Improving the nation’s health: striking the right balance between national and local

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In mid-August, I chaired an event with five former Secretaries of State and Ministers of State from the Department of Health (and now Social Care). While outside the sky crashed with thunder and lightning, in our virtual launch the only thing that was powerful was the agreement between politicians from all the main parties about the future direction for health.

The politicians were part of the Health Devolution Commission and had come together for the launch of its final report, Building back health and prosperity. Started before the Covid-19 pandemic took hold, its findings are all the more relevant as we grapple with the pandemic and think about how health and health and care services can emerge stronger.

So, what was it they agreed on?

First, that our health is much more than our health and care services. At the core of the commission’s thinking was a clear view about the central importance of the wider determinants of health. This is not news to many of us – but the reality is that the knowledge of this hasn’t translated into the thinking about how government approaches public service delivery and economic growth. 

'Health in all policies is easy to say but takes real political commitment (at all levels) to see it through in a meaningful way.'

The commission said part of the opportunity which devolution could grasp was about delivering in local places and communities ‘a “health in all policies” approach to other services such as housing, employment, transport, education, the environment and economic development.’ Health in all policies is easy to say but takes real political commitment (at all levels) to see it through in a meaningful way.   

I still think back to what drove Greater Manchester Combined Authority and the Mayor to focus on health as one of its devolution priorities – because it could see that the health of its population was one of the key obstacles to its economic growth. Once you combine your prospects for economic prosperity with health, you can think about health in a completely different way – it becomes an investment for growth, not a burden to shoulder. 

The second area of agreement was that, given that our health is impacted by so many different factors, there is a need to move away from further centralisation of health care services and move towards greater devolution of health to local areas. Devolving accountability and power to a more local level creates the potential to know the communities and places better and to take action that is specific to the needs of those local communities. As Andy Burnham said at the event, ‘as Secretary of State I knew numbers, as Mayor I know names, that’s the difference’.  

'At the heart of good health devolution should be close working relationships between clinical and civic leaders; community involvement and active citizenship; and parity of esteem between the public, private and voluntary sectors.' – Hope and Hardwick 2020

This push for less centralisation and more devolution to local can too easily be presented as a tension, as a battle between national and local, but it doesn’t need to be a fight. No one is saying (or certainty no one on the commission) that you can successfully improve the health of our population without both national and local action. The key is striking the right balance between the two and the right focus at each level.  For too long the scales have tipped towards the national, and at times towards the national carrying out roles that are poorly done from Whitehall. A new balance should not strip Whitehall of accountability and imperative to act – but it should act where only national action is needed to have impact (on tax, regulation, evidence and data, for example). Local areas should have the insights, capacity and capabilities to act with and for their local communities – understanding need, shaping local services and building on community strengths – and a new balance should also ensure that there is clear responsibility and accountability for this work too.

'This push for less centralisation and more devolution to local can too easily be presented as a tension, as a battle between national and local, but it doesn’t need to be a fight.'

As an aside, the ease of agreement between politicians from all parties who have left national office also made me think about the emerging list of former politicians and technocrats who now stand fully and firmly behind large scale reform of social care – a position they and their institutions often did not champion when in power. (The number of former Treasury big wigs on the Lords Economics Affairs Committee is the most obvious recent example). Is there something about the reflective wisdom of having done the job that drives these profound changes in position that were not possible when holding office? I am left wondering: how do we persuade the current generation of politicians holding national office to act differently now? How do we persuade them that giving power to others will ultimately be the smart political move to make? 

If we really want to see health improve, doing more of the same won’t work – we need a bold mix of national and local leadership and action, which means national politicians need to give away some power, while using the power they have to better effect. 

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james robertson

Medico legal dr, school and hospital gov,
Salisbury FT, Old Sarum Primary Sch , RSA
Comment date
02 September 2020

What you are saying is 100% correct, grossly over due, and due to Londoncentric political incompetence . This results from a aggressive political party system which stresses opposition and is essentially two party. We face the break up of the UK. I have watched what happened to local government and local politicians, and NHS after a never ending series of expensive changes or reorganisations. Our system is divide and rule as opposed to unite in cooperation. Covid and 2008 may yet benefit us all!

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