- This briefing calls for coordinated action across government to improve health and health equity and generate future prosperity. The economic costs associated with poor health are high, with government estimating these at around £100bn a year. Future economic prosperity requires investing in the conditions that improve people’s health – such as education and employment opportunities, housing, social networks and healthy environments.
- Improving health requires action to be taken by the whole of government, not just the Department of Health and Social Care and the NHS. The ‘levelling up’ agenda, and the reorganisation of the public health system, provide an opportunity to drive cross-government action.
- To make the most of this opportunity, government needs to set out a national framework for action. This will require strong political buy-in and mechanisms to drive efforts across the whole of government – such as a binding target to reduce health inequalities and a commitment to make improving health an explicit objective of every major policy decision.
- Government also needs to create the conditions for others to play their part in improving health. Local authorities have a central role in improving health but have experienced cuts to baseline budgets in recent years. Government needs to provide sufficient and sustainable funding but also flexibility in how funding can be spent, multi-year settlements and further devolution to support joined-up, place-based working.
- Finally, ensuring adequate accountability of efforts to improve health will mean government establishing mechanisms to ensure there is public visibility of progress. Regular independent monitoring by the National Audit Office and increased parliamentary scrutiny would build momentum.
The health of the population is one of any nation’s biggest assets. Good health is vital for prosperity, allowing people to play an active role at work and in their communities. The inextricable link between health and wealth has been made more prominent by the COVID-19 pandemic, which has laid bare the consequences of underlying poor health in the UK. Even before the pandemic, poor underlying health placed limitations on people’s daily lives, and their ability to work and contribute to the economy. As part of the nation’s recovery, a new cross-government focus is needed to address these longstanding issues.
All sectors of society have a role in improving health. The voluntary and community sector provide vital social fabric; businesses as employers and producers of goods and wealth, and local government as convenors and leaders in shaping local places. While there has been steady action from some across these different sectors, the country entered the pandemic with life expectancy improvements stalling and inequalities widening.
Sustained success in improving health requires government to reorient itself to make progress over the long term. It is time to acknowledge that real progress will not be seen for years and will only be achieved if there is a consistent focus on improving health and health equity. Attention should be paid to investing in all four capitals: financial, human, social and natural. As seen with the net zero target, a long-term focus can be effective to galvanise society around a clear, ambitious outcome. The COVID-19 pandemic provides the impetus to do the same for health improvement.
Much attention is paid to what government needs to be – the spending, regulation and policies that can improve health. Arguably the lack of traction on this longstanding agenda stems from insufficient focus being given to how government organises itself to create the conditions for others to improve health and health equity.
This briefing recognises that concerted, holistic action needs to be taken to create the conditions that improve health. It sets out the action that central government needs to take to act purposefully as a system, rather than as a series of individual actors.
We draw on desk research and consultations with members of the public and stakeholders across a range of sectors, carried out by the Health Foundation, and a roundtable with senior figures from government and the third sector, convened by the Institute for Government.
The opportunity to ‘level up’ the nation’s health
Investing in the conditions that improve people’s health – education and employment opportunities, housing, social networks, and healthy surroundings – will be an essential part of the pandemic recovery. Poor health is strongly linked with lower labour market participation, which carries a high financial cost and lost opportunity both to individuals and the state. In 2019, employment rates in the UK were 17 percentage points lower for people with long-term limiting health conditions. These conditions also reduce productivity, as people experience higher levels of sickness absence.
People’s health status also influences the age at which they can continue to make an economic contribution through work. Only half of men living in the most deprived tenth of areas in England report good health in their late 50s (well before retirement age), while in the least deprived tenth of areas it is not until their late 70s that a similar proportion report being in good health (well after retirement age) and a similar pattern exists for women. The economic costs associated with poor health add up: the total economic cost of lost output and health costs are estimated at around £100bn a year.
