In recent years, both of the UK's largest political parties have sought to orientate their policy offering around missions. Both have made explicit commitments to tackle the country's geographic health inequalities. In their starkest form, health inequalities – whether based on race, class, gender, geography and so on – will mean that those at the wrong end have, on average, fewer years to live and worse health when alive. In comparison to London and the South East, a baby born in the North East will live three years fewer, while the north of England as a whole has 144 extra infant deaths a year.1
It is not just that these injustices are self-evident; it is also that the economic consequences that flow from them matter. At a time of labour shortages, sluggish economic performance and underperforming cities, economic inactivity due to ill health is much higher in the north than in the South East.2 It is unsurprising but welcome that both main parties have developed ambitious missions to tackle these inequalities as part of their headline domestic policies of ‘levelling up’ and ‘mission-driven government’.
And yet, since 2010 when the Marmot review laid bare the millions of years of life lost to health inequalities, very little has changed.3 Life expectancy has stalled in England overall, it has decreased in deprived parts of the country and the gap continues to grow.4 What is missing is not ambitious political rhetoric or ambitious government objectives; the two main parties have almost identical missions on healthy life expectancy. Nor is there an absence of understanding about the causes; both parties acknowledge the wider determinants of health that underpin growing spatial health inequalities.5 The problem, we argue, is the failure to identify mechanisms of change.
Over the past five years, the government has put health at the heart of its levelling-up rhetoric, defining levelling up as “people everywhere living longer and more fulfilling lives, and benefitting from sustained rises in living standards and well-being”.6 The focus on longer lives and wellbeing is reflected in the levelling-up missions. Mission 7 targets improvements in healthy life expectancy and mission 8 targets people's self-reported wellbeing.7 Both also entail a commitment to reduce the geographic disparities of their respective metrics.
The government has legally bound itself to these missions, enshrining them in Part 1, Section 1 of the Levelling-up and Regeneration Act 2023, which requires the government to report each year on levelling-up progress.8 Unless the Act is repealed, these same requirements will bind future governments too.
There are, however, concerns with the way these missions are formulated. While there are clear targets for improving outcomes overall, such as the target for a five-year increase in healthy life expectancy by 2030, there are no specifics on the reduction in health inequalities. All that is required is for th