District councils: time to waken the sleeping giants of public health?

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Most of us recognise the importance of local government but very few can have an accurate image of how it all works – the various bodies, boundaries and committees look like a tangled mess of spaghetti. District councils are part of that tangle; their role in improving the health of their citizens is less well known and recognised than it should be.

Today we seek to change that by publishing The district council contribution to public health: a time of challenge and opportunity, an editorially independent report commissioned by the District Councils’ Network.

District councils are part of two-tier local government. While some areas, mostly urban and city centres, have single-tier local authorities the rest of England is covered by two-tier arrangements: county councils and district councils. District councils cover two-thirds of England’s land mass and close to 40 per cent of its population. They deliver nearly 90 essential services – many of which are important for public health – for around 25 million people. Our report sets out their role in delivering these services, the health economics of this and includes some case studies.

District councils have three functions that directly influence our health: housing; leisure and green spaces; and a wide range of activities covering environmental health. We have set out before how these affect health and the favourable economic case for intervention. Beyond this, district councils have a wider role in economic development, planning and community development; their work in these areas affects health directly and indirectly.

Although district councils therefore have their hands on many of the wider determinants of health, public health reform seems to have passed them by. Despite being so well placed, they have no statutory seat on health and wellbeing boards and no direct public health grant. Some district councils are working closely with other tiers of local government, including being delegated public health funds (for example in West Sussex and Hertfordshire), and some work closely with NHS trusts and commissioners, particularly on housing issues. However, there is still the sense that district councils are not fully engaged partners in population health.

It is high time to wake these sleeping giants. The opportunity to do so may be devolution in England. District councils have a strong case that they are critical to two of the twin focuses of devolution: the move towards place-based, integrated public services; and the development of a more enabling and local state. By stepping up in these roles, district councils that choose to do so can deliver health benefits by taking a health-promoting role across their housing, leisure and environmental services and their wider role in economic development, planning and community development.

If devolution is to live up to its promises on health for the 40 per cent of us who live in two-tier areas, district councils need to be critical partners with other tiers of local government and the NHS.

Our report concludes with a set of 10 recommendations for district councils and their partners which focus on three key aspects:

  • partnership and alignment
  • health and wider economics of districts’ roles
  • innovating for outcomes.

There needs to be better engagement between district councils and bodies including CCGs, county councils, public health bodies and NHS England. District councils also need to collate the evidence and the economics of their impact on health; Public Health England should help them do that, given its role in supporting local government to make the case for public health.

If district councils make good progress on our recommendations and respond to the opportunities that devolution offers, we are confident that they will not remain sleeping giants for long.


Bryony Lloyd

Specialty Registrar in Public Health,
Comment date
07 January 2016
Really insightful and relevant report.

I just wonder how we incentivize district councils, who are already heavily stretched delivering their statutory obligations, to take a more active role in public health. Especially when the majority of savings will be felt by the NHS, rather than the district council.

David Buck

Senior Fellow,
The King's Fund
Comment date
18 January 2016
Bryony, thanks for reading and for responding. A very good question. The answer - as ever - is a range of things. Raising awareness and starting conversations is the first step (we've had good feedback about the report's role in this); bringing district's into the fold in terms of HWBs would also help; supporting and challenging the NHS to be a corporate citizen for health is also important (see some of the local fairness and poverty commissions for examnple). The move towards a "place-based" NHS framework (as signalled in the NHS planning guidance), wider trends on devolution and - potentially- some of the Vanguard programme may also be useful. Overall we need to move on from integrated care to population health systems as the overall goal of the local and national systems (some places are starting to do this, see our last integrated care summit).

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