The government has set out an aim to level up the country, promising to increase prosperity, widen opportunity and ensure that no region is left behind. It is an ambitious agenda and action to ‘level up the nation’s health’ has been described as part of it, although specific plans are still in development. There is clear motivation for action, with Health Foundation polling showing that the public expect government to act on improving health and there is unparalleled public awareness of health inequalities following the pandemic. There is political motivation to act too: at the 2019 election, female healthy life expectancy in seats gained by the Conservative party was 4 years lower than in the seats the Conservatives held, and 6 months lower than in Labour held seats.
Our recently published COVID-19 impact inquiry showed that the UK did not have the resilience to respond to shocks, like the pandemic, partly due to poor underlying health. The difference between those with the best and the worst health in the UK widened in the years prior to the pandemic. These inequalities were brought to the fore during the pandemic and risk widening further following the significant impact on society and the economy. International comparisons indicate that the UK’s health is falling behind other comparable countries. This partly reflects the stalling of improvements in life expectancy, particularly in more deprived areas of the country. Unless steps are taken to permanently reverse this trend, we will be unable to truly level up or build resilience to respond to future shocks.
The Health Foundation and other organisations, including the Inequalities in Health Alliance, are making a strong case for further action to improve health and health equity. Independent and public accountability for action taken are important, but the government itself needs to seize the momentum and make the most of the opportunities posed by the recovery and levelling up agenda.
Improving health requires action to be taken by the whole of government
The NHS is often cited as the great leveller of health, founded on the principle of providing treatment based on need rather than the ability to pay. The NHS Long Term Plan sets out its role, including that of integrated care systems, in making funding decisions that meet the needs of the whole local population and prevent ill health. But this is only part of the story. A greater influence on people’s health are the factors that shape their opportunity to stay well in the first place: the social, economic, commercial and environmental conditions in which people live. Addressing these requires action to be taken by a broad range of organisations, of which the NHS is just one.
Despite this, action to improve health continues to be seen in public discourse, and in Whitehall, as the job of the Department of Health and Social Care and the NHS. Yet evidence shows that improving people’s healthy life expectancy, and with it their ability to live a full and active life, will require continued action from across the whole of government and beyond.
Concerted cross-government action has the potential to make a bigger difference. Between 2000 and 2010 a wide-ranging and multi-faceted health inequalities reduction strategy was implemented in England. The policies led to reductions in social inequalities in the key determinants of health, including unemployment, child poverty, housing quality, access to health care, and educational attainment and an overall reduction in health inequalities. When this strategy ended, inequalities started to increase again, underlining the importance of activities continuing beyond political cycles as successive governments need to pick up where others left off. Changing these determinants and seeing the impact on healthy life and life expectancy takes many years and requires long-term planning and change. Building cross-party consensus would help to advance the work.
The current government has created an opportunity to drive the necessary cross- government action, through the levelling up agenda (including the new Department for Levelling Up, Housing and Communities) and the reorganisation of the public health system. However, maximising the potential of these initiatives will require an explicit and concerted focus on the opportunities to improve the conditions that create and maintain good health. The new Office for Health Inequalities and Disparities will play a key role in driving progress but will need the right mechanisms and strong political backing to ensure a whole-government approach.
To date, the government’s levelling up plans have a narrow focus on separate, short-term, infrastructure funds that local areas can bid for. As well as being narrow in scope, our analysis of the fund showed that some areas with either high levels of deprivation or low levels of healthy life expectancy did not receive the most funding through the fund; 35 local authority areas with very low healthy life expectancy were found not to be a priority for investment via the Levelling Up Fund. The forthcoming white paper and levelling up activity supported through the Spending Review, can redress this balance and secure the coordinated and long-term action needed.
A strong national framework for action
To reduce lost potential and opportunity for individuals and the country, focused and coordinated government action is needed to improve and maintain people’s health. This action is needed both through how government organises itself to deliver impact and through pursuing the policies that will make a real difference. This briefing focuses on the first of these.
A government committed to levelling up health and creating opportunity for individuals and the country has the power to set an ambitious framework for action. The necessary actions fall into two broad areas, with progress measured through strong accountability measures.
