How to include the wider determinants of health in the levelling up agenda - Part 1

In the first of a two-part blog, senior research analyst in the House of Commons Library, Mark Sandford, discusses the social determinants of health and how these might be more effectively taken on board via devolved structures.

Introduction

The UK Government’s levelling up mission 7 sets a target that “by 2030, the gap in Healthy Life Expectancy (HLE) between local areas where it is highest and lowest will have narrowed, and by 2035 HLE will rise by five years.” The existence of this mission acknowledges that health disparities are a core dimension of the regional disparities that the ‘levelling up’ agenda seeks to address. This has been confirmed by Government ministers and local leaders alike. For instance, Neil O’Brien, then minister for local government, emphasised the importance of health to levelling up in a seminar in March 2022. This is reflected in local priorities: in June 2022, when asked what the key indicators would be that levelling up was happening, Andy Burnham, mayor of Greater Manchester, cited “the health of the population” as the most important.

The Levelling Up White Paper states that the mechanisms used to achieve mission 7 will include:

Investment in the NHS, including building new hospitals, and the Core20Plus5 initiative, that aims to “improv[e] cardiovascular disease, cancer, respiratory, maternity and mental health outcomes in the poorest 20% of the population”;
a ‘Tobacco Control Plan’, intended to reduce smoking rates in disadvantaged areas;
investment in weight management services;
a programme called Better Health: Rewards, intended to incentivise diet improvements, being piloted in Wolverhampton;
improvements to cookery teaching in schools, and provision of vouchers for fruit and vegetables;
investment in drug treatment services, based on the December 2021 strategy From Harm to Hope;
establishing community diagnostic centres.

The role of the wider determinants of health

Conventional health service delivery approaches dominate these mechanisms. This is not the only route to improving health, however. Researchers suggest that the Government’s planned interventions draw on “an individualistic, medical model of health … [providing] access to screening and diagnostics or promoting information, support and incentives to encourage people in disadvantaged communities to improve their lifestyles”.^[1] This approach has been critiqued from a number of sources, on the grounds that “social and structural determinants of health account for a far greater burden of non-communicable diseases and contribute more to health inequalities than individual behaviours”. The wider social and structural determinants of health include policy in areas such as housing and the built environment; environment and green space; air quality; transport; policing; education; and employment.^[2] The Levelling Up White Paper does acknowledge the importance of wider determinants in making health policy – for instance, it says that DHSC will “consider health disparities at each stage at which they arise, from the wider determinants of health, to the behavioural factors that influence health, to the health services that people access and receive” – but this awareness is not reflected in the programmes that are intended to achieve the health mission.

In part this may reflect the influence of ‘silo government’. Researchers from the Universities of Edinburgh and Glasgow have argued that: “health policy makers lack influence over broader social and economic areas so inevitably tend to focus on the levers they can pull such as preventive healthcare, health promotion, and pharmaceutical interventions, with a limited impact on health inequalities”. Equally, a focus on service provision may simply reflect the information ecosystem within which policy-makers are operating, where “evidence on tackling the wider social determinants [is] less apparent and less accessible to policy makers and practitioners”.

Taking social determinants on board

To counter these pressures, some commentators advocate health perspectives being taken into account across all government policies. For instance, health.org argues for a “‘whole government’ strategy where improving health is an explicit objective of every major government policy”. The Mental Health Foundation has made a similar case regarding mental health policy. This calls to mind the ‘whole systems approach’ lauded by the Levelling Up White Paper, in respect of initiatives such as the Supporting Families Programme and Shared Outcomes Fund. This type of approach is intended to break down barriers between conventional policy areas. Public health and the wider determinants of health are examples of policy matters that are most effectively addressed by harmonised action across a broad swathe of public policy.

Tackling health issues via policy directed at its social determinants could assist in some of the challenges facing the NHS. The think-tank New Local has argued that continued rises in the percentage of GDP spent on healthcare are a symptom of an unsustainable system: “there is far too much ill-health for the NHS to treat in anything like a timely and safe fashion with its current level of resource. … the cumulative impact of the demand crisis is potentially existential for the NHS”. They suggest three correctives to this challenge. One of these is for healthcare bodies to play a greater role in addressing the social determinants of health; the others are viewing individuals holistically and seeing them as participants in improving their own health. This parallels “the expectation that [the new Integrated Care Systems in the NHS] will develop partnerships with local authorities and other agencies to improve the health and wellbeing of the populations they serve”. The DHSC’s recent announcement of funding for research into health inequalities, to be coordinated by 13 pilot local authorities, indicates Government interest in these relationships.

