What is the role of Metro Mayors in Neighbourhood Health?

Introduction 

Neighbourhood health is built on the simple idea that services should be organised around people, place and prevention, not institutions. 

Whilst the vision is clear for what neighbourhood health needs to the deliver, the question of who enables it at scale is less straightforward. 

As devolution expands across England, Metro Mayors are emerging as influential actors in the political landscape, with increasing anticipated powers in Health following the passing of the English Devolution and Community Empowerment Act. Metro Mayors are directly-elected leaders of Mayoral Combined Authorities with executive powers and funding available to make strategic decisions over a region within key areas including skills, public transport and planning. Their role is of growing importance in public sector reform and therefore we need to explore what role Metro Mayors can play in delivering the Neighbourhood Health agenda.  

As explored in our recent white paper, Beyond Neighbourhood Health: reframing public services around people, place and prevention, delivering neighbourhood models requires system-level enablers as well as local delivery models. Metro mayors hold the key to unlocking system-level enablement. 

Why does this question matter now? 

In line with manifesto commitments, the current government set out its plans early on in its tenure, through the English Devolution White Paper, to give more power to local areas. It recognised that England had unusually high levels of centralisation and that, for the system to work better for local communities, a significant transferring of power out of Westminster was needed. The White Paper recognised the successes of Metro Mayors in driving local growth and integration in areas such as Greater Manchester and the West Midlands. Noting the patchy coverage of devolved powers across the country, the paper led to a commitment to full devolution coverage across England, with all areas to eventually have a directly elected Metro Mayor.  

These intentions were formalised through the passing of the English Devolution and Community Empowerment Act in April 2026. The Act represents major constitutional change, expanding the power and responsibilities of Combined Authorities across England, as well as explicitly creating a new tier of English government. Broadly, it brings other Mayoral Authorities on par with the types of powers that were previously only possessed by the Mayor of London. 

The Act introduces a new health improvement and health inequalities duty on combined authorities. In essence, this means that authorities must embed health in all the decisions they make. This, combined with their expanded powers, creates an opportunity for Metro Mayors to take a key role in generating more local cohesion and deliberate action across both healthcare and non-healthcare services to drive better population health. With this devolution happening in tandem with the NHS’s move to a neighbourhood-based model, it is vital to think about how these new structures can move forward with a coordinated vision, rather than remaining in policy silos.  

How can Metro Mayors support Neighbourhood Health? 

To understand how Metro Mayors can support Neighbourhood Health, clarity is needed on what is and is not within their remit. The English Devolution and Community Empowerment Act has made it easier to gain a consistent vision of this, introducing a default framework nationally which replaces a patchwork of case-by-case agreements.  

Metro Mayors do not directly fund or organise the NHS and social care services within their geography. Rather, through levers discussed below, they have influence over the contexts in which these services operate in. Population health cannot be addressed from within the health system alone, meaning the collaboration and coordination of health service actors with Metro Mayors is vital for the success of a Neighbourhood Health approach.   

There are five key areas in which Metro Mayors can influence significant determinants of health: 

Transport

This is a key determinant of access to healthcare services. Even if good services exist, absent or poor public transport can act as a significant barrier to their optimal utilisation. Poor transport can widen the gap between the least and most deprived people in a Neighbourhood, with the latter having less access to personal transportation. Transportation can also affect people’s ability to access other resources within the community that contribute to physical and mental wellbeing, and can contribute to isolation, especially among older people.  

The English Devolution and Community Empowerment Act formalises the role of Mayoral Combined Authorities as transport authorities, suggesting their role in this space will grow in the coming years. Metro Mayors can have important influence in this area by ensuring transportation networks are aligned with local need. For example, this can mean developing bus networks that connect communities to the acute and community healthcare services that they rely on, as well as to locations such as key community hubs or sports facilities. Greater Manchester’s Bee transport network, delivered under former Mayor Andy Burnham, is widely regarded as an example of the success of this approach, through its integration and simplification of transport services in the area.  

Housing

Housing is the foundation of a Neighbourhood as the availability, affordability and quality of housing is pivotal to the health of individuals. Damp and mould can affect respiratory health, housing insecurity can place a severe burden on mental health, and high housing costs can make a healthy lifestyle unaffordable. Often, people suffer from several housing-related issues at once, compounding the negative impact upon their health and wellbeing. With England’s demand for housing (particularly affordable housing) far outstripping the delivery of new homes, the need for coordinated action in this area is clear.

The English Devolution and Community Empowerment Act has expanded the powers all Metro Mayors have over housing. The provisions of the Act focus on new development and planning, rather than the improvement of existing housing stock, including the ability to call in and accelerate planning in priority areas, and to assemble land for housing-led development. These powers present an opportunity to take a more strategic approach to the development of new housing for Neighbourhoods, aligning development with Neighbourhood Health needs. However, Mayors (outside London) still have less formalised power to mandate the development of affordable housing. 