1. Placing improving health and health equity at the heart of government’s agenda
Just as the pandemic has shown that health is everyone’s business, improving health and health equity needs to be a shared goal of government. To make this a reality, the initial actions to be taken are:
- strong cross-government coordination to prioritise actions that improve health
- strong political buy-in that secures long-term investment
- a binding target to increase healthy years of life and reduce the gap between those living in the most and least deprived areas
- improving health and health equity as an explicit objective of every major policy decision
- government investment decisions to prioritise opportunities to improve health, and
- maximising the potential of government agencies and arm’s-length bodies.
Strong cross-government coordination to prioritise actions that improve health
The new cross-government ministerial board on prevention, announced in March 2021, is the best-placed existing mechanism to provide this coordination. It can ensure government departments work towards a common goal, are held accountable for individual and collective progress, and are engaging effectively with key stakeholders.
The board on prevention will need a broad membership, with input from the Office for Health Improvement and Disparities, local and regional government, academia and practice. A theory of change will be needed that links policy proposals and their intended impacts with the overall shared ambition, as well as clarifying what is to be measured. This will enable progress to be tracked alongside realistic expectations, given the timeframes over which much of the action will have impact. Working through the Number 10 Delivery Unit, or a Secretariat in the Cabinet Office, the board can establish baseline datasets, encourage innovative thinking and bring in new perspectives. Regular reporting on progress will help with public accountability and building visibility of the work.
Strong political buy-in that secures long-term investment
Lessons from previous cross-government initiatives show that to be effective, such boards require strong political backing and momentum generated by personal commitment from the Prime Minister. Early engagement is also needed from the Treasury, with new activities to prioritise spend on health and health improvement, to build credibility for the work with other departments. A long-term plan to shift the balance from short-term treatment to longer term prevention would help to improve health. The Health Foundation long read on how to plan for the long term highlighted a need to anticipate future issues; plan how to mitigate a threat; integrate insights into policy development; invest in resources over time and monitor and adjust assumptions as new issues emerge.
The work of the board on prevention will need to be visible and subject to a level of independent oversight. This will focus attention on action and make it less vulnerable to changes in political priorities. Options here include an annual report to parliament, parliamentary scrutiny through select committees and an independent body reporting health metrics, such as the ONS health index. As the work of the board is evaluated, measurement will need to recognise both the complex and interrelated nature of the wider determinants of health and the long timescale required to see change. Historically such frameworks have failed to last, so it will also be important to build this more fundamentally into the day-to-day workings of government, as we set out.
A binding target to increase healthy years of life and reduce the gap between those living in the most and least deprived areas
A new ambition needs to replace the commitment made in the 2017 Industrial Strategy.A target would signal ambition and vision and help build coalitions of support both inside and outside government, highlighting the priority and cementing a commitment to long-term progress. Targets can play an important role in building momentum, acting as a rallying point and creating momentum to keep on the trajectory. For example, the publicly stated commitment to the Millennium Development Goals helped to create a cross-Whitehall ‘consensus’ behind the aims of the new approach to development.
For targets to be successful, they need clear ownership. The board on prevention will have an important role in setting out a strategy for achieving the target, based on a clear understanding of what will drive change. It will be important for the board to measure progress against the target and hold members accountable for delivery, through departmental Outcome Delivery Plans and other mechanisms. Exactly how the final target will be achieved may change over time; in fact, this flexibility can be important to ensure action is driven by learning from implementation. The approach taken by the Climate Change Committee shows the importance of having intermediate targets and a clear reporting and measurement framework that shows routes for achieving the overarching ambition. Intermediate targets will be particularly important in this work given that outcome measures will be slow moving. There is potential to be guided by the new ONS health index here to track progress in different domains of health, but also the determinants of health.
Improving health and health equity as an explicit objective of every major policy decision
Making progress will require a different approach to how policies are developed, with recognition that health improvement is the responsibility of a range of departments, not just the Department of Health and Social Care. There needs to be a new impetus with all departments taking steps to understand the health implications of decisions they make, looking for opportunities to improve health and health equity through their work and avoiding making decisions that negatively impact it. This is particularly the case in relation to regulatory activity on primary risk factors or disinvestment in state services and support.
