This blog post is based on a discussion with leading public health experts in January 2021, as part of London Futures. Participants included local politicians, public health doctors, academics, policy makers and campaigners on key health issues. The event was held under the Chatham House Rule. Special thanks to Impact on Urban Health for making this roundtable possible.
Public health professionals use a vast range of tactics to reduce illness and improve wellbeing in the population, from targeted interventions to encourage people to stop smoking to broad brush public awareness campaigns and long term policy change. All of these are important, but at this roundtable we were particularly interested in policy change. Where is it most important for us to push our politicians? We asked our participants to focus on the medium term rather than the immediate and very pressing issues of coronavirus infection control and vaccination – although of course the experience of the pandemic may change how we think about health priorities in the longer term. In fact some participants felt that the pandemic, together with the Black Lives Matter protests last year, have created a good moment to talk about fairness and try to build back fairer.
Tackling poverty is the key to improving Londoners’ health
We began by asking our participants which public health issues are the biggest priority for them. Economic inequality was seen as more important than any of the condition-specific issues like obesity and alcohol use. There was a strong consensus in the room that poverty is a key driver of poor health outcomes and that tackling poverty and so, reducing inequality is the single best way to improve the health of London’s population. Poor health outcomes in London map closely to poverty: people living in our poorest areas have the shortest life expectancies, and the gap is even starker for healthy life expectancies (the amount of time someone can expect to live before developing a life limiting disability).
The problem of course is that reducing poverty and inequality mostly lies with central government: they would need to raise benefits or the minimum wage, probably backed by changes to taxation. In the 10 years or so leading up to the pandemic, income inequality was at best static; it seems likely that it’s now rising. Regional, city and local government can do things to try to improve health by reducing inequality, for example by providing services like children’s centres in the areas of greatest need, but their political and financial power is limited. It’s especially difficult in London with its 33 local authorities, Mayor and Assembly, and complex NHS infrastructure – but good work between the NHS and local government in Manchester shows that there is scope for real progress at a city level.
Embedding health into all our policies at a city or local level isn’t enough in itself. Citing Janette Sadik-Khan, one participant reminded us that ‘if you push the status quo, the status quo pushes back, hard’ – this might be in the courts, where cases about prioritising health over other desired outcomes often end up, or at the level of local intervention – the vital daily grind of working at the frontline to make sure that good ideas are put into action, again and again.
Poor housing, poor air quality, poor working conditions
The mechanisms which link poverty to poor health are complex and differ for people of different ages and in different situations. We spoke about three significant ones in London: poor housing, poor air quality, and poor working conditions. The first of these is especially salient in London. Compared to other parts of the UK, London house prices are very high relative to incomes. Far too many people live in homes which are overcrowded, (making life stressful for everyone and making it hard for children to learn at home and be active indoors), or cold and damp, which makes respiratory and other illness more likely. Building high quality homes – and getting the right people into them – can be a public health intervention. As well as living in more cramped homes, poorer people are more likely to live in areas with poor air quality, further increasing their chance of heart and lung problems.
Bad work is actively detrimental to our health: people in low paid roles often have to deal with the most stress and physical strain at work, as well as dealing with the stress of not having enough money. Interventions by employers, like offering access to counselling, subsidised gyms (or simply showers so people can run or bike to work), “duvet days” and genuinely flexible working tend to be used more in higher paid jobs, and so risk widening the health divide further. Some of our most important key workers – adult social care professionals – are usually paid below the Real Living Wage, and sometimes below the minimum wage. The NHS, one of London’s largest employers, does not guarantee paying the Real Living Wage to its staff, and it would be hard for it to afford to: the trouble is that then it has to pay for the health costs of some of its own people living in poverty.
This is a hard moment for public health policy in London, surely the hardest for a century. The urgent priority of coronavirus has pulled people’s attention away from other key public health issues even as many of these issues – poor mental health, poverty, access to exercise – worsen. But London has an exceptional cadre of public health thinkers and doers, and they are looking to the post-pandemic future even as they cope with the present. The will to collaborate is very clearly there, even if the structures make it difficult, and there is much to learn from other cities. Despite the enormous challenges, the next few decades could see London at the healthiest it has ever been.
This phase of London Futures has been made possible with the generous support of our Funders, City Bridge Trust, Impact on Urban Health, Mastercard, and Van and Eva DuBose, our Major Sponsors, Greater London Authority, and the London Borough of Lambeth, and our Supporting Sponsors, Bosch, Port of London Authority, University of London, and Wei Yang & Partners.