Written evidence - Impact on Urban Health (PTC0031)

1. About Impact on Urban Health

Impact on Urban Health is a part of Guy's & St Thomas' Foundation. We explore how living in cities impacts on people’s health. We take an applied approach, testing whole-system solutions to complex health issues. While we focus our efforts in inner-city London and work in areas that experience the widest health inequalities, we seek to generate evidence and learnings which can benefit people in urban areas across the UK and around the world.

Through our work, we challenge health inequalities and help urban areas become healthier places for everyone to live.

2. Executive Summary

We welcome the COVID-19 Committee’s inquiry into the long-term impact of the pandemic on the UK’s towns and cities.

People in urban areas can face distinct pressures on their health and wellbeing, from deprivation and insecure employment to poor air quality and crowded and inadequate housing. These pressures are not experienced equally, either within or between urban areas. Too often, already marginalised groups in urban areas experience the worst health inequalities, with the best health outcomes existing alongside the worst.

These extant inequalities have been exacerbated by the pandemic. The local authorities with the highest rates of diagnosis and mortality from Covid-19 are urban[1]. The acute pressures brought by lockdown on health and wellbeing have been followed by rising financial insecurity and housing uncertainty, as the economic implications of the pandemic begin to bite[2]. These challenges have been particularly hard for people from minority or lower income backgrounds. Far from being a great leveller, the pandemic risks widening already devastating health inequalities.

That need not be the case. As central Government and local leaders plot a route to recovery, it is essential that they acknowledge the experiences within many of our urban areas. There is now an opportunity to tackle these underlying inequalities, and to foster healthier and more secure urban populations as part of a resilient recovery.

This response details the impacts of the pandemic in the urban areas in which we work, noting that many of these impacts will be common to cities and towns across the UK. Each region has unique experiences of the pandemic, but there are recurrent challenges which have been faced in urban areas. Many of these challenges are structural and existed before the onset of Covid-19. The pandemic, and its accompanying economic and social pressures, has only served to further highlight and exacerbate these inequalities.

As part of this submission, we have detailed projects which Impact on Urban Health supports in our place. Some of these projects aim to better understand inequalities in our area – many of which will be similar to those present in towns and cities across the country. Other projects seek to test and provide solutions to the inequalities we know are present. Of course, as leaders seek to plot a post-Covid recovery they will need to acknowledge the circumstances in different towns and cities in the UK and build approaches accordingly. But we believe there are common themes and principles in how best to most effectively and equitably develop those approaches.

That includes working closely with local communities to understand their lived experience and empower them to develop and advocate for solutions based on their needs. It also means a focus on coordination, noting that health inequalities are often the result of complex, interlinked issues across multiple sectors such as housing, employment and healthcare provision. Where actors in any one of these sectors move to address challenges alone there is a risk of an inadvertent impact in another, so solutions should seek to bring together cross-sectoral coalitions – acting for mutual benefit, and finding the most effective, equitable way forward.

Those solutions also need to join up local, regional and national action. That means local leaders being aware of and utilising wider frameworks, policies and trends when designing local action. And it means Government acknowledging where there are common structural challenges across urban areas in the UK and moving to address them, and providing the support and flexibility to local leaders to tackle those challenges which are more specific to their locality.

In particular, this response draws on:

• Yet-to-be-published research carried out with the School of Population Health and Environmental Science (SPHES) at King’s College London analysing longitudinal healthcare data from interactions between GPs and patients in Lambeth in 2020 to demonstrate the scale of health inequity;
• Our Easing Pressures report, which explores the social determinants of health and their role in the progression from one to many long-term health conditions.

As stated, this response relies heavily on the lived experience of people within our communities. Those who experience the worst health inequalities are often those whose voice is least heard, and who are most distant from decision-making processes. Again, as local and national leaders seek to understand the specific impacts of the pandemic in urban areas, and to design an effective and equitable road to recovery, it is essential they engage the communities who have most acutely experienced those impacts.

We would be pleased to share further information with the Committee on this work if helpful.

3. Increasing financial pressures

Between a severe economic downturn and social restrictions affecting individuals’ ability to work, we know that the pandemic has brought with it financial pressures for many in our cities and towns. Clearly, the causes of and impacts of this increase in financial insecurity are various. But we know that there is a reciprocal relationship between financial health, and physical and mental health.

The relationship between financial health and physical and mental health is particularly acute for people living with multiple long-term conditions (MLTCs). The life circumstances of people living in urban areas with multiple long-term conditions can mean they are more likely to have fewer healthy years than others. Living with MLTCs may severely impact quality of life, and can trigger vulnerability to other social risk factors associated with poor health, such as financial insecurity and unemployment. People with MLTCs often have increased financial pressures as they may be less able to work regular hours, or at all, and face increased expenses. Simultaneously, financial stresses can impact on food, heating and housing, and increase anxiety – feeding back into poor health[3].

According to (yet-to-be-published) research we have undertaken in Lambeth in partnership with King’s College London, the prevalence of MLTCs varies depending on both ethnicity and gender:

• The highest prevalence of multiple long-term conditions (≥2 LTCs) is amongst Black women, at 35% of the population, while 28% of Black men are living with ≥2 LTCs. This is compared to 22% in White women and 20% in Asian women.

At the same time, the financial pressures of the pandemic are now beginning to bite. We know that people from Black communities have experienced particular impacts from the Covid-19 pandemic: they are now twice as likely to anticipate difficulties in paying regular bills and expenses as the national average (34% compared to 14%)[4]. And shifting patterns of employment, detailed in this response, threaten to increase financial precarity in our urban areas and hit those already financially disadvantaged the hardest.

