Delivering devolution in practice, not just principle

With the English Devolution and Community Empowerment Act now in place and reforms underway, there is real hope in the public health community that we are a step closer to being able to enact changes at a local level that give people more freedom to live a healthier life for longer. But, as with any significant legislative change, there are risks that must be mitigated, and considerations made to deliver its benefits in practice.

It is against this backdrop that ADPH recently published an updated position on devolution, setting out the actions and considerations Directors of Public Health are urging Government to make so that devolution can live up to its potential.

One key recommendation is to ensure that decision-making reaches all levels where it can have the greatest impact, starting with our communities, faith groups, and voluntary sector partners, and embedding engagement and consultation throughout to ensure decision-making is grounded in local knowledge and lived experience. Directors of Public Health must also play a central role as we have the expertise, skills, knowledge, and statutory remit to design measures and initiatives that champion our local population’s health and wellbeing. This role must be fully recognised and utilised, and crucially, not duplicated, in the new devolved structures.

Essentially, devolution should create a collaborative momentum for change, with Government supporting local partners through the provision of appropriate powers, resources, and funding they need to deliver effective interventions and services to support local health and wellbeing. At the same time, devolution must not simply serve to pass on all responsibility out of Government. There are several areas that require – and are best suited to – a national level response. Take obesity for example. Devolution should not be seen as a reason to stop or slow regulating the harmful commercial influences and tactics that promote the sale and consumption of foods high in fat, sugar, and salt, or to avoid taking stronger action on the alcohol industry through taxation. The challenge is to ensure that responsibility is shared, with every partner clear about the role they must play. Without this, we run the risk of remaining at square one, looking across the system to pinpoint whose responsibility it is to reduce these unfair differences in health outcomes.

This is where we must get the balance right – stronger powers for local partners, but equally, stronger accountability in Government. For example, a statutory duty on the Secretary of State to reduce health inequalities should be implemented so that tackling health inequalities becomes a substantial part of every decision-making pathway, at every level of Government.

At a local level, public health teams, and partners must be supported to make the most of the systems newly devolved powers and responsibilities. It has been encouraging to read that Government recognises the need to release savings and enable resources to reach local areas, alongside giving those areas stronger policy responsibilities. However, the true test will be whether local areas are adequately equipped to exercise their powers effectively. Crucially, this must also be supported by proactive sharing of detailed population health data, across all levels of governance, so that decisions remain grounded in community need.

Getting this right also relies on recognising that health responsibilities extend far beyond the NHS. As Parliament considers the Health Bill today, there is an opportunity to embed this principle more firmly in legislation by ensuring health improvement is treated as a shared responsibility across Government, rather than an issue for the health service alone. Historically, much of our resource and effort has been placed on healthcare when in actual fact, nearly 85% of our health is determined by conditions which sit outside of it, such as the places we live and work, our opportunities for social connection, and our access to healthy, nutritious food and green spaces. This is not an argument against investing in the NHS, it has an indispensable role to play, but we should be safeguarding this service by preventing ill health wherever we can, long before we need to rely on the service to fix our populations health. This will require a genuine cross- governmental, and cross-departmental approach to health and wellbeing which is effective from the start, with coordinated action from neighbourhood teams to mayoralties to national level.

There is no question that devolution can be the change we need to create fairer outcomes for our communities and public health is absolutely ready to support this change. But it needs everyone to share in this commitment, no matter where they sit across the system.