Levelling up the UK: what you need to know – NHS Confederation

8 February 2022
While much has been spoken about levelling up since the 2019 general election, the white paper is the first time the government has publicly clarified a working definition for it and a formal approach.
In short, levelling up will require the country to:
The white paper is focused on understanding where public policy can address these four objectives in ways that are feasible and desirable from both an economic and a social perspective. The breadth of the government’s approach reflects the nuanced, complex and multi-layered nature of addressing decades of economic and social divergence across the UK.
The government is taking a missions-based approach to levelling up. The 12 chosen ‘missions’ are medium-term attempts to provide targeted, measurable and time-bound objectives from which a programme of change can be developed. Missions have been used before in national policymaking, including for example the industrial strategy, and are distinct from delivery targets.
The levelling up missions have target dates of 2030 and will serve as the focal point around which the whole of government orientates itself, as well as catalysing new ideas and forging collaboration.
Boost productivity, pay, jobs and living standards by growing the private sector, especially in those places where they are lagging
Spread opportunities and improve public services, especially in those places where they are weakest
Restore a sense of community, local pride and belonging, especially in those places where they have been lost
Empower local leaders and communities, especially in those places lacking local agency
While ‘levelling up’ as a term is indelibly linked with the current government’s post-2019 agenda, the issues behind the white paper, and the subsequent strategies and vehicles designed to address them, have exercised successive government administrations.
At the heart lies the continuing need to rebalance the UK economy and address significant regional inequalities. Productivity, routinely measured by the amount of work produced per working hour, is seen as the main driver of long-term growth and living standards. Not only has UK productivity nationally lagged behind that of many Organisation for Economic Cooperation and Development (OECD) countries since the 2008 financial crash, but there remain significant regional disparities today. Put simply, many parts of the Midlands and the North of England are now among the poorest in Europe. This low productivity routinely manifests itself in poor physical and social infrastructure, health and educational standards, as well as other indicators of social cohesion, such as increased child poverty, reducing life expectancy and rising crime rates. 
Particularly over the last decade, governments have responded to this stagnant economic performance with an acceptance that the UK is overly centralised, and that decentralisation, through various forms, can breathe new life into local economies. The vehicles for this transition of powers and resource away from Westminster, and the overarching strategy narrative, represent a journey in itself. The levelling up white paper should be seen as the latest in a long line of attempts to resolve this patchwork policy approach to our stubborn spatial inequalities.
Taking the four key objectives in turn, we have highlighted the most relevant provisions for those responsible for strategic health and care planning, focusing where possible on what is new rather than pre-existing commitments.
Keywords: investment, R&D, transport, digital 
As with many national initiatives to grow and rebalance the economy, the private sector draws a special focus. To help drive improvements in productivity, pay, jobs and living standards, the UK Government is setting four core missions, spanning living standards, research and development, transport infrastructure, and digital connectivity.
‘By 2030, pay, employment and productivity will have risen in every area of the UK, with each containing a globally competitive city, and the gap between the top performing and other areas closing’
‘By 2030, domestic public investment in R&D outside the Greater South East will increase by at least 40 per cent, and over the Spending Review period by at least one third. This additional government funding will seek to leverage at least twice as much private sector investment over the long term to stimulate innovation and productivity growth.’
‘By 2030, local public transport connectivity across the country will be significantly closer to the standards of London, with improved services, simpler fares and integrated ticketing.’
‘By 2030, the UK will have nationwide gigabit-capable broadband and 4G coverage, with 5G coverage for the majority of the population.’
Keywords – health, education, skills, training, employment 
The white paper stresses the links between people’s health, education, skills and employment prospects and focuses on policies that can ensure that everyone, wherever they live, has the opportunity to live fulfilling, healthy and productive lives. Here, the government sets out three core missions, spanning education, skills and health, as well as an overarching mission on wellbeing.
‘By 2030, the number of primary school children achieving the expected standard in reading, writing and maths will have significantly increased. In England, this will mean 90 per cent of children will achieve the expected standard, and the percentage of children meeting the expected standard in the worst performing areas will have increased by over a third.’  
‘By 2030, the number of people successfully completing high-quality skills training will have significantly increased in every area of the UK. In England, this will lead to 200,000 more people successfully completing high-quality skills training annually, driven by 80,000 more people completing courses in the lowest skilled areas.’ 
‘By 2030, the gap in healthy life expectancy (HLE) between local areas where it is highest and lowest will have narrowed, and by 2035 HLE will rise by five years’ 
‘By 2030, wellbeing will have improved in every area of the UK, with the gap between top performing and other areas closing.’
Keywords – regeneration, housing, communities
Recognising that people’s lives are shaped by the social and physical fabric of their communities, the white paper sets out three missions focused on how to strengthen the civic institutions, assets and relationships within communities that anchor local pride in place.
By 2030, pride in place, such as people’s satisfaction with their town centre and engagement in local culture and community, will have risen in every area of the UK, with the gap between top performing and other areas closing.’
‘By 2030, renters will have a secure path to ownership with the number of first-time buyers increasing in all areas; and the government’s ambition is for the number of non-decent rented homes to have fallen by 50 per cent, with the biggest improvements in the lowest performing areas.’ 
‘By 2030, homicide, serious violence and neighbourhood crime will have fallen, focused on the worst-affected areas’ 
Keywords – devolution, funding, local growth
The white paper recognises that achieving the levelling up missions relies on local leaders being empowered to develop local solutions to local problems. At the heart of this objective lies a renewed mission to extend, deepen and simplify devolution in England.
