Health inequalities are one of the most pernicious and tenacious challenges that any government, and wider society, has to address. And judged by the coalition government’s own commitment “to increase the health of the poorest, fastest”, there are good reasons to be critical of its track record on health inequalities.

Various institutional tweaks and changes have led to a plethora of disconnected strategies in the approach to health inequalities. New central bodies such as NHS England and Public Health England have been created, while the Department of Health has seemingly lost its strong oversight function and the public health subcommittee has been disbanded. No doubt some of these were worthy initiatives, but the King’s Fund has concluded that the lack of someone holding the ring and accountability at the centre led to failure.

In this context there is obviously a very strong challenge for a more local approach to overcome. But first some myths need to be dispelled, not least about the NHS. Its principles of equal access and tax-based funding continue to mean the NHS is one of the most equitable systems in the world in terms of direct access to primary and, to a lesser extent, secondary care. Far fewer people struggle here to access health care for financial reasons than in most places in the developed world.

However, there has always been much greater variation in what people actually receive from the NHS than many realise. Indeed, one of the reasons for the last Labour administration’s early focus on National Service Frameworks was to tackle the ‘postcode lottery’ of services and outcomes. These were accompanied with increased funding and a raft of targets. Despite this, there remains much variation in services between people in different parts of the country, as documented in the NHS Atlas of Variation Series.

So, the NHS already has some of the fears of localism embedded within its provision of services. The questions are: how much of this variation is justifiable clinically? How much is actively chosen by local patients or citizens? And how much does this contribute to inequalities in health? These are also the questions we must keep in mind when assessing the impact of ‘more localism’.

Arguably, the coalition government gave more power to clinicians to influence the answer to the first of these questions, through the disbanding of most NHS targets and giving greater control to clinical commissioning groups. Latterly, however, NHS England has flexed its muscles through the NHS Five Year Forward View, including its aggressive support for a limited range of new models of care. One of the unanswered and frankly unaddressed questions is how this new policy approach of “choose amongst our options” conflicts with the strategic role of health and wellbeing boards. They are, after all, the bodies who are meant to set the overall health and wellbeing strategies for their areas. In order to tackle inequalities in health effectively, all those who sit on the health and wellbeing board need to align their strategies and actions to this end. But there is little sign that inequalities in health are at the heart of NHS England’s new models of care, or more broadly the focus on integration, or that these models are subservient to local health and wellbeing board strategies. Unless this is rectified, this increased central control could end up undermining the fight against health inequalities

The challenge to the NHS and health and wellbeing boards

So there is no reason why greater localism should mean greater inequalities in health per se. But if localism is to be successful in reducing health inequalities, health and wellbeing boards will clearly need to up their game. They must hold the NHS to account locally in order to ensure that new models of care are aligned to achieve these aims. Health and wellbeing boards will also need to work harder on other factors that drive local health inequalities too. That means a stronger focus on the wider determinants of health and on understanding the complexity of behaviour change.

Early reports on health and wellbeing boards were positive about the former, indicating wide support for the principles set out in Sir Michael Marmot’s review on health inequalities. But statements of strategy mean nothing if not translated into reality. There are signs that some local authorities such as Blackburn with Darwen are doing this through mechanisms such as local social determinants of health funds. Other areas such as Islington, York, Wakefield, Sheffield and Liverpool have engaged the local NHS in wider debates on inequalities through health, poverty and fairness commissions. This is important: a big deficit in national policy is that the NHS’s role is seen only through the narrow lens of providing treatment, and at a stretch prevention. When it has a budget of over £110bn and a staff of 1.4 million, the NHS is actually one of the largest wider determinants of health in every local community. It needs to be simultaneously valued and challenged for this contribution.

Local authorities have taken well to their new roles in public health after a year of transition. But as well as the challenges of working across many fronts on the wider determinants of health, they need a more nuanced approach to their work on lifestyles. National and local studies have shown that lifestyles cluster in population groups and that is storing inequalities in health up for the future. Local strategies need to factor this in if we are to address this. At the moment at least, judging from experience in London, there seems little sign this is happening.

Localism or regionalism?

One of the benefits of devolution of healthcare in Manchester is its regional approach. Looking at the common factors that affect the wellbeing of 2.7 million residents across 10 local authorities has led to a realisation that integration cannot rest at health and social care. If inequalities in health and wellbeing are to be addressed, integration needs to go much further into the economically inactive working age population, raising skills, improving health (including mental health) and focusing on families as much as individuals. This insightful, tailored approach is way ahead of the national debate on integration and could be transformative for future inequalities in health.

The LGA’s database of health and wellbeing board priorities shows some clear agreement across local authorities in Greater Manchester, notably in the focus on the early years. However, there is actually more divergence than commonality overall. Already there have been concerns that devolution in Manchester has happened behind closed doors without adequate public consultation. Greater Manchester, and those that may follow in its wake, therefore need to avoid mistaking more regional control for permission to override either local priority-setting, or key national rights – particularly those related to NHS care. That means difficult decisions will need to be made regarding who is responsible and accountable at each level.

The ultimate challenge? Moving to a true population health system

So there are lots of challenges. Despite the Greater Manchester deal, the trajectory of the NHS seems to be towards more centralisation – or perhaps more accurately, a very tightly controlled range of new models of care. When the NHS budget is so squeezed this might be sensible, but it clashes with the idea of health and wellbeing boards being in the lead locally. Health and wellbeing boards could also see themselves squeezed by regionalism on the local government side too, with devolution in Manchester a case study in the making.

Furthermore, greater political participation around health is a doubled-edged sword. More localism in health and care is likely to lead to greater democratic participation as has happened in New Zealand, for example. But there is a real danger that the electorate will vote on the basis of saving the iconic hospital down the road, rather than the complexity and interplay of the factors that drive inequalities in health, which are not easily reducible to political soundbites. Avoiding this pitfall will remain one of the greatest challenges to local leadership.

At its best, localism could help lead us to a true population health system with inequalities at its heart. For me that means: inequality reduction becoming a core goal of health and social care integration locally; integration moving upstream to working age populations; local behaviour change strategies recognising and addressing the clustering of health behaviours; a local NHS playing its full role in the wider determinants of health as much as treatment and prevention; and health and wellbeing boards moving from rhetoric on inequalities in health to delivery.

If localism can deliver all this, it can deliver a reduction in inequalities in health. All this relies on strong, resilient local leadership and appropriate subsidiarity, supported by central government policy that is also subject to rigorous health impact assessment.

This was first published by the Fabian Society

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