Would regional government have been good for your health?BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7484.159 (Published 20 January 2005) Cite this as: BMJ 2005;330:159
- David J Hunter, professor of health policy and management,
- John Wilkinson, director (, )
- Edward Coyle, director
- School for Health, University of Durham, Stockton on Tees TS17 6BH
- North East Public Health Observatory, School for Health, University of Durham, Stockton on Tees TS17 6BH
- Wales Centre for Health, Cardiff CF11 9LJ
England may have missed an opportunity to improve public health
The resounding “no” vote for a regional assembly in the North East of England has firmly put the lid on the prospect of elected regional government for the foreseeable future. There is considerable debate in the North East as to the reasons for the rejection of the proposal, which may have come down to a distaste for having more politicians, a suspected higher council tax, intraregional rivalries, too few powers, or perhaps a mix of these. In the white paper announcing the regional referendums, assemblies would not have any direct responsibility for health care,1 although many would have liked to have seen such an outcome in the spirit of the government's devolution policy and commitment to localism.2 But the assemblies would have had a specific remit for public health.
The white paper announcing the regional referendums pointed out the high impact that housing, transport, and economic development have on public health and promoted the joining up of these policies to reduce health inequalities. Nevertheless, it remained a cautious document, produced against a background of little interest in the issue of elected regional assemblies.3
A public health presence already exists at regional level—a process that began with the NHS Plan and the move of regional directors of public health to the nine regional government offices in 2002. This was designed to enable the regeneration of regions to embrace health as well as environment, transport, and inward investment.4
What, if any, would have been the health benefits of regional government? Integrating public health with regional activities in social and economic development and inclusion would go some way towards meeting Derek Wanless's view that good health is also good economics.5 Regional development agencies are already investing in the regions, and an even closer working relationship with those involved in health improvement could be facilitated by an elected regional assembly—to which regional development agencies would be directly accountable. Moreover, given the difficulties of joining up and integrating central government, doing so at a regional level for public health may have been easier.6 Regional devolution also potentially offered the democratisation of policy and its adaptation to place.7 It also fitted in with the government's declared wish to see more localism in public services.
Devolving responsibility is not without risks. Tensions between central and regional government, sometimes leading to poor policy formation and implementation, are a feature of countries such as Spain, which have strong regions. There were fears that regional government might have occurred at the expense of local government and increased, rather than decreased, the pull to the centre. Can assurances that regions will draw down powers from central government rather than suck up powers from local government be trusted? National policies in respect of data collection, and prevention programmes may have been vulnerable to regionalism and the fragmentation that could have occurred. Poor communication between regions, resulting in waste and duplication of effort, was also a possibility.
In contrast with England, which remains the most centralised country in Europe and beyond, regionalism is a strong movement in parts of Europe. Since the 1950s contiguous regions from European Union member states have created administrative “Euro-regions,” which enable the sharing of services across borders to the mutual benefit of their populations.8
Elected regional assemblies in England would have had some important public health functions as well as being involved in many activities that have a bearing on public health. In particular they would have had a duty to promote the health of the region (through, for example, overview and scrutiny committees of local authorities to promote better health outcomes in the region) and support the development and implementation of a health improvement strategy for the region working with the regional directors of public health and other partner organisations.
Experience from devolved government in the United Kingdom can be gleaned from Scotland and Wales where political devolution has been happening since 1999 and administrative devolution for considerably longer. Health is regarded as a high level, cross cutting theme.
In Wales, unlike England, structural alignment and conterminosity of statutory bodies delivering public health functions have been maintained since the 1974 reorganisation. Both Scotland and Wales have developed their own detailed approaches to public health while pursuing common overarching policies to tackle inequalities in health.9–11 In Wales, the Richard Commission has recommended further development of devolved powers but has not specified added powers in the field of health, nor the inclusion of devolved powers as in Scotland, such as policing and justice that contribute to wider determinants of health.12
The experience of the Greater London Authority has also shown that progress is possible even when public health is not an executive function but an influencing one. The London Health Commission is an advocacy coalition for public health. Its most important contribution has been to carry out health impact assessments on various of the mayor's strategies, including transport.
If regionalism is to become a potent political force in England with a remit for creating a health promoting economy, then the following issues are important. Health should not be ignored in the regional debate. An opportunity is provided to have a more coherent, and integrated, public health approach if regionalism proceeds. Some risks exist, notably in regard to central-local relations, which would need to be managed with appropriate safeguards introduced. Most European Union countries are looking to promote and develop their regions and health needs to be debated at this level.
With the publication of the English public health white paper,13 the issue is whether elected regional assemblies might have been well placed to take forward much of the ambitious agenda set out. The answer must be an unreserved “yes,” for the reasons set out here. Although the white paper is firmly stamped as an NHS document, most of what is proposed to improve the public's health concerns other agencies and policy sectors. Certain functions are best undertaken or coordinated at a regional level, so regions will always be required. At issue is whether they should be democratically elected and transparent or appointed and largely invisible.
Regional government might have been good for health—but in England we shall never know.
Competing interests EC is a member of the BMA Council, the reporting body of the BMJ Publishing Group.
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