Such an approach would lead to departments being more proactive in looking ahead to potential issues that risk future health, for example the negative impact on levels of debt following reduced incomes and job losses as a result of COVID-19. Annex A lists a range of evidence-based policies that government could take forward to increase health in populations, which received widespread stakeholder support.
Outcome Delivery Plans begin to identify some of the activities needed and share responsibilities between relevant departments. For example, the priority outcome to support the most disadvantaged children through high-quality local services so that no one is left behind, will have a direct bearing on future health, which is at the heart of the Health Foundation’s Young people’s future health inquiry. Government activity on this outcome is led by the Department for Education and supported by the Department for Digital, Culture Media and Sport; the Department of Health and Social Care; the Department for Work and Pensions; the Home Office; the Department for Levelling Up, Housing and Communities and the Ministry of Justice. The range of actors across government in just this one example illustrates the importance of effective coordination. The delivery plans are, perhaps understandably, high level, and alone will not create the conditions for the required scale of change to be delivered. Strong leadership, through the mechanisms outlined, will be needed to drive the required progress.
Throughout the pandemic, the UK saw unprecedented activity across the whole of government, with the sole aim of protecting the NHS and saving lives. Avoidable ill health needs to be considered with the same urgency: pre-pandemic there were over 136,000 deaths considered ‘avoidable’ in the UK and 40% of health care provision in the UK is being used to manage potentially preventable conditions. There is an opportunity to build on the new approaches to sharing data, cross-departmental working and movement of civil servants across departments to maintain the focus on health outcomes.
Government investment decisions to prioritise opportunities to improve health
The Chancellor has been clear that he intends to aim for a balanced budget in normal time and reduce national debt over the medium term. This raises questions over the impact of future budgetary restrictions or cuts to public services, with Spring Budget 2021 implying that compared with 2009/10, spend in unprotected departments would remain lower.
In making funding decisions, the Treasury should support joint bids that enable different parts of the delivery chain to join up. It is also able to change the way in which investment decisions are made so that there is recognition of the range of outcomes improved by a measure, rather than only looking at the outcomes set out in an individual department’s Outcome Delivery Plan. This would help with the common situation in which departments are not incentivised to take action that benefit agendas other than their own. For example, investment in children’s social services and young people’s services by the Department for Education and Department for Digital, Culture, Media and Sport will lead to savings in the criminal justice system that the Home Office and Ministry of Justice will benefit from.
One way to shift the focus would be to look beyond short term and purely financial outcomes, to consider the implications for social, health and natural capital over the longer term, as has increasingly been done elsewhere. 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.
There is more the UK can do here. In 2020 the Treasury Green Book was reviewed to increase the importance of place-based analysis and boost the levelling up agenda, but no extra consideration was added for health criteria. In 2021, supplementary green book guidance on wellbeing appraisal was published and, while this is a step in the right direction, it is unlikely to fully address the lost opportunity that comes from poor health. Over the past 8 years wellbeing measures have improved while health outcomes have stagnated. Wellbeing measures are a mixture of objective and subjective data and as such may reflect some with poor health reporting positive wellbeing, possibly through normalising their condition, while some in good health report negative wellbeing.
Maximising the potential of government agencies and arm’s-length bodies
Government departments have considerable influence over policy delivery through their associated agencies and arm’s-length bodies. Activities that invest in health can be incentivised through the annual business planning cycle, mandate setting process or powers of direction. While organisations such as NHS England or the newly created Health Security Agency have an explicit reference to improving health in their remit, there is an opportunity to build a stronger focus into a broader set of governmental bodies that support the wider determinants of health. For example, Natural England will support the Department for Environment, Food and Rural Affairs to deliver the 25-year environment plan. This sets out a blueprint for a healthier environment and recognises that connecting people to the environment can improve their health and wellbeing. There are similar opportunities to identify how other government bodies can work to improve health. Likewise, these bodies can use the data from the ONS health index, alongside any local data they hold, to make the case to their sponsoring department of the need to invest to improve health outcomes.
