1 Key Messages

Cities are drivers of health. The COVID-19 pandemic has highlighted the disproportionate impact poor health has on disadvantaged communities within cities. Although a whole systems approach is the most effective way of reducing health inequalities in urban areas, it is all too often approached as a conceptual exercise, rather than a series of practical, action-orientated steps, supported by data and focused on impact.

Understanding the root causes of inequalities and how multiple disadvantages influence health outcomes is essential in redressing the balance between high- and low-income communities. This means starting with neighbourhoods facing worse health outcomes and focusing on reducing the gap so that they are in line with those from wealthier households.

Collaboration across all sectors—e.g. housing, education, health and those disproportionately affected by poor health—is needed to achieve sustainable health improvements in cities. Strong political leadership and commitment to address the disparities between and within differing populations, will ensure long-lasting health improvements for future generations.

Guy’s and St Thomas’ Charity is an independent, urban health foundation. We take a systematic approach to tackling health inequalities, focusing on Lambeth and Southwark, two areas in inner London, UK. These areas are characterized by densely populated built environments, high levels of deprivation and income inequality and cultural and ethnically diverse communities. Like many other neighbourhoods in cities across the developed world, they face similar challenges of health inequalities. These similarities allow us to implement potential solutions to urban health problems here and share our learning with similar cities and places internationally.

We believe that a whole systems approach is the most effective way of achieving health equity in cities. In practice this means we focus on:

  • ‘Place’ to understand the context in which poor health outcomes can arise in urban areas like ours.

  • A small number of health issues that are locally and globally relevant: childhood obesity, health impacts of air pollution, adolescent mental health and multiple chronic conditions.

  • Working in partnership with public bodies, corporate and private business, civil society and community organizations to deliver practical solutions in a defined geography.

This approach allows us to layer initiatives in a specific place to test and learn effective solutions to achieving health equity in cities.

2 Case Study: A Whole System Approach in Practice

In our programme on childhood obesity, we’re taking a multi-layered, cross-sectoral approach to improve the food environments of one of our most disadvantaged neighbourhoods. This means using data to identify how and where we work, and developing partnerships that can help us create impact at each level, for example:

Neighbourhood: Our hyper-local work involves us growing partnerships and layering different initiatives within a small geography, sometimes covering a handful of streets. It means building a deep understanding of the communities living in that area and tailoring initiatives to address the need.

Borough: For a new idea to be viable and well evidenced, it may need to happen at a larger scale than a neighbourhood, therefore, we look at practice and policy-driven by statutory bodies and others at boroughs level. With the Consumer Goods Forums, we’re testing ways to move consumers towards healthier shopping baskets by working with retailers responsible for over 200 grocery stores across our boroughs.

City: Responsibility for some environments often sits with the city’s authority, for our boroughs, it’s the Greater London Authority (GLA). We partnered with the GLA to help start London’s Child Obesity Taskforce—an effort to ensure the city and its spaces support children to have a healthy weight.

National: Progress on local health may only be possible through influencing policy coming from central government or the NHS. By collaborating with the UK’s largest medical charities and the Royal College of General Practitioners, we’re contributing to national decision-making which impacts health care of people in our boroughs.

International: Some influences on our health are from international systems or organizations, understanding these can help us to create local impact. We partnered with charity ShareAction, encouraging investors to put pressure on large multinational food and drink companies who could change practices that contribute to childhood obesity.

Our approach engages with policy solutions beyond health care, government institutions and beyond national boundaries. Working in collaboration with private, public, civil sectors and communities, we layer multiple, modest but meaningful interventions to identify opportunities to influence policy and practice. This requires a coordinated, collaborative, and concentric approach, starting with neighbourhoods who are disproportionately affected by poor health and focusing on closing the gap in health outcomes, so they are in line with wealthier ones.

3 Why Cities Matter

Cities sit at the centre of modern life. According to the UN, by 2070, two-thirds of the world’s population will be living in cities. In the UK alone, cities take up 9% of the landmass but contribute over 50% of the UK’s population, jobs and high-level skills. It is the focus on the positive attributes of cities, that mask the inequalities that exist within it. Through their ability to generate wealth and opportunity, cities shape our health. This has never been more evident than during the COVID-19 pandemic, which has highlighted the undeniable health impacts of structural and racial inequalities.