Skills and employment

The interdependency of health and employment cannot be understated, with unemployed people nearly six times more likely to have poor health than those in employment. Unhealthy communities are less able to work, and, at the same time, communities with fewer employment opportunities are less able to build prosperous, healthy lifestyles. It is vital, therefore, that this complex issue is addressed through a whole-system approach. 

Skills and employment support are a named  “area of competence” of the Act, suggesting expanded powers and responsibilities for Mayors in relation to this area, although detail on what this will entail is absent from the Act itself. Nonetheless, greater leadership from Mayors around building employment opportunities and necessary skills within communities can contribute positively to Neighbourhood Health. This should be adequately targeted to maximise impact, such as by creating paths for people living with long-term conditions to rejoin the workforce. Both Metro Mayors and health service actors need to take accountability here, and to coordinate their efforts, to end vicious cycles of poor health and unemployment.  

Inclusive growth

This has been a focus of the English devolution agenda for the past decade, and is the idea that economic growth should be measured by how broadly benefits are shared across a population, rather than by overall figures like GDP. It encourages a place-based approach in which the most disadvantaged groups (who are also those most likely to suffer from poor health outcomes) receive an equitable share of resources. 

While the new Act does not create new formal powers specific to inclusive growth, maintaining inclusive growth as a lens through which Metro Mayors formulate their strategic vision is symbiotic with a Neighbourhood-based approach. Inclusive growth and Neighbourhood Health share the logical foundation of Places being the unit through which we tackle disadvantage, breaking populations down into units that allow us to understand genuine need and drive effective change, rather than succumbing to broad generalisations and overly standardised approaches.  

Strategic investment and infrastructure

This is about long-term thinking that spans the themes above, as well as other factors which influence the health, wellbeing and overall prosperity of an area. This ranges from the generation of economic growth leading to more employment opportunities, to new infrastructure allowing better transport connectivity. Public Health England’s Healthy High Streets framework illustrates this link concretely at the town centre level: a high street that is inclusive, walkable, low in noise and air pollution, well-served by green and public space, and home to a health-promoting retail offer is a genuine driver of population health, not just economic activity.

Importantly, this theme highlights that Metro Mayors have the role of driving holistic improvement for local populations. In the same way a Neighbourhood Health approach looks at the complex web of care that surrounds people and communities, the real opportunity of Metro Mayors is to ensure everything in the local area is working together to deliver the best outcomes for the people in that area. Health is a fundamental component of this. 

The Opportunity for Metro Mayors 

There is a clear opportunity for Metro Mayors to play a distinctive and valuable role in advancing neighbourhood transformation, but this is unlikely to come from formal authority over healthcare services. Instead, the most effective Metro Mayors will be those who can focus on convening, sense-making and brokering across complex systems.  

Create a shared lateral vision for Neighbourhood Health 

Metro Mayors have an opportunity to reshape how health is understood within the context of neighbourhood health and local regions. Rather than approaching this through a traditional NHS lens, focused on services and pathways, they can take a broader view centred on residents and communities. This means prioritising the social determinants of health, including housing, employment, education, environment and social connection. By taking this more lateral perspective, mayoral systems can help reframe health as something that is created in everyday life, rather than something that is solely delivered through healthcare services. This creates the foundation for a shared, place-based vision for neighbourhood health that reflects local needs, assets and ambitions. Crucially, this vision can act as a unifying narrative across a system, bringing partners together around a common understanding of what good looks like and which outcomes matter. 

Convening agencies 

Once the lateral vision is established, Metro Mayors are critical to convening the agencies behind it. Within a place-based system context, Metro Mayors are well positioned to bring partners and organisations together across local government, NHS organisations, the voluntary sector, transport providers, local businesses and wider system stakeholders. 

Their role is not to replicate existing governance structures or become drawn into organisational complexity; instead, their value lies in creating the conditions for alignment. This means bringing organisations together around shared local priorities, rooted in population need, and maintaining a focus on collective outcomes. 

In practice, this involves brokering decisions, navigating competing interests and helping to resolve tensions between partners. In this sense, mayoral influence is relational rather than hierarchical. It is about enabling collaboration, sustaining momentum and ensuring the system remains focused on delivering the shared vision for neighbourhood health. 

Building the capacity and capability to lead 

Combined Authorities need to be set up with the right capacity and capability from the outset for effective delivery. As relatively new organisations, there is significant opportunity to design these in a way that supports taking a system leadership role with the capabilities to drive neighbourhood health. 

