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The levelling up white paper lacks the detail and funding needed to address health inequalities

4 min read

The “levelling up” express was long overdue. Passengers were close to giving up and wondering if they needed to make their own way to their destinations. Three years later and the white paper is finally here.

Without good health, economic participation is reduced: in the areas of England with the lowest healthy life expectancy, more than a third of 25 to 64 year-olds are economically inactive due to long-term sickness or disability. So how does the white paper measure up? Is it the orient express, kitted out for luxury travel or a replacement bus service?

It is positive that the white paper recognises the role health must play in levelling up. But there is a lack of detail about how health would be improved.

We are now counting on the disparities white paper to focus on the drivers of good health, such as a decent home, a good education, a stable job, green spaces and clean air. However, it is a concern that the main focus is on the behaviours that these determinants shape, such as obesity and smoking, and tackling the diagnostic backlog. In addition, it appears likely that the focus will be on targeting the individual, instead of population-level measures that impact everyone, which are demonstrated to be the most effective and equitable. 

Without new money the ability to do anything very different at local level will be limited

The white paper appears to be the product of cross-government working which is a welcome recognition that all of Whitehall needs to be oriented around the levelling up agenda. Many of the measures proposed to support this “golden thread” reflect ideas we set out last year. However, we advocate a different golden thread – that every policy decision needs to place the health impact at the centre. For example, generating good work and economic resilience, not jobs at any cost.

There is a heavy focus in the white paper on regeneration through hospitality, an industry that has a low proportion of high-quality work. This risks favouring short-term economic gains over long-term economic resilience.

Devolution is a central thrust of the white paper, with a strong focus on new combined authorities. This is welcome and we have already seen elected mayors seizing the opportunity to take action to address the drivers of health in London, Manchester and the West Midlands. However, without new money and with public health grant budgets cut by 24 per cent since 2015/16, the ability to do anything very different at local level will be limited.

Improving the quality of rented homes and targeting school outcomes are noble and will contribute to efforts to improve health, but the mission will only be a success if we see significant new funding and policy ideas from across the whole of government.

We should be giving local areas the flexibility to direct long-term funding to improve local areas in ways supported by local residents. The announcement that government will undertake a review to streamline and simplify funding is helpful, but it will require a fundamental change of approach to stop government earmarking funds in this way. 

It is good to see employment and pay specifically included as one of the missions in the white paper, particularly narrowing the gap between the best and worst performing areas. However, the focus should be on employment, instead of investment and trade.

Ideally, there would be a twin focus on keeping people who develop health conditions in employment as well as helping those who can work back into employment. But there are welcome steps on in-work progression – our analysis has shown over half of those in low quality jobs get stuck in them, with consequences for their health.

So where does this leave us? The levelling up white paper articulates the challenge around health inequalities and sets a bold vision for a different future. However, it is light on detail and once again we find ourselves left waiting. The disparities white paper will be the last chance to make any significant progress in this Parliament.  

Roll on the next white paper.


Katherine Merrifield and Gwen Nightingale are the joint Assistant Directors of The Health Foundation. 

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