HEALTH

Rays of hope for health

Katherine Merrifield says that while the Devolution White Paper and the funding settlement set out positive ways local areas will be enabled to improve health, ongoing cuts could hold back progress

(c) Jannarong/Shutterstock

(c) Jannarong/Shutterstock

New data published in December showed that healthy life expectancy in England and Wales has fallen below 2017-19 levels. The gap between the most and least deprived areas of England has now reached 19 years for men and 18 years for women—a shocking reminder that where you live can still determine how long and how well you live. Tackling this will not be achieved through action from Whitehall alone; local areas need to be empowered to act on the building blocks of health, such as decent housing, a stable job, and a good education. 

For those of us advocating for greater support to local areas in addressing these inequalities, there were some glimmers of hope last year. The first was the publication of the Devolution White Paper, which made 44 encouraging references to improving health. Importantly, it gave a new duty around health improvement and health inequalities to Strategic Authorities. This new responsibility ensures that all Strategic Authorities will have a stake in improving local health outcomes, bringing us closer to realising a ‘health in all policies' approach.

Place-based action risks being undermined by fragmented governance and accountability structures. Research we have funded highlights the lack of coordination between councils, Combined Authorities, and Integrated Care Systems (ICSs), resulting in duplicative efforts and missed opportunities for bold action

The White Paper also discussed clearer expectations for Mayors in local health systems and improving population health. While the detail is yet to be established, this shows promise, including a strengthened role for Mayors in Integrated Care Systems (ICSs), a long-term movement towards coterminous public service boundaries, devolution of specific responsibilities in several policy areas, and a commitment to make prevention the default approach. 

The White Paper also introduces a new statutory duty for Mayors to deliver local growth plans. In the face of competing demands on councils' time and resources, this has the potential to motivate more strategic thinking in prioritising inclusive growth in allocating investment and funding. However, improving health must be made a more explicit aim of local growth plans, and is critical to their success. 

The second glimmer of hope, albeit more mixed, was around the local government finance settlement. Together with the Institute for Fiscal Studies (IFS), the Health Foundation has highlighted how local government funding allocations have become increasingly unfair and inefficient, driving local and regional inequalities. Decade-long uncoordinated policy changes have disproportionately affected deprived areas, and failure to account for population growth and other demographic shifts has led to the most deprived fifth of areas receiving, on average, 9% less funding than the least deprived areas.

The provisional local government finance settlement for 2025-2026 introduces a new Recovery Grant to increase funding for the areas in greatest need. While this is a crucial step for local areas to start to capitalise on the health opportunities outlined in the White Paper, the settlement fails to address the £2.3bn shortfall councils face in 2025/26 due to long-term underfunding, and does not recognise the estimated £2bn increase in costs to local authorities purchasing social care due to changes in employer National Insurance and the National Living Wage. 

While it's positive to see the government seeking to empower local and regional governments, much more is necessary to ensure the complexities of local systems do not undermine good intentions. Critically, funding pressures mean local authorities have had to cut or reduce access to many services. Discretionary services such as libraries and leisure facilities are often the first to go. As Demos has argued, prioritising statutory demand-led services also risks sidelining key functions such as leadership and place-shaping, reducing their ability to focus on the long-term, preventative work needed to improve health. 

Local government action is further compromised by ongoing inaction on the public health grant, which funds various services from health visits to drug and alcohol services. The grant has been cut by 28% on a real-terms per-person basis since 2015-16, with the most significant cuts falling in more deprived areas. While we await 2025-2026 allocations, we do not anticipate an increase in real-terms funding, representing another missed opportunity to prioritise long-term, preventative measures for improving health.  

Finally, place-based action risks being undermined by fragmented governance and accountability structures. Research we have funded highlights the lack of coordination between councils, Combined Authorities, and Integrated Care Systems (ICSs), resulting in duplicative efforts and missed opportunities for bold action. While the White Paper promises a framework for clearer powers and accountability, its focus on the relationship between Mayoral Strategic Authorities and Whitehall leaves horizontal coordination between local entities unresolved.

There are some positive steps to explore further in 2025, but the devil will be in the details. While the Devolution White Paper and the new funding settlement set out positive ways local areas will be enabled to improve health, the continued financial pressures on councils and ongoing cuts to public health budgets risk undermining the potential of new policies. We need more than just positive rhetoric—we need a concerted, long-term commitment to fairer funding and the empowerment of local authorities and Combined Authorities to lead in improving health. 2025 could be a pivotal year, but only if the necessary resources and structural changes back these intentions.

Katherine Merrifield is assistant director of healthy lives at the Health Foundation

 

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