North East Devolution and Levelling Up

Devolution can help tackle health disparities – Haldane

Worsening health among the most deprived households requires co-ordinated local solutions, which would be assisted by devolution, according to one of the authors of the Levelling Up White Paper published in February.

Recognition of the importance of health to regional development comes six years after North East councillors, squabbling over devolution, missed an opportunity to tackle health inequalities.

The focus of government development policy in the past has been exclusively on economic outcomes, writes Andy Haldane, in an essay for the Royal Society of Arts, of which he is chief executive*. But in a decisive break with that past, issues of health, inclusive growth and wellbeing now need to be centre stage.

‘Today’s dramatic squeeze on household balance sheets from the ongoing cost of living crisis will, if history is any guide, lead to an equally dramatic worsening of health outcomes among the least well-off households, compounding the pressures arising from the Covid-19 crisis’ he writes.

‘The link between socio-economic and health outcomes can be seen from the strikingly high correlation between outcomes for health (physical and mental) on the one hand, and pay or productivity on the other, across the UK’.

Haldane adds: ‘Recognising these costs, later this year the UK Government will publish a white paper on health disparities. It has already set itself a target of shrinking health disparities by 2030 and raising healthy life expectancy by five years by 2035. Achieving these objectives would mean turning a tide that, if anything, has been gathering pace over recent decades. A reversal of these trends has eluded governments, of all colours and across many countries, since at least the late 1990s’.

He goes on: ‘Health and economic outcomes are often hyper-local. That means they require hyper-local solutions, which in turn need to be designed and delivered by local anchor institutions – local government, local healthcare providers, and local community groups. Only these institutions have the knowledge, as well as agency, to tackle these problems at source. The push towards…devolution…across the UK in the government’s recent Levelling Up White Paper will, I hope, help put more power in the hands of local communities.

‘These interventions are most likely to be effective when they are part of a coordinated local plan, embracing not just health but transport, business, social care, employment, education and skills policies. These are all key parts of the local ecosystem, and any misfiring element jeopardises the chances of system-wide success. Another benefit of local control is that it enables collaboration in a way that is likely to be more successful than if it were done at the central government level.’


Public health is an important part of the potential devolution agenda, but sometimes overlooked by councillors who normally (though not always during the pandemic) seem to find buses and trains more interesting. The Levelling Up White Paper says (p. 142):

‘Opportunities will be explored for MCAs [mayoral combined authorities] to take on a duty to improve the health of their residents, concurrent with the existing duty of their constituent upper-tier councils. This duty will complement the health improvement role of local authorities and their directors of public health, making it easier for MCAs to participate alongside local authorities in initiatives that can improve health and proactively consider health as part of key strategies and investment decisions.’

The North East Combined Authority (NECA), when it was pursuing devolution as a body representing all seven councils in its area, commissioned a health-related report which could have given it a head start on dealing with health inequalities as long ago as 2016. But it blew the chance when it rejected the government’s devolution offer.

In an early initiative under its proposed devolution deal, NECA co-operated with local NHS organisations to set up the North East Commission for Health and Social Care Integration to investigate the health and wellbeing gap between the North East and the rest of the UK and health inequalities within its own area.

Though eventually devolution did not proceed, the commission completed its work in 2016 and according to its chair, Professor Duncan Selbie, founding chief executive of Public Health England, its recommendations could have been implemented through existing structures.  But this author was told at the time by a well-placed NHS governance volunteer:

Because of the failure to sign off as a properly devolved authority that’s all gone; it’s just not there. Nothing is happening…There has been no support for this from any of the authorities in the combined authority.

Six years later, an online search today shows that the Selbie Report is no longer to be found. What a waste.

*For transparency: this author is a Fellow of the RSA.