We know how to level up health: here’s how and why

  • Levelling up

Dr Jennifer Dixon, Chief Executive, Health Foundation 

In this piece Dr Jennifer Dixon emphasises the importance of improving public health if we are to truly level up in the UK. Jennifer makes the case for improving working conditions; reducing smoking; investing in the NHS; creating new cross-ministerial mechanisms and institutions; and devolution of decision-making and resources to local government.

It’s worth making three background points for starters. The first is that while the health of the population is generally improving over time in terms of life expectancy, the gap in health between people living in the most and least deprived areas in the country has grown over the last decade[i].  The second is that poor health is associated with lower productivity in the economy, and vice versa. And third, that the factors affecting our health lie mostly outside the NHS, for example in our living and working conditions, and life chances.

Any government with a ‘levelling up’ agenda will need to show short term outcomes, as well have a longer term strategy. So I’ve stretched the brief for this article slightly and have made five rather than three policy suggestions. Below I offer three suggestions that could have short term impact and two further suggestions with a longer term benefit to population health.

In the short term

The first suggestion would be to improve on the working conditions of the lowest paid workers, many of whom ironically work in the care sector.  Poor quality work injures health more than unemployment[ii]. Care work is disproportionately undertaken by those who are already more socioeconomically disadvantaged and includes women (who make up 82% of the workforce) as well as people from minority ethnic backgrounds[iii]. A quarter of care workers are employed on zero hours contracts, increasing numbers are paid at or close to the National Living Wage, there are over 100,000 vacancies across England and turnover is high.[iv] By improving the pay and conditions (and therefore health and wellbeing) of essential workers, multiple aspects of a levelling up agenda could be supported. The recent Queen’s speech was notable for the absence of an employment bill and provisions to protect the low-paid, and those in insecure work.

The second would be much more serious action to reduce smoking. Half the difference in life expectancy between the richest and poorest in society is estimated to be due to smoking, and smoking kills a similar number of people prematurely per year as did COVID in 2020. While rates are declining – on average 14% of the population smoke –25% of unemployed people smoke, as do 1 in 4 of those in routine or manual work. A stronger set of evidence-based actions[v] now will help achieve the Government’s own ambition of a Smokefree 2030 (with smoking prevalence of less than 5%), from price rises, to support to quit, to packaging, to increasing the age for sales.

The third would be to invest more in the NHS to reduce the backlog of unmet need for care built up over the pandemic. We know the areas in England worst affected by COVID – serving poorer communities – have bigger backlogs and longer waits. Even before the pandemic, people in the most deprived parts of England generally had worse access to elective care (eg hip replacement[vi]) than those in the least deprived. So this is effectively a triple whammy – worse access to begin with, more COVID cases, admissions and deaths, and longer waits/bigger backlogs to recover post-COVID. The NHS has reduced waiting lists before, with huge success in the early 2000’s, via a combination of investment, financial incentives, targets and performance management and other policy instruments[vii].

Longer term

The suggestions above should produce short term noticeable gains to health. But they are a sticking plaster on what should be a longer term and coherent set of strategies to reduce the growing health gap between the well-off and less well-off. Health can only be improved over the long term by prioritising the root causes of ill health and inequality.

The first suggestion then is for a more coordinated cross-central-government approach.[viii] The government has already set out a number of relevant commitments that can be developed into an ambitious strategy. On population health, most notable is the ‘grand challenge’ to ensure people are able to live an extra 5 years of healthy life by 2035, while ‘narrowing the gap between the experience of the richest and poorest’.[ix]

A truly cross-cutting approach would be best owned and driven by the very centre of government. A cross-ministerial board with teeth should be formed: for example, reporting directly to the Prime Minister, attended by secretaries of state and with a secretariat provided by the Cabinet Office to act as a broker across government. The programme should be firmly linked to the wider levelling up agenda. Binding targets, as well as new mechanisms and institutions, should be considered to drive sustained improvements in the nation’s health. There is a lot to learn from effective strategies tried by previous governments, such as the health inequalities strategy in operation in England from 1997–2010.[x] Models such as the Future Generations Commissioner established in Wales[xi], or New Zealand’s Wellbeing Budget,[xii] are also examples of mechanisms that could aid progress.

