The Prime Minister has set out a vision to place greater decision-making authority closer to communities, saying power should reach “every postcode”. Ministers and health leaders describe this as a move towards subsidiarity — the principle that choices should be made at the level closest to those affected.
What subsidiarity would mean in practice
Under the approach being advocated, responsibility would start with individuals and their families or carers and extend outwards only when necessary. Proponents argue this flips the conventional model in which services are planned centrally and then delivered to people, instead recognising citizens as active agents in shaping their own health.
Supporters point to a range of local roles and teams that could exemplify the model, including community health and wellbeing workers recruited from the neighbourhoods they serve. These workers are intended to build trusted relationships, help people address social and environmental drivers of health, and link individuals to services and support.
| Level | Primary focus |
|---|---|
| Individual & family | Personal agency, shared decision-making |
| Community | Local teams, trusted relationships, place-based services |
| Higher tiers | Support functions, resources and activities that cannot be managed locally |
Policy ambitions and practical challenges
Advocates argue that decisions taken closer to the point of care can be more responsive and better tailored to local needs. They say subsidiarity encourages high-quality shared decision-making between professionals and the people they serve and could help tackle the wider determinants of health — such as housing, employment and community support — that shape outcomes outside hospitals and clinics.
However, translating the concept into consistent practice across the country raises immediate questions. These include how to ensure equitable funding, how to measure effectiveness, and how to preserve clinical safety and standards while allowing local autonomy. Devolution of power can create space for innovation, but subsidiarity sets the rules for how that power should be exercised and when higher levels must step in.
- Accountability: Who answers if a local team’s decisions cause harm or worsen inequalities?
- Capacity: Do local systems have the workforce, skills and infrastructure to take on new responsibilities?
- Evidence and evaluation: How will success be measured and scaled where effective?
There is international and academic literature suggesting that place-based care and community involvement can improve access and patient experience, but evidence on long-term population health and cost-effectiveness is mixed and often context-dependent. It is therefore important to distinguish correlation from causation when appraising early local successes.
Implications for workforce and training
Embedding subsidiarity in health and care would likely require changes in workforce composition and training. Community health and wellbeing roles emphasise relational skills, local knowledge and the ability to navigate social supports — competencies not always prioritised in traditional clinical training. Scaling such roles means recruiting from communities, investing in supervision and ensuring career pathways so these posts are sustainable.
Policymakers will also need to consider how to maintain clinical governance and consistent standards across diverse local arrangements. Some functions — procurement, specialist services and regulatory oversight — are unlikely to be effective if fully decentralised.
Conclusion: opportunities and limits
The Prime Minister’s pledge to devolve power to local areas reframes longstanding debates about who should make decisions that affect health and care. Subsidiarity, as advanced, prioritises individuals and communities but does not eliminate the need for strong systems, funding frameworks and evidence-informed oversight. Real-world outcomes will depend on how devolution is structured, how responsibilities are defined, and whether local systems are given the resources and evaluation frameworks needed to succeed.
Until robust, peer-reviewed evaluations of expanded local approaches are available at scale, claims about broad improvements in health and cost savings should be treated cautiously. The concept offers a coherent organising principle, but its benefits will hinge on careful implementation, transparent measurement and safeguards against widening regional inequalities.