For people facing disadvantages, their “health journey” from childhood to adulthood begins with the place and the context of their lives. A person’s social context—their education, housing, employment and ability to cope with life events such as bereavement, debt, isolation—influences the likelihood and severity of their health outcomes. Poor health at a young age will likely have a negative impact on the quality of life for many years ahead. Poor health in working-age adults has a wider societal impact, not least on the health of a country’s economy, as this pandemic has demonstrated.

Achieving health equity in the complex environments of cities and urban areas is not easy, it is not impossible either. Complexity should not be a barrier to addressing the challenge, what is important is getting started. The COVID-19 pandemic has shown us that the risks of starting somewhere, however, small, are far outweighed by the risks of doing nothing at all.

4 Implications for Policy

With learning from our programmes, we set out key considerations for policymakers to take away from our work:

Focus on preventing poor health in the first instance:

  • Support local bodies to tailor interventions that support the needs of the community they serve. The emphasis of effort should be on practical coordinated programmes, moving away from targeting specific individuals to initiatives that target whole populations within deprived areas. For example, our work on childhood obesity focuses on the three environments where children spend most of their time: their homes, education settings and streets (including commercial and recreation settings).

  • The context of the place in which people live, especially those on low incomes, has a huge impact on health. Socio-economic influences layered on top of a neighbourhood impacted by the removal of public services and years of disinvestment contribute to poor health outcomes. Therefore, review all current and new policy, e.g. planning, housing, social care, education—through the lens of health equity, or risk exacerbating existing inequalities.

    Rebalance environments to support health.

  • Address the physical environment so that the health-promoting features of the more deprived environments cumulate to outweigh those that are health-destroying.

  • The aim is to improve the availability of affordable healthy food options that makes every home, school, high street and green space an area that encourages nutritious diets and everyday activity. This requires the engagement of the owners of those spaces to buy into the business case for systemic changes and support in driving and financing the work needed. For example:

    • Address the commercial determinants—engage with supermarkets on regulatory risks of unhealthy food including advertising and promotion of unhealthy convenience food, especially to children and young people.

    • Engage with housing associations on the costs of poor health. Investments in suitable affordable and social housing for families can maintain social networks and avoid disenfranchisement. The positive impacts that family connections and social networks have on both physical and mental health support a family’s ability to manage personal finances and reduce rent arrears.

    • Environments that support physical health, psychological wellbeing and cultural and social connections support the growth of thriving and productive people. Consider engaging with insurers on the economic benefit of healthy workforces.

Focus on the communities disproportionally affected by poor health outcomes and design interventions for maximum impact.

  • Aggregate different data types:“big” data (quantitative data); lived experience (qualitative data); issue-specific insights (evidential data) to understand and drive targeted interventions.

  • Ensure interventions are universal across the population but more intense for those from more disadvantaged communities.

  • Reduce focus on education and make uptake and participation of any intervention easy. Purely educational interventions are less likely to be effective and have the potential to widen health inequalities.

  • Invest in solutions with realistic expectations of the amount of spare time and cognitive effort people may have to engage, particularly amongst people living in deprived areas, for whom scarcity will have a disproportionate impact.

5 Conclusion

Our insights have shown that the context in which people live their lives matters. The COVID-19 pandemic has highlighted the disproportionate impact poor health has on disadvantaged communities and reinforced the fundamental underlying factors that drive poor health. Although cities are the centres of prosperity, culture and opportunity, right now cities across the world hold a disproportionate share of deaths due to COVID-19. This pandemic has exposed the fault lines of our unequal societies and our cities are at their epicentre. It has never been more important to take a collective effort to redress the balance of these systemic inequalities. This can only be achieved through future policy addressing the root causes of inequalities and understanding how multiple disadvantages as well as race, class and gender influence health outcomes.

There is no doubt that we live in an interconnected world, and this pandemic has fast-tracked the need for an international conversation on health, equity and the power of cities to drive change. Tackling this issue takes time and sustaining a collective effort will be hard without strong political leadership and commitment to address the disparities between and within differing populations. By better understanding inequalities and their impact across the life course, policymakers, leaders and decision-makers will be able to clearly define what needs to change, in what type of place, to advantage which group of people, for the benefit of our local and global community.