Prevention, population health and prosperity: a new era in devolution

There are growing parallels between local government devolution and integrated care systems (ICSs), in terms of a genuine and shared interest in geography, place, role, purpose and outcomes. Leaders are now actively asking how they can work together to best serve their populations.

In spring 2023, the NHS Confederation and Local Government Association jointly established a Health and Devolution Working Group to understand the priorities, opportunities and challenges in bringing together health and local government devolution.

This report builds on the rich learning from the working group and sets out why ICSs and devolved administrations (referred to throughout this report as combined authorities) should work together to jointly improve health and support economic prosperity, how they can maximise their collective impact for their shared populations, and what government needs to do to support and accelerate the health and devolution agenda in future.

Devolution in England is the delegation of powers, programmes and funding from Westminster to local government. As of November 2023, devolution deals have been agreed with 17 areas in England and this trend is set to continue and accelerate. With every part of England an ICS, we
will see increasing and sustained interactions between these models.

Even before the pandemic, there was a growing focus on fostering more inclusive forms of growth that balance economic and social development and seek to spread wealth much more evenly across places. Given the tumult of the past four years and the current state of the economy, it is rapidly becoming apparent that health, and the NHS, plays a key role in our prosperity. In recognition of this shift, health is now explicitly and implicitly part of many local devolution deal discussions.

In many parts of the country, local devolution arrangements are already an integral part of an ICS. In all current combined authority arrangements, local authorities are statutory partners in the ICS, while the mayoral combined authority (MCA) as a body itself is often represented on
system partnership boards. With these building blocks already in place, the challenge is to understand the commonality in reforms, and further develop the relationships between NHS and local government partners to better understand and use their collective value.

It is important when seeking to understand the connections between health and devolution that leaders are firstly able to visualise, comprehend and explain what closer, more effective integrated working could feel like for colleagues on the front line and, importantly, what it would mean for local populations. This report articulates a new central vision for the shared future for health and devolution.

While this central vision can underpin health and devolution more broadly, local leaders will be required to implement it according to their own context and nuance. We believe making this new vision for health and devolution a reality will require a phased, three-stage approach, developed
through coordinated local leadership and sustained national support.

These three steps include: focusing on people and the places where they live and work; supporting populations to improve their own health; and recognising that everything has an impact on health. For each of these steps, this report sets out the context, findings, national
recommendations, local priorities and illustrative case studies.

Delivering on these steps, and this report, will involve stretching what we can do within existing frameworks, duties and powers, before understanding what is needed to go further still; increasing and resourcing local capacity and capability; focusing on community engagement and empowerment; understanding and using soft power and system working; and above all, consistently engaging and co-developing a future of shared thinking, shared projects and shared positions.

As the report makes clear, we believe:

• Health, and health metrics, should be prioritised by government as a formal part of negotiations for future devolution deals, given their importance for and relevance to economic prosperity, the growing interest from system leaders and the clear commonalities in ongoing reforms.

• The ICS-combined-authority relationship should be recognised by government and national bodies as one of equals, fostering a mature, two-way relationship and acknowledging the support needed to ensure system leaders have the capacity and capability required to best deliver on their potential.

• While no universal operating model to align health and devolution locally exists, it is important ICSs and combined authorities create a positive vision for integration for their local populations, underpinned by a series of thematic priorities which can guide leaders on where and how best to work together.

• The timing of this report is important. There is a narrow window open in which to simultaneously look back and learn from past approaches to devolution from either a geographical or a health and care perspective, but also to look forward at what a more standardised approach to decentralisation might look like and entail, before various reforms make merging these vital areas too complex a task.