As the government looks at the health landscape through the creation of the Office for Health Improvement and Disparities, there is an opportunity to review whether existing health organisations are undertaking the most effective role to progress improvements in health and narrow inequalities, including whether NICE could undertake a more significant role in promoting evidence-based public health interventions around the wider determinants of health.
2. Government creating a framework that supports wider activity to improve health
Government creates the conditions so that others can play their part in improving health, unlocking the potential of individuals to contribute to society. Levers the government can deploy to support and encourage those outside of central government to act include:
- sufficient and sustainable funding for all local government activities
- flexibility and certainty for local government to use funding to prioritise the needs of residents
- further devolution of powers to support joined-up, place-based working at a local level and
- government using the breadth of its convening and regulatory powers to involve stakeholders outside of health.
Sufficient and sustainable funding for all local government activities
Councils have repeatedly had to make difficult decisions about services as a result of significant cuts to the baseline budgets of local authorities in the past 10 years. This has eroded their capacity to invest in broader services and take actions that improve health and boost prosperity.
The Fair Funding Review of how to allocate funding between councils, now delayed but originally set to take effect from 2020, could have led to local authority funding allocations being skewed away from the most deprived areas. The formula was expected to reflect recent local authority spending patterns, but cuts to provision since 2009-10 had been greater in more deprived areas, with the potential effect of taking support away from the areas with the worst health outcomes. The Office for Health Improvement and Disparities has an opportunity to work with the Department for Levelling Up, Housing and Communities and the Treasury to review the metrics that determine how local and regional funding is allocated to take deprivation and need into account. Future allocation of funding for levelling up should ensure that funding is given to local authorities most in need in relation to their population’s health, given the impact that good health has on economic activity and quality of life.
Driven by cuts to funding from central government, council spending on local public services – which includes housing, early years and social care – dropped by 23% on a real terms per person basis between 2009/10 and 2019/20. This is equivalent to nearly £300 per person. The public health grant has also been cut by 24% on a real terms per person basis, the equivalent of £1bn since 2015/16. The disinvestment has happened at a time when demand for services has increased, reducing capacity to respond to issues that may prevent the need for further intervention down the line, for example family support, and despite good evidence that spend on public health is highly cost effective.
Flexibility and certainty for local government to use funding to prioritise the needs of residents
The current local government funding landscape is complex and fragmented. Alongside the reduction in funding, there has been a proliferation of small grants and local authorities have little discretion in the spending of these funds. Local authorities often lack resources or time to frequently bid for new funding schemes, meaning grants risk going to those most able to bid, not those with the highest need. These grants are also limited in effectiveness in that, unlike core funding programmes, they are often very specific and short term. This limits what councils can deliver and creates duplication around factors such as set up and commercial arrangements. In addition, where reactive grants are allocated they are often designed to manage rising levels of demand, replacing flexible funding oriented towards prevention.
More discretion over how the money is spent and more certainty about budgets over longer timescales would give local areas the power to determine how best to meet local needs. Issuing funding through multi-year settlements would also support local government to make the longer term, joined-up investments needed to improve health. Further additional funding delivered through core local government funding, rather than ringfenced programmes, would give local areas maximum flexibility. It may also help for government to go further in giving local areas the flexibility to raise money themselves, taking into account the varying abilities of councils to do this. To accompany this, clear targets and accountability would need to be put in place for local government, but with the flexibility to determine how they would achieve those outcomes.
Further devolution of powers to support joined-up, place-based working at a local level
Local – not national – leaders have the relationship with stakeholders and partners needed to deliver change in their local area. The COVID-19 pandemic has demonstrated the value of place-based leadership and the agility that local government had to act. Local leaders also led and promoted a single mission to partners in an area, driving all resources in the same direction and towards a common goal.
