The new health duty on strategic authorities

This article originally appeared in the Municipal Journal.

The Government’s White Paper on devolution in England introduces a commitment to create a bespoke duty related to health improvement and health inequalities for strategic authorities (SAs).

The Centre for Local Economic Strategies (CLES) and The King’s Fund are working jointly on a programme of work, commissioned by The Health Foundation, to understand the potential for strategic authorities to have an impact on health inequalities. As part of this we have thought through how this new duty needs to be designed and implemented to be successful, taking into account learning from existing duties.

“a narrow focus could actually exacerbate health inequalities”

In our earlier briefing we recognised that English devolution could have a positive impact on health inequalities, but that it is viewed as a primarily economic policy lever, to generate economic growth in lagging regions.  Our evidence review showed that a narrow focus could actually exacerbate health inequalities if the distribution of growth benefits is not considered; and even in other countries where regional policy has narrowed economic inequalities, it does not necessarily follow that health inequalities narrow too.  The inference is that health inequalities will not narrow simply as a result of the fact of more devolution, it needs to be accompanied by strong and consistent intent. This has been the case in Greater Manchester which has had clear success, and in other areas such as the West Midlands where health has been a core area for action of the Combined Authority.

In our view, the new health duty could help broaden the devolution paradigm, aligning it with health improvement goals and supporting the government’s manifesto commitment to halve the healthy life expectancy gap between the richest and poorest regions of England.

“mixed and limited success”

However, the government needs to learn from the existing experience of health-related duties.  These have frankly met with mixed and limited success.  For example, since 2012 the Secretary of State has had a duty to report on health inequalities progress which has been largely ineffective in driving change, while the health inequalities duty in relation to integration introduced at the same time has rarely been tested. Meanwhile, the Social Value Act has been implemented in the NHS only very slowly, despite some excellent practice in places such as Cheshire and Merseyside and Manchester.  The duties already in place provide clear lessons for the development of a new one: including how a new duty adds value to those that already exist; a connection to a clear theory of change and accountability; and a wider supportive policy environment.

In our view, the duty should focus on health inequality reduction rather than a general health duty and provide a minimum floor for what is expected of strategic authorities.  These are the biggest opportunities – and risks – in devolution as it progresses at pace. These should be pursued, if possible, in ways that promote alignment with existing legislation and bodies and provide space for those at the frontier to move faster, further.

“sustain a focus on health over time”

The duty’s design also needs to be connected to a clear theory of change for how SAs are expected to act through their own functions, and through their partnerships.  We therefore propose that the duty has several specifications, including for SAs to: be core members of integrated care partnerships  – or, as current speculation suggests, integrated care boards; develop a health inequalities strategy (or similar process/output looking to the longer term); have an internal health team (a function and a capability); and, to develop a co-owned outcomes framework for health which includes the SA’s role in improving the wider determinants of health (a focus on outcomes and form of accountability).  We believe these “anchors” for a duty, alongside some initial funding, would help integrate how SAs function and help sustain a focus on health over time.

The government should provide a clear roadmap for how the duty will support, and be supported more broadly, including how English devolution will support the mission of halving the healthy life-expectancy gap between regions and how the imminent 10-year health plan will connect with English devolution and the role of strategic authorities.  We see this as an opportunity to reboot and refresh the overall narrative, accountability and support systems around the existing health and related duties which fall on partners of SAs, and will apply to them too.  Ideally, all of the above would be connected as part of a wider national cross-government health inequalities strategy to cohere and signal that the policy context for health inequalities will remain key and stable over time.

“a crucial role”

In conclusion, the new health duty has the potential to significantly improve health outcomes and reduce health inequalities if – and only if – it is designed and implemented effectively.  For that to happen, the duty needs a clearly stated purpose, to be connected to a theory of change and to be robust enough to survive a changing policy environment. If designed and implemented effectively, this new health duty could play a crucial role in advancing health equity alongside economic growth.