Health and devolution reforms 2025: what you need to know

Overview

Devolution in England is the delegation of powers, programmes and funding from Westminster to local government. The publication one week apart of both the 10 Year Health Plan for England and the English devolution and community empowerment bill build on the English Devolution White Paper, published in December 2024. Together with the Life Sciences Sector Plan, these two documents set out the government’s approach to this agenda, spreading the reforms across England and accelerating the pace of change, and providing clarity and detail on the links between health and devolution. 

There are clear overlaps between the government’s ongoing reforms in health and devolution. Across both the 10 Year Health Plan for England and the devolution and community empowerment bill there are a number of references to the commonalities, which this briefing examines.

At the NHS Confederation, this is an issue that we have closely followed for many years. Our report Prevention, Population Health and Prosperity: A New Era in Devolution, published in May 2024, explored the parallels in the health and devolution reforms and how ICBs can and should be working with combined and, in future, strategic authorities. 

The 10 Year Health Plan for England and devolution 

The 10 Year Health Plan for England contains several references to working with mayors and strategic authorities, identifying them as a key partner in achieving the new long-term vision for health.

The role of strategic commissioners

• The government will make strategic authority mayors (or their delegated representative) board members of their ICBs, rather than 79 local authority representatives, to best align the opportunities for strategic planning between the NHS and the renewed commitment within local government to support the strategic authority as a key body for growth and prosperity.

New partnerships with local government

• Since ICBs will be critical to establishing better partnerships with local government, they will be encouraged to adjust their boundaries to match those of new strategic authorities. The government’s aim is that ICBs should be coterminous with strategic authorities ‘wherever feasibly possible.’
• The government will work with the Local Government Association (LGA) to consider democratic oversight and accountability in light of the new NHS operating model, the role of mayors and reforms to local government. This is particularly important given the intention to abolish integrated care partnerships (ICPs).
• Where devolution and a focus on population health outcomes are most advanced, the government will work with strategic authorities as ‘prevention demonstrators’, starting with the Mayor of Greater Manchester. These will be a partnership between the NHS, single or upper tier authorities and strategic authorities to trial new innovative approaches to prevention, supported by mayoral ‘total place’ powers, and advances in genomics and data. The government will support these areas with increased autonomy, including through exploring opportunities to pool budgets and reprofile public service spending towards prevention.

Work and health

• In developing approaches to economic inactivity, the government will expect ICBs to seek the closest possible collaboration with local government partners – including mayors and strategic health authorities in particular – so that citizens benefit from a seamless work, health and skills offer in their area.

Innovation

• The government will establish Regional Health Innovation Zones, to give health systems the permission and flexibility to be more radical and forward-looking on innovation. Empowered by devolutionary freedoms, the zones will bring together existing entities, including ICBs, providers, mayors and industry, to experiment, test and generate evidence on implementing innovation. They will have the means to experiment with new commissioning models (including commissioning industry to deliver services on a payment-for-outcome basis), to redesign patient pathways, and simplify procurement. Initially, two to three regions with strong life sciences, health and data assets will be selected as trailblazers. The intention is to scale zones nationally over time.

The English devolution and community empowerment bill (2025) and health

While the bill largely confirmed what had already been announced in the English Devolution White Paper, it provided welcomed detail regarding strategic authorities’ health duty and the breadth of responsibility mayors will have over the determinants of health. The key areas in the bill for ICB and NHS leaders are below:

Defining the new tier of local government 

• The bill creates in law a new category of authority in England, the strategic authority, and confirms the different tiers of devolution in England:

1. Single foundation strategic authority: an interim arrangement where it proves challenging for a combined authority or combined county to be established across a particular area at this stage of its devolution journey.
2. Combined foundation strategic authority: a combined authority without a mayor.
3. Mayoral strategic authority: a combined authority with a mayor, including the GLA.
4. Established mayoral strategic authority: available to mayoral strategic authorities that are able to satisfy additional governance requirements.

Health improvement and health inequalities duty

• The bill introduces a new legal requirement for almost all strategic authorities to ‘have regard’ to the need to improve the health of people in their areas and reduce health inequalities between people living in their areas when they act. This requirement will not apply to the GLA and any single foundation local authority designated as strategic authorities as they have existing and overlapping public health duties which will be retained.
• The duty states that ‘when considering whether or how to exercise any of its functions, a combined authority must have regard to the need to (a) improve the health of persons in the combined authority’s area, and (b) reduce health inequalities between persons living in the combined authority’s area.’
• Health inequalities are broadly defined as ‘inequalities in respect of life expectancy or general state of health which are wholly or partly a result of differences in respect of general health determinants.’
• With the ‘general health determinants’ listed as ‘(a) standards of housing, transport services or public safety, (b) employment prospects, earning capacity and any other matters that affect levels of prosperity, (c) the degree of ease or difficulty with which persons have access to public services, (d) the use, or level of use, of tobacco, alcohol or other substances, and any other matters of personal behaviour or lifestyle, that are or may be harmful to health, and any other matters that are determinants of life expectancy or the state of health of persons generally, other than genetic or biological factors.’
• This responsibility means that when a strategic authority uses any of its powers and functions it must consider and seek to minimise any negative effects it might have on the health of the people living there, as well as any impact it might have in increasing health inequalities. It will ensure strategic authorities consider how their actions will impact wider health outcomes across their areas and will give them a stronger role as active leaders for health, supporting their engagement with wider health and care system partners.
• This will also reinforce the government’s ambition to make sure health is considered in all policies, supporting the health mission in England to halve the gap in healthy life expectancy between the richest and poorest regions.

