Assessment and Qualitative Comparative Analysis of English Local Authority Joint Health and Wellbeing Strategies to Improve Health under Austerity Conditions, 2013-2017

Background. Local government is important for health equity because local policies often affect place-based health, health equity, and their wider social determinants of health. In England, local governments must produce Joint Health and Wellbeing (JH&W) Strategies, outlining local strategies for health improvement. These strategies have been produced concurrently with budget cuts to local governments that are associated with adverse health and mortality outcomes. Using a novel approach, we assessed whether English local governments' strategies for place-based health and equity help explain why some disadvantaged areas have better mortality trends than others. Methods. We sampled "Joint Health and Wellbeing" (JH&W) Strategies for 20 disadvantaged localities covering the years 2013-2017. We sampled areas to include some with larger and some with smaller budget cuts. We developed a qualitative appraisal process for scoring the extent to which JH&W strategies focused on (i) place-based social determinants of health and (ii) health equity. Using qualitative comparative analysis, we assessed whether mortality trends might be explained by JH&W scores or wider contextual factors such as budget cuts, population age, and disadvantage. Results. JH&W strategies on place-based social determinants of health and equity were often underdeveloped. Only a minority of strategies were highly rated (i.e., scoring >2 out of 3) for addressing social inequalities of health (n = 6), and even fewer scored highly for place-based social determinants of health (n = 3). Our qualitative comparative analysis found that external and contextual factors (e.g., budget cuts and disadvantages) offer more plausible explanations than JH&W strategies for place variations in life expectancy trends. Conclusion. Budget cuts and other contextual factors better explain mortality trends than JH&W strategies. This raises concerns about what such strategies can realistically achieve in the face of structural disadvantage and national policies that restrict local spending.