Levelling up: rural vs. urban

As part of our series of blogs on ‘levelling up’ we ask experts about the lived experiences in both urban and rural settings, their different contexts and what they can learn from each other to create a more balanced society.

In the context of social inequalities, ‘levelling up’ is not a new term and was used in 2006 by Margaret Whitehead and Goran Dahlgren in their discussion on tackling inequalities in health. More recently, as we know, in the UK the term was foregrounded by Boris Johnson during his leadership bid and was used mostly in the context of an economic rebalancing between London and the southeast of England (the reference level) and the rest of the UK. The rhetoric is appealing in that it is about action to lift so-called “left behind places” to the same level of prosperity and success as the best off. The term levelling up rather than levelling out or levelling to the average is deliberately used to diffuse any concerns that there is some sort of zero sum game of resource distribution where in order for some to gain others may lose. It is not yet clear which of these levels will be used for the purposes of setting targets and ultimately to measure the degree of success of this ambition.

Two central assumptions in the levelling up discourse need further examination because the way in which problems are understood will inform the solutions and strategies employed to manage them.

The first assumption, seen clearly in the most prominent election campaign commitments and Prime Ministerial statements, is that this particular policy problem as one of disparities in productivity, employment and earnings. It suggests that economic stimulation in the form of capital investment, business support and increased earning capacity through investment in further education targeted at underperforming places are the policy solutions. There is little doubt that meaningful employment and educational attainment are part of the wider determinants of better health and wellbeing (surely the ultimate outcomes of levelling up), however; in areas outside urban conurbations and large cities, social deprivation may have a greater impact on wellbeing than material deprivation. The shortcomings of a superficial policy of ‘throwing money’ at serious and enduring disparities in so called left-behind places is evidenced by a current lack of correlation between public spending and economic success and earnings. The Institute for Fiscal Studies (IFS) has published its own analysis that shows public spending per head is actually greater in Northern Ireland, Scotland and Wales than in England. Within England’s nine regions London does attract higher public funding per head than the other regions however; almost 20% more is spent on current (day-to-day) public funding in the North East than in the South East of England.

The second assumption relates to the way ‘place’ in ‘left behind places’ is operationalised. Boris Johnson’s left behind places are commonly interpreted as left behind ‘regions’ (but have also been framed up using the common urban-rural dichotomy). This ‘regional’ focus is perhaps a legacy of the now defunct Regional Development Agencies (RDA) established at the turn of the century. RDAs were established by the government of the time to create economic development plans that were designed to contribute to national economic agendas whilst taking account of more localised (in this case regional) characteristics. Importantly though, they were also expected to shape policy on education, public health and social care, housing, transport crime prevention and contribute to the Labour Government’s policy of regional devolution. Under the Act that established RDAs they were also obliged to explicitly take account of the needs of rural and urban populations and perhaps more importantly the pockets of deprivation that sat within larger otherwise prosperous areas. RDAs were decommissioned in 2010 by the Coalition Government and replaced by Local Enterprise Partnerships (LEPS) which were largely business-local authority bodies brought together to promote local economic development. Although LEPs were able to ‘take the form of the existing RDAs in areas where they are popular’ the social and public health elements were largely jettisoned and there was little evidence of a more granular consideration of the place-based inequalities and the kinds of policy needed to address them. The authors of the recent Townscapes Report argue that a binary urban/non-urban or more recent categories of settlement types (e.g. coastal or post-industrial or university town) are not useful and that more data driven typologies using drivers of health and community wellbeing would be better used to determine targeted strategies for increasing community success and prosperity.

We, as writers of this blog, also feel that levelling up shouldn’t be about rural vs. urban or geographical areas, but about people. Now, more than ever, it is vital to ensure that research or policy decisions are not done to us, but with us, particularly when talking about our health. Health and wellbeing is an indicator of social deprivation which has been very clearly highlighted as a result of the COVID-19 pandemic and is outlined in the recent ‘Independent SAGE Report: COVID-19: what are the options for the UK?’:

“COVID-19 is not just a health crisis, but also a social and economic one — bringing into sharp relief pre-existing socio-economic and racial inequalities”.

We believe that it is important that decisions about our health do not take place in isolation. These decisions should not be taken by any individual or group alone, but in partnership with those involved in its delivery, and those who will be affected by it in different ways.

Local Solutions for Local Problems

Since the unsuccessful attempt at establishing regional devolution by New Labour, subsequent governments have controlled delivery of strategies through central policy handing local actors responsibility for delivery but with no real say in what the policies look like. A recent report by the OECD (Enhancing Productivity in UK core cities) linked low productivity in big UK cities outside the South-East to over-centralisation. Effective policies focussed on area based problems need to involve the people who are going to deliver them in the design process.

Co-production is a good example of a methodology that could be used in this type of design process. Co-production supports the sharing of power and decision making, in relation to policy, research or service development, amongst those with lived experience and those working in organisations or for local government. A people centred approach to health and co-production are especially important for those whose voices and needs are less often recognised, bringing them together with healthcare practitioners and researchers. The ‘Marmot Review 10 Years On’ highlights the need to:

“Fund and adopt a proportionate universalist approach to building community resources and involve communities in the design and implementation of programmes to reduce inequalities”.

We feel that diverse forms of expertise need to be recognised more readily and valued, no one form of expertise (lived experience and research expertise for example) is less important than another, just different. If you are able to develop trust and build relationships with people with these diverse forms of expertise then you will be able to co-produce policy, services and research together, producing outputs that are actually fit for purpose and more practically applicable in the long-term.

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About the Authors

Mark Gussy is Global Professor in Rural Health and Social Care, Lincoln International Institute for Rural Health, University of Lincoln.

Niccola Hutchinson-Pascal is Head of the UCL Centre for Co-production in Health Research, University College London.

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