‘By 2030, every part of England that wants one will have a devolution deal with powers at or approaching the highest level of devolution and a simplified, long-term funding settlement’
Level 3: A single institution or county council with a directly elected mayor (DEM), across a functional economic area (FEA) or whole county area
Level 2: A single institution or county council without a DEM, across an FEA or whole county area
Level 1: Local authorities working together across a FEA or whole county area, for example through a joint committee
* refers to functions which are only applicable to combined authorities
^ refers to functions which are currently only applicable to mayoral combined authorities
The white paper recognises that central government decision-making itself is often a barrier to levelling up. By reviewing the information, incentives and institutions which underpin spatial decision-making, the government is committing to:
Supportive changes to the national architecture including streamlining the funding landscape; establishing the Leadership College for Government, incorporating the Civil Service Leadership Academy and the National Leadership Centre; and setting up a new independent body in England focused on data, transparency and robust evidence.
To support this new way of working, a Levelling Up Cabinet Committee has been established which will embed levelling up across central government policy design and delivery. There will also be a new cohort of levelling up directors appointed to act as a single point of contact for local leaders and a first port of call for local policy proposals, and a Levelling Up Advisory Council created to provide independent advice. Finally, in terms of transparency, a statutory obligation will ensure annual reporting on progress towards meeting the levelling up missions.
A serious, collective attempt at understanding and responding to decades of growing regional inequality
The levelling up white paper is certainly ambitious. With missions that straddle the full breadth of Whitehall and local policymaking, as well as a timescale that covers at least UK two general elections, this is a serious, collective attempt at understanding and responding to decades of growing regional inequality. The government finally has a framework for assessing and understanding regional disparities, the benefits of addressing them and how public policy might most effectively do so.
What is noticeable is the acceptance that this is a social and moral purpose, not just an economic one. Past attempts at rebalancing the economy have been accused of placing too much emphasis on investing in narrow centres of excellence at the expense of raising opportunity everywhere. The impact of the pandemic, and the nature of the local cross-sectoral response, has shown the intrinsic value of health, education and skills to communities and to the wider economy.
We await to see how government will embed the wellbeing mission throughout its agenda
This is particularly the case when considering the growing role of the health sector. In general terms, the level of interaction between the NHS and those responsible for local strategic economic planning since 2010 has been extremely limited. This will change. As the white paper makes clear, some of the most striking spatial disparities in the UK are in health, with previously disparate groups now finding common cause in making a clearer alignment between population health and population wealth.
However, if the need to focus more on social development and wellbeing is borne out by the depth of the analysis that underpins the white paper (including a bewildering amount of graphs and charts), it doesn’t immediately follow through into policy and actions. We await to see how government will embed the wellbeing mission throughout its agenda and the full potential of investing in public services. The relationship between health and productivity is not close to being realised, despite the evidence.
For the health sector, the focus will turn to the new white paper on health disparities, to be published this year and which, we are told, will set out an ambition for reducing the gap in health outcomes. With a policy programme focused on improving public health, supporting people to change their food and diet, and tackling diagnostic backlogs, many of the levelling up references to health link to previously announced commitments, which while positive that they are included, do not easily relate to a renewed sense of achieving the healthy life expectancy mission within eight years.
Devolution in England finally has a framework
Of course, we should look beyond simply this mission to understand the broader health connections.
Devolution in England finally has a framework. It should be a priority for NHS and ICS leaders to understand the local implications of this new transition of powers. Over what footprint, and with which priorities in mind, will local powers be sought? How will the broader health of the population form an explicit part of new and existing deals? Relationships matter, and this includes reaching out positively to the new levelling up regional directors.
The overly complex funding landscape will have a welcome spring clean, though concerns remain over the government’s preference for an episodic, centralised and competitive approach. The NHS was an active partner in many European Structural and Investment Funding projects and should be enthusiastic about engaging with its replacement, the UK Shared Prosperity Fund, as it develops and in supporting local partners to strengthen and secure their applications.
ICSs should be leading new conversations with schools, colleges and universities to understand the forthcoming changes
Skills and education will remain a focal point for many. As the largest employer in every local economy, the NHS has more to gain than most in understanding the wider skills landscape and the local labour markets in which systems and organisations operate. ICSs should be leading new conversations with schools, colleges and universities to understand the forthcoming changes and their role in education investment areas and bodies such as the local skills improvement plans.
Although being clear that levelling up is not a ‘North vs South’ battle, there will be some shifting of resource away from the Greater South East, and particularly in relation to R&D. This presents a very tangible opportunity for ICS and NHS leaders in these areas to develop new clusters and align innovation priorities with MCAs and industry in ways which enrich our populations and services.
The breadth of the white paper is in many ways its greatest strength and its main weakness
Finally, the focus on community is essential. One of the interesting aspects of levelling up is the meeting of both macro and micro policy. For many citizens, the safety and appearance of the high street will be their test of success. For an NHS becoming more interested in community engagement there are welcome signs of engaging civic society in local decision-making – our goal should be to support this and to help unlock our local assets. Many have already started this journey, looking at health on the high street, for example.
The breadth of the white paper is in many ways its greatest strength and its main weakness. A relentless, long-term cross-government focus on addressing spatial inequalities is needed to have any chance of being successful, yet this requires the continued focus and priority of several departments and in particular the muscular support of the Treasury. Regarding the latter, too much of the white paper looks back at past announcements rather than unleashing new solutions. Early tests of their support will come in the plethora of white papers due to be published in the coming months and the next time the Chancellor sets out his fiscal policy.
Our Health Economic Partnerships work programme supports the NHS to understand its growing role in the local economy, to develop anchor strategies at institutional, place and system level and to facilitate new local partnerships. We will remain at the heart of the levelling up agenda as the government engages; advising members on policy, helping them access funding and facilitating new partnerships with the key players.
For more information contact Michael Wood, our head of health economic partnerships, and visit our web section for further information and resources.
NHS Confederation (2022), Levelling up the UK: what you need to know.
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