The second suggestion is even bigger. Levelling up health is far too complex a task for central government to lead alone. Much of the agency to act on the wider determinants of health is in the hands of local government. Being much closer to communities than Whitehall, local authorities are more easily able to assess where investment is likely to be most impactful. Local government should therefore be heavily involved and given considerable autonomy to invest in areas and communities with the greatest needs, tapping into their experience of ‘what works’. This links with the need to develop a future strategy for devolution within England, due to form part of the forthcoming levelling up white paper.

Plans between central and local government, and other key stakeholders, can be developed today. But one problem is investment. Even before the pandemic, council spending on local public services had dropped by 23% since 2009/10 – equivalent to nearly £300 per person.[xiii] This has reduced the ability of local government to deliver services vital for levelling up health including housing, education, early years, social care, and public health, and its capacity to work on economic regeneration. More deprived areas fared the worst, with an increasing reliance on council tax meaning that poorer areas – those more dependent on funding from central grants and redistributed business rates – experienced bigger cuts. Despite good evidence that spend on public health is highly cost effective, the public health grant is also 24% lower on a real-terms per capita basis than it was in 2015/16 following years of cuts.[xiv] A serious strategy for investment and devolution within England must be central to level up health in the medium to longer term.


[i] https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on
[ii] Tinson, A., Health Foundation What the quality of work means for our health. February 2020 (https://www.health.org.uk/publications/long-reads/the-quality-of-work-and-what-it-means-for-health)
[iii] Skills for Care, The state of the adult social care sector and workforce in England. October 2020(www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx)
[iv] The Health Foundation, ‘The Health Foundation’s response to the Health and Social Care Committee inquiry on‘Workforce burnout and resilience in the NHS and social care’. September 2020 (www.health.org.uk/sites/default/files/2020-12/health_foundation_submission_to_hsc_workforce_burnout_inquiry_0.pdf)
[v] https://ash.org.uk/wp-content/uploads/2021/06/APPGTCP2021.pdf
[vi] https://www.nuffieldtrust.org.uk/public/files/2020-01/quality_inequality/v2/#hipReplacement
[viii] Ref House of Lords Public Services Committee report
[ix] Department for Business, Energy & Industrial Strategy. The Grand Challenges. Department for Business, Energy & Industrial Strategy; 2019 (https://www.gov.uk/government/publications/industrial-strategy-the-grandchallenges/industrial-strategy-the-grand-challenges#ageing-society)
[x] Barr B, Higgerson J, Whitehead M. ‘Investigating the impact of the English health inequalities strategy: time trend analysis’. BMJ. 2017;358(8116):j3310.
[xi] Future Generations Commissioner for Wales: https://www.futuregenerations.wales/resources_posts/future-generations-framework/
[xii] Government of New Zealand, ‘Wellbeing Budget 2020: Rebuilding Together’, May 2020 (https://www.treasury.govt.nz/publications/wellbeing-budget/wellbeing-budget-2020)
[xiii] Harris, T., Hodge, L. and Phillips, D., Institute for Fiscal Studies (IFS), English local government funding: trends and challenges in 2019 and beyond. November 2019 (https://www.ifs.org.uk/publications/14563)
[xiv] Health Foundation, Public health grant allocations represent a 24% (£1bn) real terms cut compared to 2015/16. Health Foundation response to announcement of the public health grant allocations for 2021–22 (March 2021) (https://www.health.org.uk/news-and-comment/news/public-health-grant-allocations-represent-a-24-percent-1bn-cut)

About the author

Dr Jennifer Dixon is Chief Executive of the Health Foundation. She was formerly Chief Executive of the Nuffield Trust from 2008 to 2013. She was also Director of Policy at The King’s Fund and was the policy advisor to the Chief Executive of the National Health Service between 1998 and 2000.

The perspectives expressed in these commentary pieces represent the independent views of the authors, and as such they do not represent the views of the Academy or its Campaign for Social Science.

This article may be republished provided you place the following statement and link at the top of the article:

This article was originally commissioned and published by the Campaign for Social Science as part of its Levelling up programme.