If you catch the number 83 bus in Sheffield, as Naga Munchetty did recently in her Radio 5 live show, you travel just a few miles, but across nearly a decade in life expectancy. As the bus travels from the more affluent south-west to the more deprived north-east of the city, the map of the route becomes a map of inequality. People in different neighbourhoods experience vastly different chances of good health, shaped by their jobs, housing, education and local environment. These inequalities reflect Sheffield’s socio-economic past and present, realities no national policy alone can hope to address.
Yet the national picture is urgent. New analysis shows that premature mortality is nearly twice as high in some areas, and for younger adults and preventable causes, the gaps have widened over time. Gains in life expectancy are stalling, gaps in healthy life expectancy are widening. We’re spending more on working age ill-health and losing more working days to it.
Still, the national response falls short. The 10-Year Health Plan claims to signal a shift from sickness to prevention, with welcome commitments on smoking, obesity, and physical activity. But it largely focuses on managing ill-health, not preventing it. There is little sign of a joined-up strategy for primary prevention: no bold action on alcohol harm, no clear plan for poverty, and a narrow framing of prevention largely limited to health services.
"For too long, DHSC and MHCLG have operated on parallel tracks"
Notably, the plan omits the proposed new duty on Mayors and Strategic Authorities to improve health and reduce inequalities, first set out in the English Devolution White Paper and now included in the English Devolution and Community Empowerment Bill published last week. The plan does reference closer working between the NHS and local and regional government, including Mayors joining Integrated Care Boards and a goal for more coterminous boundaries between ICBs and Strategic Authorities. But this misses the bigger opportunity.
If the government is serious about a shift to prevention, it must go beyond structural changes. It needs to actively support Strategic Authorities as drivers of better health, not just economic growth. This means formalising their role, aligning incentives, and backing them with long-term investment.
As Angela Rayner said at the recent LGA Conference, empowering local leaders means trusting them to lead on health and wellbeing – not just growth – and giving them the tools to do so. This includes better coordination across government. For too long, DHSC and MHCLG have operated on parallel tracks. A more consistent approach to supporting strategic and local authorities to plan, invest and deliver on the building blocks of health will be essential if local systems are to deliver real progress on health equity.
But even without central backing, Mayors and Strategic Authorities are taking action, recognising that better health underpins economic growth. Andy Burnham, mayor of Greater Manchester, has long championed this agenda, most recently reflected in the new Greater Manchester Strategy which places health and wellbeing at the heart of the region’s long term vision. He’s no longer alone. Across the country, more mayors are putting health at the heart of their work – understanding, in a way Whitehall often doesn’t, that ambitions for economic growth won’t be realised if there isn’t a healthy population to support it.
Mayors and Strategic Authorities have the ability to act on many of the building blocks of health: transport, housing, employment, skills and economic development. They can convene partners across local systems, unite people together around a long term vision, and bring place-based insight that national actors can’t. Crucially, they can respond to the lived experience of inequality, not just with broad policy statements but with tailored action grounded in local reality and what communities want.
The new health duty for Strategic Authorities, if implemented well, could provide greater visibility and accountability for this agenda. But local leaders are already stepping up.
Take South Yorkshire Combined Authority’s new Health is Wealth Strategy. The region includes the 83 bus route and the plan understands both the specific challenges of the inequalities across the region and that addressing these requires good jobs, decent homes, education and social connection. The strategy reflects mayor Oliver Coppard’s aspiration to make South Yorkshire the healthiest region in the country. And it’s here that we see the real value Mayors can bring – setting a unifying ambition, backed by over 100 practical recommendations that build on existing action. A similarly bold vision for tackling health inequalities in London has recently been set out by the GLA. The Mayor’s 2025 Health Inequalities Strategy Implementation Plan recommits to the ten year vision to improve the conditions that shape health and create a “fairer, healthier city”. The plan sets out actions to tackle the root causes of poor health, including improving child wellbeing, improving mental health and addressing structural and economic inequality.
These are not isolated examples. The West Midlands, West Yorkshire, and North East are among others taking innovative approaches to improve health. The recently published Health in All Policies Toolkit for Combined Authorities, funded by the Health Foundation as part of the Mayoral Regions Programme found over 100 different case studies of action being taken.
There are challenges of course. Leadership risks resting on individual champions, making progress harder to sustain or replicate. Accountability for improving health is still fragmented and there are challenges around cross-system working, particularly given the bandwidth taken up by ICB reforms and local government reorganisation. And while some departments are engaging, central government still lacks a joined-up approach to supporting places to act on the building blocks of health.
Yet, regional leaders are showing what leadership for health equity can look like: strategic, place and systems based, and built on real insight into what communities want. Because if you want to improve health, you don’t start with hospitals, you start where people live, work and travel. Just like the 83 bus route.
Katherine Merrifield is assistant director at the Health Foundation, a think tank, an independent charity and think tank