As the Government prepares to set out the next phase of English devolution in its upcoming Devolution White Paper, much of the debate will focus on structures, funding and accountability. But as Mayoral Strategic Authorities (MSAs) take on a more significant role, another question deserves attention: what will enable them to use their growing responsibilities effectively?
This question is pressing for health. We have long argued that devolution matters for health and that ambitions for economic growth will be harder to achieve without a healthier population. MSAs shape many of the conditions in which people live and work, including transport, housing, employment and economic development. Meanwhile, healthy life expectancy has fallen by around two years over the past decade, and there is a gap of around 20 years between the most and least deprived parts of England.
The new statutory health duty for MSAs to have regard to improving health and reducing inequalities makes their role in health explicit. The question is shifting from why health should be part of devolution to how it becomes embedded in the way MSAs work. As the first phase of the Mayoral Regions Programme ends, it is a good time to reflect on what we have learned.
Since 2023, the programme, supported by the Health Foundation and led by a team in the West Midlands Combined Authority in partnership with MSAs across England, has helped build capacity through practical tools including a resource on implementing the health duty, communities of practice, peer networks and stronger strategic leadership and collaboration. One message stands out: powers alone are not enough. Authority, resources, accountability and organisational capability need to develop together.
The emphasis will shift further towards implementation: helping authorities fulfil the new health duty, embed Health in All Policies in decisions, strengthen local and regional relationships and develop the capability to work in a more devolved health and public-service system. The Health Foundation will also invest in a new delivery fund to support activity in places and share learning.
The first lesson is that building capability takes time and deliberate investment. Most MSAs were not established with health responsibilities and expertise does not automatically follow new responsibilities. Phase 1 has shown the importance of public health expertise, people who can build relationships across policy areas and senior leaders who champion health. In more mature authorities, health is seen as everybody's business. But turning that aspiration into routine practice requires sustained capacity, not just ambition.
The second lesson is that health is more likely to shape decisions when mainstreamed rather than treated as a separate programme. The programme has helped MSAs adopt Health in All Policies approaches, integrating health into strategies, governance, impact assessments and investment decisions. Its Health in All Policies toolkit helps authorities assess their starting points, identify opportunities across devolved functions and prioritise action.
The third lesson is that shared learning can accelerate progress. No authority should have to solve every problem from scratch, particularly as newer MSAs develop. Phase 1 has created forums through which authorities can learn from each other on work and health, housing and planning, impact assessment and the implementation of the health duty.
The fourth lesson is that devolution should strengthen local action, not centralise it at regional level. Health improvement depends on relationships with local government, the NHS and wider public services. The aim should not be to pull existing functions upwards, but to act at the right spatial level: using regional scale where it adds value while protecting local and neighbourhood leadership. There is also a question about how NHS and wider public-service investment can support shared ambitions for prevention. Central government, the NHS and arm's length bodies need to consider how funding, data and decision-making can better align around shared outcomes for places.
These lessons matter as devolution expands. New powers can be created quickly; the expertise, relationships and organisational capability needed to use them well cannot. MSAs will also start from very different positions, so support needs to reflect their levels of maturity.
This is the starting point for Phase 2 of the Mayoral Regions Programme. It will support up to 20 MSAs over the next three years, including new and emerging areas. A universal offer of tools, evidence and peer learning will be complemented by targeted and intensive support tailored to local needs.
The emphasis will shift further towards implementation: helping authorities fulfil the new health duty, embed Health in All Policies in decisions, strengthen local and regional relationships and develop the capability to work in a more devolved health and public-service system. The Health Foundation will also invest in a new delivery fund to support activity in places and share learning.
The debate is moving beyond whether devolution matters for health. The task now is to make it work: matching responsibilities with the resources, relationships and capability needed to use them well, while ensuring regional leadership strengthens local action. Done well, devolution can do more than add health to the responsibilities of MSAs. It can reshape how public services work together around prevention, place and population health.
Katherine Merrifield is deputy director, health and inequalities at the Health Foundation and Mubasshir Ajaz is head of health and communities for West Midlands Combined Authority and SRO of the Mayoral Regions Programme
