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  • Writer's pictureAndrew Laird

How can the NHS work with councils on ‘levelling up’?

Andrew Laird says the levelling up jigsaw is missing one major piece – the NHS – and points to an ethical barrier to it playing a full role in this crucial policy agenda. This article was first published in the MJ on 15th October 2021.

New Levelling Up, Housing and Communities Secretary Michael Gove and Junior Minister Neil O’Brien toured the fringe events of the Conservative Party Conference explaining (in a very consistent and disciplined way) their emerging thinking on levelling up. There are four main ‘themes’: Empower local leaders and communities; Grow the private sector and raise living standards (through better jobs); Spread opportunity through improving public services; And restore a sense of pride in places shaken by deindustrialisation.

Another important contribution to the levelling up debate was a paper written by ten new Conservative MPs, published by New Local and the New Social Covenant Unit entitled ‘Trusting the People’. If it was possible to set politics aside, I think most people could get behind the ideas in this paper. It focuses on devolving power as close to people and communities as possible and ‘giving people real control over the way that local services are run’. The paper also calls for a reignition of the drive to create more locally-based public service mutuals and social enterprises to deliver public services and manage local assets. Personally, I was delighted to see this!

These ideas are not ‘owned’ by one political party or another (many of the ideas in the report come from Labour-led councils e.g. the Wigan Deal and also from thinkers like Hillary Cottam). I think it captures the spirit of co-operation people like Andy Burnham have been calling for.

So far so good. To cap it off we are expecting the Levelling Up White Paper around the time of the Spending Review at the end of this month. The word is that huge efforts are going into this. For better or for worse, ‘levelling up’ will be the Government’s defining agenda.

However, the Levelling Up jigsaw is missing one major piece - the NHS. In fact, there is a quite a significant disconnect.

The Government is focusing its rhetorical and policy energies on levelling up and is dealing directly with councils. Alongside this, the most significant chunk of new government money is going to the NHS. However, the NHS is not playing a significant role (if any) in the local levelling up discussions I am part of.

So what’s going on?

Language is important. The NHS doesn’t talk about ‘levelling up’, it talks about ‘health inequality’. Making a link between the two might seem easy at first - but the levelling up agenda largely ignores individuals and is focused (putting it crudely) on the economic output of a place – whilst the NHS is very much focused on the health needs of individuals. For sure, the more recent messages about levelling up appreciate the importance of social capital as well as physical infrastructure (especially now with the appointment of Andy Haldane to lead the Levelling Up Task Force) - but it’s still all about the assets and outputs of a place rather than individuals. That’s why councils with affluent areas but also pockets of deprivation were essentially ‘averaged out’ of contention for levelling up funding.

There is also a moral/ethical barrier to the NHS playing a full role in levelling up. The Government’s Levelling Up Fund process involves councils bidding for funding and the Government then choosing which areas to fund. There will be winners and there will be losers. Many experts (including Sir Michael Marmot) argue that health and wellbeing is a critical factor in achieving levelling up and that some areas of the country are less healthy than others. So, following the lead of the Levelling Up Fund, should NHS funding be skewed towards those areas at the expense of areas with healthier populations? Imagine asking local places to “bid” for NHS funding… The NHS is a universal service and is not designed operationally or ethically to pick winners and losers. Thinking back to the report by the ten Conservative MPs, I am also not sure I can imagine local people being given meaningful ‘control over the way that local [NHS] services are run’. This would present a further postcode lottery risk that just doesn’t fit with the ethics of the NHS. Clear local democratic mandates make councils much more comfortable with their services being different/better than those of a neighbouring council.

So what’s actually happening on the ground? Councils and the NHS are definitely talking to each other and collaborating more than ever. This is due to the current NHS reforms and the emergence of Place-based Partnerships. It is also down to the fact that hospitals now have block contracts rather than being paid based on activity. So, it’s in everyone’s interest to get people well and back into their communities, which necessitates closer collaboration between council and NHS services. The lines of communication are there and they are working - they just aren’t being used to drive the levelling up agenda.

This could become a problem if Government investment in the physical and social infrastructure of a place is not matched by a corresponding boost to the underlying health and wellbeing of the population. A person is less well prepared to take advantage of new opportunities if they are not physically and mentally healthy.

The truth is that genuine and sustainable levelling up can only be achieved if all public services, the third sector, the private sector and communities are pulling in the same direction. The Levelling Up White Paper needs to find a way to stitch all of this together.

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