How local leaders can include the wider determinants of health in place-based policy - Part 2

In the second of a two-part blog, Mark Sandford, discusses the role local leaders play in relation to the wider determinants of health for supporting place-based policy found in the Levelling Up and Integrated Care white papers.

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 relates 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.