streams.

These metrics should be distinct from progress against the operational delivery of a specific set of government initiatives, which may be prioritised by the Prime Minister’s Delivery Unit or the new levelling up taskforce charged with overseeing the strategy.

Accountability

There is a strong case for regular independent monitoring of these wider trends, outwith a government unit/department or central cross-government unit. To an extent, the Office for Budget Responsibility (OBR) performs a function like this for financial capital, the Infrastructure Commission for infrastructure capital, and the independent Committee on Climate Change for some aspects of natural capital. An equivalent regular independent assessment of the nation’s health capital, scrutinised by parliament at regular intervals, would clearly be in the long-term interest – helping to sustain attention over time and build cross-party consensus and accountability on the need for action.