‘Areas of competence’ for mayors 

• The bill outlines seven ‘areas of competence’ for strategic authorities, with mayors allowed to appoint up to seven commissioners in these areas to assist them.
• The areas of competence are: transport and local infrastructure; skills and employment support; housing and strategic planning; economic development and regeneration; the environment and climate change; health, wellbeing and public service reform; and public safety.

Deepening devolution

• The bill will create a power to expand the Devolution Framework over time using secondary legislation, giving more powers to devolved areas.
• The bill will also create the ability for specific strategic authorities to pilot devolved powers before the government decides whether to add them to the Devolution Framework and make them available to all strategic authorities.
• The bill will empower established mayoral strategic authorities with a ‘right to request’, which allows them to propose further powers, funding and partnerships to expand the Devolution Framework. The government will be required to officially respond to these requests.

Mayoral powers of competence

• To empower mayors, the bill will give mayors of strategic authorities new powers known as ‘the mayoral powers of competence.’  These powers will strengthen the role, giving them the means to drive growth, collaboration and improvements within their areas. The mayoral powers of competence are made up of:
  • the general power of competence; a broad power enabling mayoral strategic authorities, and mayors, to do anything an individual can legally do
  • a power to convene; enabling mayors to convene local partners to address local challenges
  • a duty to respond; placing a duty on local partners to respond to a mayor’s request when they make use of the power to convene
  • a duty to collaborate; ensuring that mayors have a formal process by which they can collaborate with neighbouring mayors to deliver projects and strategies together.
  • a list of ‘local partners’ will be set out in regulations and will include organisations such as local authorities, NHS partners, police and fire services and organisations providing other public services.

Public service reform

• Through this bill, where mayoral geographies align with police force and Fire and Rescue Authority geographies, mayors will be, by default, responsible for exercising these functions.

Local growth plans

• All mayors must also produce a local growth plan. These must include an overview of the area’s economic conditions, priorities for growth agreed with the Secretary of State, and key projects. The bill will require certain public organisations to ‘have regard’ to the shared priorities of each local growth plan, if they are relevant to what they do.

Neighbourhood governance

• The bill will introduce a requirement on all local authorities to establish effective neighbourhood governance. The intention is to move decision-making closer to residents, so decisions are made by people who understand local needs. Additionally, developing neighbourhood-based approaches will provide opportunities to organise public services to meet local needs better.

Audit

• The bill will establish a new body – the Local Audit Office (LAO) – to oversee local audit and to simplify and streamline the current system. 
   

Analysis

Both these documents point to a more integrated policy approach to health and devolution. In particular, we would draw attention to the following areas:

• Future changes to ICB boundaries, to align with strategic authorities, remain a possibility. While there is no indication for when such change could occur, the greater involvement of mayors in ICBs does make the issue of boundary alignment more pertinent. It remains unclear what the arrangements will be when an ICB spans across multiple mayoral strategic authorities.
• Both publications entrench the interdependence between the NHS and local government. The expected involvement of mayors in ICBs will have a direct impact on the NHS at the system level. Through their power over many of the determinants of health, and the new powers of competence, mayors will have direct and indirect influence over both the demand for and delivery of NHS services. Similarly, the NHS is a key anchor institution and so a vital partner if mayors are to improve the lives of those they serve. The strengthened convening power of mayors will be especially important given the plans to abolish integrated care partnerships.
• Prevention and prosperity are at the heart of future government policy. The new health duty is an important step in formalising the links between health and devolution and further solidifies the NHS as a key local partner in stimulating economic growth. Mayors and strategic authorities are primary voices in developing and testing innovative new approaches to prevention, with government increasingly open to taking the learning on board. Similarly, economic inactivity is another high priority area where this partnership will be expected to deliver results. 
• The new health duty provides a universal minimum for strategic authorities. The duty’s broad scope, general metrics and consideration for the determinants of health gives mayors the opportunity for interpretation and a springboard for action. Therefore, a degree of variation across England should be expected as the priorities and policies of mayors differ.   
• It will be vital for NHS organisations to engage with the requirement for new neighbourhood governance. Many of the aspirations of neighbourhood health require close working across local public services and this new tier of governance will knit together a bottom-up view of service delivery in parallel to the strategic authorities.

Further information and next steps

We will follow and engage throughout the English devolution bill process to represent the views and interests of members and continue to work nationally and locally to analyse what devolution means for the NHS. 

If you have any questions please contact Michael.Wood@nhsconfed.org or Christopher.George@nhsconfed.org