This includes appointing the right people who can operate across organisational boundaries and drive the vision forward. Roles such as health commissioners or equivalent leadership positions can play an important part in providing focus, expertise and continuity. 

Ultimately, while the influence of Metro Mayors is primarily relational, it still depends on having the right structures and people in place. Without this, there is a risk that the vision remains aspirational rather than being translated into meaningful system change. 

Within the great opportunity for Metro Mayors to help drive neighbourhood health transformation, there are important limitations to the mayoral role that will shape how far and how quickly this opportunity can be realised.  

Much depends on how the Devolution Act is implemented in practice, with uncertainty remaining about the formal scope of mayoral responsibilities in health. Even where new duties are introduced, these are not always matched by additional powers or funding, which can constrain the ability of Metro Mayors to drive meaningful change.  

Accountability for health also remains inherently complex, spanning the NHS, local government and Combined Authorities, with arrangements differing across regions depending on local relationships and ways of working. 

Clarity is needed in roles and responsibilities, not just from the Mayoral perspective, but also from local agencies such as NHS organisations. Local authorities need to be clear about how they work with the Combined Authorities, leveraging effective channels of communication and regional system decision making.  Without greater clarity on roles, responsibilities and incentives, there is a risk that the mayoral role in health becomes more symbolic than transformative, with influence that is visible but limited in its practical impact.

Where are these ambitions being turned into reality? 

In York and North Yorkshire Combined Authority, the opportunity for Metro Mayors to support neighbourhood health is beginning to take shape within a region with a distinctly rural profile. Unlike dense urban areas, neighbourhoods here are defined by dispersed populations, rurality and variable access to services, which create additional challenges around coordination, workforce availability and service access. Within this landscape, Mayor David Skaith is exploring how existing levers such as transport, housing, skills and inclusive growth can be used to enable and support neighbourhood health across the region. Crucially, the mayoral role is not to design or deliver neighbourhood models directly, but to convene the right stakeholders and create the architecture and enabling conditions that allow locally led approaches to emerge and scale effectively.  

In South Yorkshire, Mayor Oliver Coppard has supported Barnsley’s “Health on the High Street” model, including the redevelopment and repurposing of the Alhambra shopping centre into a town-centre health and wellbeing hub, bringing outpatient services and community provision closer to residents and improving access to care in a familiar, accessible setting. Similarly, in West Yorkshire, Mayor Tracy Brabin has commissioned and backed a region-wide “Creative Health” approach working with NHS, local government, VCSE and cultural partners to embed prevention, tackle inequalities and build community-based support that complements formal health services. 

In Greater Manchester Combined Authority and South Yorkshire Combined Authority, it has been announced that NHS England will appoint a new NHS ICB chair in each area, who will also serve as the mayor’s health commissioner. This is a significant shift in local decision-making out of Whitehall into regions as part of the 10 Year Plan, neighbourhood health and the Devolution Act, and signifies intent to drive more integrated working between NHS bodies and Combined Authorities.  

These examples illustrate how Mayors can act as system leaders: bringing together sectors, shaping investment, and creating the enabling environment for neighbourhood health to take root and deliver meaningful improvements in outcomes. Following the Devolution Act’s passage, it will be exciting to see what Mayoral Combined Authorities will do next to drive the neighbourhood health ambition forwards.  

So, what is the role of Metro Mayors for Neighbourhood Health? 

Metro Mayors are not the delivery arm of neighbourhood health. They do not run services, control the NHS or resolve system fragmentation alone. However, their role is becoming increasingly important in a different and equally critical way: shaping the conditions in which neighbourhood health can succeed at scale for local populations.  

The opportunity for Metro Mayors lies in their ability to operate as system leaders rather than service owners. This means embedding health across all policy areas, from transport and housing through to skills and inclusive growth and using their convening power around a shared vision to bring local stakeholders together.  

Metro Mayors can act as visible place-based champions for health equity, reframing health as a whole system responsibility and ensuring it is considered in all layers of policy and decision making. This focus on prioritising prevention and place, means they can play a key role in shifting focus from reactive services to the wider determinants of health that shape people’s lives every day.  

As set out in Beyond Neighbourhood Health, delivering neighbourhood models requires both local redesign and system wide change. Metro Mayors sit squarely within that system role, helping to create the architecture, vision and enabling conditions that allow neighbourhood approaches to emerge and scale.  

For the potential of Mayoral Combined Authorities to be maximised, buy-in is also needed from within the NHS (and other health and social care actors). This means building a sense of shared accountability, identifying where collaboration can add value, and clearly defining roles and responsibilities. While this is easier said than done, it creates exciting opportunities to develop a far more cohesive approach to how we build the health of communities.