Siloes across government departments can thwart the ability of local areas to deliver joined-up, place-based agendas. Giving local areas greater flexibility, as has been the case in combined authorities, can make it easier for local partners to work together on shared priorities. Local areas need the space to set their own agenda, alongside partnership of the voluntary sector and communities. Regional and local arms of government agencies should also be incentivised to work with local stakeholders on measures to improve health. In areas where there is limited civil society support, the government needs to target grants that support and enable local voluntary and community sector bodies to nurture and champion the social sector. Local areas should be given a voice in the conversation about the national strategy and targets, but also flexibility to decide how to make progress in their area.
Recent research by The King’s Fund and the Health Foundation on the experience of directors of public health during the pandemic found their public profile had grown significantly during the response. There is an opportunity now to support directors of public health and their partners to lead recovery efforts. But doing so will require greater certainty about funding and the national and regional public health system reforms.
While more local powers are to be welcomed, there are clearly interventions where governments and regions working on population-wide activities would be beneficial. Especially where the evidence for action is strong, such as minimum unit pricing for alcohol, or where there are opportunities to work together to develop capacity in the system – for example, building research capability to strengthen the evidence base on what works.
Government using the breadth of its convening and regulatory powers to involve stakeholders outside of health
Most risk factors underlying ill health – poor diet, lack of physical activity, smoking, alcohol and drug misuse – are strongly influenced by wider socioeconomic circumstances. Therefore any strategy to improve health equity must go beyond an emphasis on identifying personal risks to ill health or influencing individual behaviours. 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 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 persuade 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 foods, and improve conditions for the lowest paid workers. Government can also intervene to drive the powerful institutional investor community.
ESG (environmental, social and corporate governance) investing is now mainstream but is very largely focused on the ‘E’, especially regarding climate change. Given the strong influence of environmental factors on health outcomes, ESG framing for investments can also extend to assets that are not primarily health focused, but nevertheless have sizeable positive health effects. Social, or ‘S’, factors such as ‘good work’, labour rights and human rights all contribute to employee and community health. There is room for government to work with civil society actors who advocate for responsible investment practices, such as Share Action and their bill for responsible investment. This could embed health as a priority topic for institutional investors to assess company investment risk and drive better company stewardship and engagement through responsible investing activities.
3. Strong accountability to drive and show progress
There is a strong case for regular independent monitoring of wider health trends and a range of mechanisms beyond the board on prevention, that would promote accountability and drive progress. These include:
- National Audit Office conducting a value-for-money study on activity to improve health and health equity across government and a subsequent Public Accounts Committee, following the start of Office for Health Improvement and Disparities work.
- Parliamentary Select Committee investigation into progress and plans to improve health and health equity. This would need to be a joint committee, with focus across a range of government departments and activity. With cross-party membership, a select committee could have an important role in building the consensus needed to maintain momentum beyond this parliament.
- Annual reporting to parliament on progress to improve health equity. A regular independent assessment of the nation’s health, scrutinised by parliament at regular intervals, would help to sustain attention over time and build cross-party consensus and accountability on the need for action. It would also enable scrutiny of public spending on preventative action, relative to the management of avoidable problems.
- A Commissioner for Equitable Futures. The function could be similar to the Future Generations Commissioner for Wales, who acts as a guardian of future generations, encouraging public bodies to take greater account of the long-term impact of policies.
- Office for Budget Responsibility taking greater account of future fiscal risks due to future changes in population health, such as greater inactivity from an unhealthier population, reduced productivity and the implications for welfare spending.
Annex A: Policy areas to improve health equity
Table A1 lists evidence-based policies that can be taken to increase health in populations. The list was developed from the research and consultation previously mentioned. Our future work will further explore high-impact health improving activities and also cost-effective interventions through the public health grant.
Table A1: Evidence-based policies that can improve health with estimated costings
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Thank you to Adam Tinson, Louise Marshall and all the participants in the discussion facilitated by the Institute for Government. Thanks also to Dave Finch, Theo Clay, Lucy Brinkley and Alice Major.
When referencing this publication please use the following URL: https://doi.org/10.37829/HF-2021-HL13