The English Devolution White Paper: a long read, but will it be good for your health?

In light of the focus on the 10 Year Health Plan, the media spotlight and action from the Department of Health and Social Care have all been on the NHS, and latterly social care, with a raft of announcements, including on elective reform and another social care review. But the rest of government has been busy, too. Just before Christmas both the Get Britain Working and English Devolution White Papers were published. So are they going to be good for your health?

The English Devolution White Paper is hugely ambitious, seeking to both spread and deepen devolution. This is to be achieved through the principal vehicle of strategic authorities – regional aggregations of local authorities. The goal is for all areas of England to be covered by strategic authorities, designed around how places interrelate as economies, or ‘functional economic areas’. This builds on the voluntary evolution of bespoke devolution deals, where national government have given existing combined authorities more control over decisions and funding streams in key areas such as skills, transport and employment support.

The White Paper is a step change in pace, coverage and approach. Existing deals have developed slowly and been stop-start over the last 10 years or so, seen intense negotiation over powers and funding, and each one has been different. The White Paper seeks to break this mould. These strategic authorities will be a regional tier of government, essentially larger jigsaws created from existing local authorities. They will be at one of three levels with each gaining progressively more powers.

• The base level are Foundation Strategic Authorities which will include non-mayoral combined authorities and combined county authorities automatically, and any local authority designated as a Strategic Authority without a Mayor.

• The next level will be Mayoral Strategic Authorities - the Greater London Authority, all Mayoral Combined Authorities and all Mayoral Combined County Authorities will automatically begin as Mayoral Strategic Authorities.

• Finally, those who meet specified eligibility criteria may be designated as Established Mayoral Strategic Authorities. This final stage unlocks further devolution, most notably an ‘integrated settlement’, much more control over funding streams from central government.

The government intends this to happen voluntarily at first, calling for local authorities that are not already part of combined authorities (mainly further south and more rural or semi-rural) to propose future boundaries of new strategic authorities. Things are moving very quickly, the first set of six additional areas to go through the process covering close to nine million people has already been announced. The White Paper is clear that over time if any areas resist the move to becoming strategic authorities the government will act to impose that status.

But why this move, why so sudden, and why so prescribed? The government argues that strategic authorities will fill a missing tier of strategic policy at the level of regions, and decisions on transport, skills, education, housing growth and other areas need to be made at the level of ‘regional functional economies’ to unlock the country’s potential for economic growth. Further, this also ideally needs the strategic ability and democratic legitimacy of an elected mayor, as in Greater London, Greater Manchester and other areas in England and further afield. Finally, the maturest areas will initially be granted an ‘integrated settlement’, allowing much greater decision-making over a raft of funding from central government and in the future more powers still. Greater Manchester and the West Midlands Combined Authority have already received theirs for 2025/26 covering over £900 million and more will join them in 2026/27.

This has big implications for health and health care. The White Paper develops – and in many areas introduces – a player with greater strategic and funding power at regional level over the wider determinants of health to complement existing local authorities. It states that the government will relate directly to them in future, allocating resources in a more direct way and moving away from competitive bidding for pots of money, a welcome move, and viewing strategic authorities as a ‘default delivery vehicle’ for new policy.

Where strategic authorities and existing local authorities ‘below’ them work well, this could be very helpful in bringing growth, employment opportunities and therefore better health (see our recent report on Greater Manchester for an example of this). In Greater Manchester there is evidence this has also had an effect on narrowing some key health inequalities. But it goes beyond this. The government expects regional mayors to have seats on their local integrated care partnerships to hardwire the relationship between them (as some are already starting to do). The health and growth accelerators announced in the Get Britain Working White Paper – partnerships between combined authorities and integrated care systems to keep people in work by preventing health problems – are a good example of the sorts of programmes we could expect much more of in future.

The White Paper also says, almost in passing, that over time the government will align public service boundaries, including health care, to strategic authorities and it also introduces a new bespoke duty in relation to health improvement and health inequalities to drive a health-in-all-policies approach, and will consult on how to do this. However, the White Paper doesn’t directly refer to the government’s health mission goal of ‘halving the regional healthy life expectancy gap’ – suggesting either that the government is backing away from that goal or that it still has work to do to join up its health and devolution agendas. Has the government got cold feet, does it have a plan up its sleeve, or is it expecting devolution to reduce the regional gap in healthy life expectancy as a matter of course? It could be any of these, but if it’s the latter, it is banking on the least healthy areas seeing greater health improvements from devolution than those that already have relatively healthy populations. Greater Manchester seems to have achieved this, but this didn’t happen as a matter of course, and it didn’t happen quickly – it has taken over a decade of constant effort and attention.

Lastly, the bit of the devolution White Paper that most caught the media’s eye was not the strategic authorities, but the proposals to abolish district councils to provide a uniform coverage of a single tier of local authorities ‘below’ strategic authorities. This, it is argued, would bring efficiencies and consistency, but as we have discussed previously district councils have been undervalued in their health role, partly due to their closeness and understanding of the needs of communities and neighbourhoods. On this reading, this therefore takes power and decision-making further away from communities and neighbourhoods at the same time as the Secretary of State for Health is talking about moving to a more ‘neighbourhood health service’ (though has not defined what that means). If, as The King’s Fund and many others have argued, public service decision-making and services need to relate to and be closer to communities and the places and neighbourhoods they affect, abolishing district councils seems a retrograde step unless government can show that the benefits of aggregation outweigh this loss.

So will English devolution be good for your health or not? Without a crystal ball, the answer really depends on where you stand as much as where you live. The impacts could work against each other – for example, making a big difference through better alignment on the wider determinants of health, while arguably moving some decision-making away from neighbourhoods and communities, rather than closer to them. The jury is out on whether the government can square this circle in terms of policy cohesion nationally, and more importantly, whether those implementing these changes can do so in practice. It certainly isn’t going to be straightforward or simple.

The King’s Fund will continue to explore this across our work, and in particular in our joint project with CLES on English devolution and health inequalities.