The role of local leaders

The imperative towards integrating health with other policies, led by the establishment of Integrated Care Systems within the English NHS in April 2022, is creating parallel debates to those concerning English devolution. Mayoral leadership debates prioritise integration; effective spending and improving outcomes; and improved accountability. Recent reports from the think tanks Onward and the Institute for Government highlight the benefits of local, particularly mayoral, leadership: innovation, policy alignment, policy consistency, and the ability to convene local networks. As English metro-mayors possess limited powers and funding, they have sought to add value by strategic alignment of policies, and by adopting ‘orphan policies’ – issues that are not the (direct) responsibility of any one tier of government.

The cross-cutting nature of policy on the wider determinants of health makes it a good fit with the operational practice of metro-mayors. Using their current range of powers, or expanding them, metro-mayors could complement the service-based focus of mission 7, and contribute to achieving it, via a strategic focus on the wider determinants of health. However, to date there has been little connection between the debate within ICSs and mayoralties. Government publications recognise the value of place-based policymaking in the sphere of healthcare to aid integration. But potential links with mayoralties are rarely highlighted. Equally, it is rare for either health services or public health to feature within devolution deal negotiations.

Enabling metro-mayors to play a role related to the wider determinants of health would assist with the aspirations towards place-based policy found in the Levelling Up and Integrated Care white papers. It would also help to fulfil the aspirations of Ministers and local leaders, to make health central to the levelling up agenda. Mayors would be well-placed to act as a link between both ICSs and local Directors of Public Health and their own range of policy responsibilities.

How could local leaders be given responsibility for wider determinants policy?

A number of actions could be taken to permit, incentivise and assist local leaders to prioritise the wider determinants of health:

Collect data and establish metrics relating to wider determinants. The Levelling Up White Paper’s ambition to extend devolution deals across England was accompanied by a commitment to a new accountability framework, which will include “clear roles and metrics for assessment and measures to support local areas”; and to improving and extending the publication of data on “place-based leadership, quality of local service delivery and organisational efficiency”. Local leaders’ policy priorities will therefore be influenced by what data is published and used for assessment and accountability purposes: decisions on this are likely to be made in 2022-23 by the new ‘Office for Local Government’.

The data and metrics used should include indicators that are known to influence the wider determinants of health. This would enable mayoral contributions to population health to be assessed. Methodologies to do this already exist. For instance, research at the University of Warwick in 2010 calculated the potential savings on health spending arising from improvements to housing. The research quantified the cost of NHS treatments arising from a range of hazards present in sub-standard homes and produced an annual figure for the savings that would result from removing those hazards. The calculations assessed the consequences of specific hazards in terms of associated health costs – for instance, the risk of a missing balustrade leading to a fall requiring NHS treatment – and so incurring costs.

Thus, for instance, the new metrics could include data on the actual improvements to housing during a given timeframe and the resulting savings for health services. This type of approach could be adopted for a range of policy areas.

Include wider determinants matters in outcome measures for local leaders. The White Paper’s new accountability framework for devolved bodies in England is to clarify the roles and responsibilities for local leaders, and “key outcomes” to enable comparison between areas. One or more outcome measures that relate to the wider determinants of health could be used. The metrics would need to be chosen judiciously (and would need to be clearly linked to local leaders’ powers). Some evidence exists regarding the cost to health services arising from wider determinants, but this is patchy and tentative. Alternatively, economic valuations of the costs of the wider determinants of health could be used to assess the benefits arising from mayoral policy.
Take account of wider determinants when negotiating devolution deals. New devolution deals could include specific powers that can have a substantial impact on the wider determinants of health. This is not about devolving broad responsibilities such as ‘planning’ or ‘housing’. It could have a more granular application: for instance, permitting local leaders to take on powers to alter building control requirements, or to require the retrofitting of properties with low energy efficiency. These possibilities could be explored in the ‘trailblazer deals’ with Greater Manchester and the West Midlands.
Acknowledge wider determinants in grant determination letters. Discretionary Government grants to local bodies are normally provided as ‘section 31 grants’, which may or may not have conditions attached. Grant determination letters could make clear that it is permissible for grant funding for transport or skills (for instance) to be used in part to address the wider determinants of health. This would counter any local reluctance to agree to spending decisions that could face legal challenge on the basis that grant funding had not been used in line with funding conditions.
Acknowledge wider determinants in grant funding guidance. Current Government practice is to channel considerable quantities of money through national competitive funds: the Levelling Up Fund, UK Shared Prosperity Fund, Towns Fund, Community Renewal Fund. These are discretionary funds, and therefore the use that local leaders make of the money is substantially influenced by the application guidance or ‘prospectuses’ that the Government publishes. Guidance on future rounds of funding could be amended to permit local interventions addressing the wider determinants of health, in matters such as planning regulations and permitted development, school readiness, building control, open space availability; school meals, and air quality. This would be in line with the aims of many of the funds: for instance, the UK Shared Prosperity Fund prospectus seeks to “boost pay, jobs and living standards” and “empower local leaders and communities”. Explicit references in the guidance are likely to encourage local leaders to prioritise the wider determinants of health within their applications.