English mayoral combined authorities have been established with a remit to boost sub-regional economic growth, enhance local democratic engagement and accountability and address knotty policy problems. Through their distinct powers, responsibilities and resources, they are also able to affect the wider determinants of health, such as people’s access to good quality work, transport and housing.
In Greater Manchester, for example, the combined authority is in the process of establishing a Good Landlord Charter, to improve the standard of renting in the city region, having also become the first conurbation outside London to cap bus fares and help ease the current cost of living crisis.
In the West Midlands Combined Authority, the Thrive into Work programme offers one-to-one job-finding support to people with health challenges, while in the Liverpool City Region, Households into Work is supporting people who are long-term unemployed and who have difficulty finding and sustaining employment.
Good, or fair, employment charters are being used to elevate employment standards across the sub-regions. Social economy accelerators have been adopted to create kinder and fairer local economies, encouraging the development of more democratic forms of business ownership such as social enterprises, co-operatives and community business.
“the city region experienced better performance on life expectancy”
As for impact, a recent study in Greater Manchester has observed that the city region experienced better performance on life expectancy than other similar parts of England after devolution. While modest, these benefits were bigger in the areas with the highest income deprivation and lowest life expectancy, although we cannot yet say for sure that the better life expectancy reported in Greater Manchester was caused by the action of the combined authority.
There is much we don’t know about the impacts of devolution. In which contexts is it most effective, for which people, in which circumstances and – more fundamentally – why?
Through our new programme of work, the aim is to develop this further insight and explore how the kind of activity described could be scaled and amplified to achieve greater impact. To this end, we foresee the potential for a greater connection to be made between the kinds of combined authority intervention highlighted and more localised initiatives that also impact on the wider determinants of health. In the West Midlands, for example, the local NHS has led an employment initiative called I Can and is now reserving a proportion of its jobs for the recipients of pre-employment training schemes, targeting disadvantaged communities and settling residents into secure employment.
Similarly, in Greater Manchester, the Northern Care Alliance NHS Foundation Trust has mapped its employment profile and identified deprived postcodes where it is not employing people and has designed specific pre-employment training packages to help local residents enter their workplace. Applicants can bypass the advert and interview process for many of these entry level positions and the Trust is reserving these positions for the recipients of the pre-employment training.
“their spending power is one of the most direct ways they can have an impact”
Our local councils, the NHS and other significant anchor institutions have now recognised their spending power is one of the most direct ways they can have an impact on the local economy. As a result, procurement is now being used with greater intent to target expenditure towards growing local SMEs, encouraging the adoption of the Living Wage, supporting retrofit and access to climate grants, as well as initiating discussions around the potential to transition businesses to worker ownership.
On housing, Salford City Council has launched its biggest council housebuilding scheme for 50 years to deliver high-quality, truly affordable mixed tenure homes on council-owned, under-used sites. The homes will be sustainable and provided at below average rent.
These kinds of projects all positively impact the wider determinants of health, but what if they were joined up with the powers and resources that combined authorities have?
Could they help more people into work and employment? Could they provide more safe, sustainable and affordable housing? Could they boost the local economy to create more jobs and deliver higher incomes? Could all of this ultimately provide more support in alleviating inequality and making our places healthier?
“devolution is termed by some as delegation”
It is not that simple. What is called ‘devolution’ is termed by some as ‘delegation’ due to the relatively limited nature of the powers and resources combined authorities have. Moreover, the process of devolution – ‘deal-making’ – has often been tortuous and fraught, with a patchwork of combinations of powers allocated to different areas.
Powers and resources only extend so far, and to link combined authority interventions with local initiatives will require careful negotiation and influencing – no easy task when all parties are running on limited funds and time.
Unpicking these challenges and shining the light on potential solutions will be a key focus for our partnership over the next two years.
Not only will we work to inform practice and policy at the combined authority and local level, we will also look to make recommendations for Westminster to advocate for national policy changes that would enable more unified action on health inequalities and the wider determinants of health.
