London and health: the best and worst of cities

Political commentators have argued that in various areas of public life, cities could succeed where nation states have failed. Benjamin Barber, for example, suggested that cities must lead the way in the fight against climate change, arguing that city leaders (particularly elected ones) are uniquely well-placed to think globally while retaining their local roots. Others have suggested devolution of further powers to large cities and city regions as a possible response to popular disillusionment with national politics in Brexit-era Britain.

The role of cities in relation to health has long been recognised. Modern public health has its roots in 19th-century efforts to improve the health of urban populations. Over time this has evolved into a more sophisticated understanding of the complex ways in which various aspects of city life interact to shape health and wellbeing. For more than three decades, the World Health Organization’s Healthy Cities programme has encouraged cities in different countries to share good practice, and more recently this has been accompanied by a focus on creating age-friendly cities.

City leaders have the power to influence the health and wellbeing of residents in at least three ways. First there are direct, material effects – for example, urban planning determines the physical environments we live in, and thereby some of the risks we are exposed to. Second, decisions made at city-level can influence individuals’ behaviour, making it harder for some to make healthy choices (for example, as a consequence of ‘food deserts’ in some neighbourhoods). Third, the psychological wellbeing of city residents is shaped by factors within the control of local and municipal governments (for example, research evidence shows that healthy city planning can help to encourage social interactions and build stronger community cohesion).

So how do England’s major cities compare on each of these three levels? Judging the relative success of different cities in creating health-promoting environments is complex because there are multiple factors involved (see, for example, ongoing work by BRE on developing a Healthy Cities Index). For the purposes of this blog, we will look at three indicators – levels of atmospheric particulate matter (a form of air pollution, and an example of a direct health risk); rates of childhood obesity (shaped in part by the choices available in terms of food, transport and recreation); and self-reported wellbeing (as a marker of psychosocial factors).

The graphs below show the performance of the nine largest cities in England against these three metrics, based on data from PHE public health profiles. Because London is composed of 33 boroughs rather than a single local authority covering the main city area, the worst- and best-performing boroughs have been included along with the London average.

A couple of things are striking from these graphs. First, no single city performs best overall. For example, while Sheffield and Leeds rank least well in terms of self-reported anxiety levels, they also have the lowest levels of childhood obesity (although still higher than average for England). Second, within-city variation may be as great or greater than between-city variation. This is certainly the case in London. The gaping distance between the best- and worst-performing London boroughs dwarfs the differences observed between other cities (the exception to this being air pollution, where most areas of London fare worse than most other cities in England, at least in relation to levels of fine particulate matter).

This data highlights that London is often in a class of its own. It is an outlier in terms of its size, complexity and heterogeneity. However, despite its uniqueness, there is still scope for London to learn from other cities; work being done on population health improvement as part of the devolution deals in Greater Manchester, the West Midlands and elsewhere will doubtless generate lessons that can be transferred to other large, complex urban areas, including London. And more broadly, London often looks beyond national borders for inspiration.

With this last point in mind, The King’s Fund is conducting a new analysis asking what London can learn from other global cities – and indeed what can be learnt from London itself. We will be exploring how cities such as London, New York and Paris have approached population health improvement, and how these approaches have been shaped by the governance and political leadership of those cities. The issue at the heart of this work is identifying what it would take for London to become the best of cities for health – while not simultaneously being the worst.