The City of the Sick

Last week I gave a 'provocation' at an event organised by Cap Gemini, the London Sustainability Exchange and the Greater London Authority designed to consider the London of 2020.  This is the text upon which I (loosely) based my remarks.  The original paper had footnotes, but I can't figure out how to do that sort of thing in Blogger, so I've listed them at the end and you have to guess which bit of the text they refer to...

When asked to identify the things that are most important to them, the people of both London and the rest of Britain consistently identify the same issues. A typical survey result is:
  • Being able to spend time with friends and family     44 %
  • Health                                                               31 %
  • Personal relationships                                          23 %
  • Work life, study and/or day-to-day activities           20 %
  • Standard of living or money                                  13 %

As policy makers or others responsible for endeavouring to manage the circumstances in which Londoners live their lives, it is salutary to consider these priorities. The prevailing orthodoxy, of attending to economic growth and job creation, seems to address the lower-ranked items. A policy regime more attuned to public preference would concern itself with enabling citizens to spend more time with their friends and family (perhaps by looking to reduce commuting times, or reducing working hours or promoting the development of convivial community spaces) and with improving the health of Londoners.

Considering health, we ought, as policy makers, to focus on these "principal social determinants of health":
  • Early childhood development
  • Having access to (high quality) health services
  • How much education a person obtains
  • Housing status
  • Being able to get and keep a job
  • How much money a person earns
  • What kind of work a person does
  • Discrimination and social support
  • Having food or being able to get food

Broadly speaking, if these determinants are improving, then so too is health; and vice versa. Cumulatively, they (largely) determine the prevalence of Non-Communicable Diseases, themselves the leading cause of premature death in the UK . The dominant NCDs, such as cancer, chronic respiratory disease and diabetes are principally driven by just three risk factors: poor diet (including the harmful use of alcohol), tobacco use and lack of physical activity . In addition, “mental ill health is the largest single cause of disability in the UK, contributing almost 23% of the overall burden of disease compared to about 16% each for cancer and cardiovascular disease.” The direct costs of this disability, and the indirect costs (through reduced productivity and/or lost working days) are substantial.

Considering London from such a perspective, we can ask: is the London of 2020 likely to be a sick city or a well city?

The outlook is not good. Cuts in government spending are likely to reduce social support, access to high quality health services and provision for early childhood development in London. The general state of the economy is such that significant employment growth is unlikely over the next few years; and such growth as does occur may well increase levels of stress-related mental ill-health among Londoners. Real incomes have been falling in the capital and, again, leading commentators and politicians are progressively extending the horizon for a genuine recovery in incomes. New housing development continues at a level far below that required to accommodate London’s growing population, and a combination of public sector funding constraints and private sector uncertainty seems set to limit any large scale investment in upgrading London’s housing stock.

On top of that, and despite recent increases in the levels of cycling, Londoners remain overwhelmingly dependent on modes of transport that do not require any physical exertion, do jobs that require no physical exertion and show only marginal increases in participating in active sport. Smoking rates have reached a plateau, alcohol consumption remains dangerously high and the consumption of high-calorie, highly-processed, high profit margin and low nutrient food dwarfs the attention sometimes secured by more wholesome, headline-grabbing diets.

In short, London is already pretty unwell; and virtually every determinant of health is heading in the wrong direction.

Although there are some London policies that are fighting the tide – current action on alcohol is a good example – they are not only woefully inadequate and uncoordinated, they are in some cases making things worse. Urgent and radical action is required if we are not to be a very sick city indeed by 2020. We can not only save money and lives; we can actually give people something that they want.

Notes & sources

Figures show, when asked what were the most important things affecting their lives, without prompting, the most common responses people gave and the proportion mentioning them. Source: “Life satisfaction and other measures of wellbeing in England, 2007-2011, from the Survey of Public Attitudes and Behaviour towards the Environment”, National Statistics/Defra, 2012. See also, for further evidence reinforcing this list and a helpful summary of the ONS work on well-being indicators etc, Houses of Parliament POST Note #421, Sept 2012

See, for example, “21 hours: Why a shorter working week can help us all to flourish in the 21st century”, New Economics Foundation, 2012

Marmot, M.G. and R.G. Wilkinson, Social determinants of health. 2nd ed. 2006, Oxford ; New York: Oxford University Press

Center for Disease Control and Prevention,

“Non-communicable diseases in the UK, A briefing paper prepared for the UK Parliament (House of Lords)”, C3Health, September 2011

World Health Organization, Preventing Chronic Disease: A Vital Investment (2005)

Department of Health, Mental Health Promotion and Mental Illness Prevention: the Economic Case (April 2011):

“Healthy, wealthy & wise”, Fell D., TCPA Journal, 2006

House Building: June Quarter 2012, England, National Statistics/Department for Communities

Source: Wikipedia accessed 5/10/12

Sport England, Active People Surveys 1 to 6

Cancer UK, Smoking Statistics,

Statistics on Alcohol 2011, NHS

[If there's a photo down here it was added August 2017 as part of blog refresh.  Photo is either mine or is linked to where I found it. Make of either what you will.]


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