‘Levelling up’ – from slogan to strategy

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‘Levelling up’ is a good political slogan. Its definition is fluid and its meaning is in the eye of the beholder.

The slogan came to prominence after the 2019 general election, when the traditionally Labour-voting ‘red wall’ of constituencies in the Midlands and the north of England switched to the Conservatives. The Prime Minister was fulsome in his thanks for this ‘lent’ vote, which gave his party a landslide win.  

However, he will know that lent votes come with a considerable rate of interest. While the events of 2020 de-railed the levelling-up agenda, 2021 will have to see some progress or risk the loan being a one-off. What kind of progress is made will really depend on how the government chooses to interpret, implement and explain ‘levelling up’.

Defining ‘levelling up’

In the very broadest terms, levelling up is a commitment to redressing regional inequalities, which should result in material improvements to people’s lives. This is not a new concept, Theresa May talked about tackling these ‘burning injustices’ and George Osborne championed a Northern Powerhouse to foster economic growth in northern cities.          

A continued focus on regional inequalities should be welcomed, as these disparities are longstanding, complex and unfair. But bear in mind that it is not simply a case of London and the South East vs 'The North', these inequalities are stark within regions, as well as between them.   

The Chancellor has put some money behind the agenda, a £4.8 billion Levelling Up Fund was created in 2020. HM Treasury recently published a prospectus setting out how the cash would be distributed and what it should be spent on. The money will not be allocated according to measures of multiple deprivation, but rather on the basis of ‘need for transport connectivity’ and ‘need for growth’. The Chancellor faced criticism that this methodology was ‘pork-barrel’ politics – that the allocations will be made on the basis of political expediency not actual need. 

This criticism aside, the prospectus does provide the clearest articulation to date of what levelling up means to this government, and that the focus is on visible infrastructure projects like road-building and high-street regeneration.   

Deprivation is bad for your health…

Improving infrastructure is a vital part of addressing inequalities, but it is not sufficient to do so entirely. For example, this approach to levelling up will not, on its own, address disparities in health and life expectancy between the most and least deprived communities.  

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Health inequalities are a clear and persistent indicator of unfair disparities between and within regions. There is a systemic relationship between health and deprivation, which sees people from more deprived communities experiencing worse health and shorter life-expectancy on average. Over the past decade the gap in life expectancy between the most deprived and most affluent communities grew, and the healthy life expectancy gap between these communities is now 18.9 years for men and 19.4 years for women. Covid-19 has followed these existing fault lines in health equity, the mortality rate from the virus in the most deprived areas has been double that in the most affluent.    

What is more, if we overlay a map showing communities with the worst healthy life expectancies, with one highlighting the borders of the ‘red wall’, we would find that they aligned closely. 

Levelling up on health inequalities

Health inequalities are not inevitable, evidence shows that a concerted approach to tackling them can make a difference. The NHS has a big role to play here. First, as a commissioner and provider of health care the, the NHS can invest in prevention and target services to directly address inequalities in outcomes and experience. The NHS Long Term Plan and the NHS Mandate set out some important actions here. Second, the NHS is an economic actor itself with a budget of £130 billion and a workforce of 1.3 million; it can leverage this influence to improve health in the communities it serves.    

But it’s important to remember that the things that affect our health are so much bigger and broader than the health service. Levelling up could help address some of the inequalities that are driven by the wider determinants of health, including not only infrastructure, but also housing, education, green space and air quality.  

The challenges to reducing inequalities are longstanding and complex. Levelling up is moving from being a political slogan to a policy strategy to tackle these challenges. If it is to be successful, a strategy to tackle health inequalities will have to be a big part of it.   

With plans afoot to move health improvement responsibilities into the Department of Health and Social Care, there is a real opportunity to link levelling up to health inequalities and form a clear, cross-cutting central policy strategy. This could be the platform needed to launch the big policy shifts that are needed to bring about the change we need to see and that the government have pledged to make real.   

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