More immediately, the pandemic has brought with it acute financial pressures on communities which were already experiencing significant health inequalities. As leaders plot a post-Covid recovery, it is imperative that it includes measures to reduce these pressures on individuals as far as is possible. Our COVID financial shield programme – bringing together NHS Primary Care Networks, councils and housing associations – supports interventions for people with financial and health difficulties, offering debt advice and breathing space for those at risk of crisis. It is an example of the pragmatic and joined-up response which will be needed to tackle financial pressures and avoid financial crises leading to worsening health inequalities.

4. Changes to employment

i)                   Unemployment and Furlough

The pandemic has had significant impacts on employment, contributing to increasing financial precarity and corresponding pressures on health. The evidence for how Covid-19 has affected and will continue to affect the labour market in cities and towns is mixed. There are indications that the rate of job losses was lower in large cities than in smaller cities and towns[5]. At the same time, early evidence suggests economic recovery may be slower in larger cities, including London[6].

Large parts of the UK, both rural and urban, have been affected by job losses. Between the first quarter of 2020 and the first of 2021, the redundancy rate in rural areas increased from 3.3 per 1,000 to 5.1, and in urban areas from 3.9 to 6.2 per 1,000 – broadly comparable[7]. But given the diverse nature of many urban areas, and a disproportionate impact of job losses and furloughing on minority communities, there is a risk that existing inequalities may be widened by the economic impacts of the pandemic.

From November 2019 to November 2020 rates of short-term unemployment increased in Lambeth by 864%, and in Southwark by 768%[8] - amongst the highest rises seen in London boroughs. Given how diverse these boroughs are, again there is likely a disproportionate impact on Black communities.

To further understand these impacts, Impact on Urban Health worked with our partners Rocket Science to understand changes to the labour market in Lambeth and Southwark in the six months after lockdown measures.

The results were stark. Redundancies increased drastically – tripling in rates per thousand from August to October 2019 and August to October 2020. Those redundancies were not spread uniformly across sectors, with food, wholesale and retail traders particularly badly affected in our place.

Redundancy can have significant impacts on financial security as well as mental and physical health. Concerningly, it is likely that the wave of redundancies after the pandemic was not felt equally. Research by McKinsey has found that people from minority ethnic backgrounds are more vulnerable to economic shocks, such as redundancy, and are likely already at a financial disadvantage[9]. That financial disadvantage, already representing a deep inequality, may well be worsened by post-Covid job losses.

Workers furloughed as part of the Government’s Coronavirus Job Retention Scheme (CJRS) also face significant financial insecurity – with uncertainty as to future prospects as the CJRS winds down and immediate pressures on income. We know that certain groups of ethnic minorities are over-represented in sectors worst hit by Covid-19, and are more likely to be furloughed than white workers[10].

Community research we supported with The Social Innovation Partnership (TSIP) to understand how the pandemic was affecting communities in Lambeth and Southwark found furlough has negatively affected already vulnerable individuals. TSIP worked with residents as the pandemic unfolded to understand how impacts were developing over time. Increasing financial precarity was a common finding, with some furloughed residents reporting that they were struggling to pay bills and expenses, or relying on limited savings or emergency support from friends and family.

ii)                 The changing nature of work

Rising unemployment has not been the only consequence: the pandemic has also changed the nature and security of work for many. The economic downturn means limited opportunities to access good, secure and regular work. We have seen a rise in the ‘gig-economy’, with zero-hours contracts and the significant uncertainty they provide. Even where people are in work, they remain in financial precarity and unsure of their future prospects.

More people are working night shifts than ever before, growing to over 7 million since the start of the pandemic and particularly common in urban areas. Night shift work can be stressful, disruptive and have serious effects on mental and physical health, with evidence that it contributes to long-term conditions such as diabetes, heart disease and depression[11]. At the same time, zero hours contracts represent enormous precarity with corresponding impacts on financial security and physical and mental wellbeing.

The move to online services and working has also impacted people in urban areas in complicated ways. TSIP reported that residents had varying experiences of shifts to online working, with those with lower digital literacy struggling to engage with changes to their current work and less confident in applying for new roles. Older people and people from poorer backgrounds are more likely to have low-levels of digital literacy and reduced access to online services[12]. For all the heralded success of shifts to at-home and online working, it is likely that these shifts have also penalised those most in need of secure income or new employment opportunities. These already shifting trends of employment have been further catalysed by the pandemic, and now present uncertainties as to how they will affect health and health inequalities in the long-term.

5. Housing security, quality and affordability

The link between precarious or poor quality housing and health is well established, including by Public Health England[13]. Insecurity of housing has severe impacts on mental and physical wellbeing, while overcrowded, unhealthy homes have been linked to respiratory and cardiovascular illness. Housing insecurity is particularly acute in densely-populated urban areas, and those areas impacts are not evenly felt:

• In Lambeth and Southwark research has found that the neighbourhoods with the highest mental health needs are more likely to have higher levels of deprivation in terms of overcrowding and housing affordability[14];
• In Southwark the proportion of people from the Black community homeless is twice that of the average[15].

It is not yet fully clear how the pandemic will affect housing affordability and security in the long-term, and indeed there is still an opportunity for positive intervention, but the initial signs are concerning. Homelessness has increased during the economic downturn[16]. Research from the Health Foundation suggests that housing affordability will be negatively affected by the pandemic, with a rising proportion of income required for housing[17]. The Resolution Foundation has found that private and social renters, already more likely to have precarious housing, were twice as likely to have lost their jobs during the pandemic than home owners[18].

These are troubling trends and, given that people from Black and minority ethnic communities are more likely to be in the privately rented properties, speak to a worsening inequality. 

Our Covid Private Renters Project in Southwark supports collaboration between a Black-led social enterprise called Kineara, Southwark Council and South Law Centre to support interventions for people who are facing eviction and are at risk of developing long-term health conditions. That includes legal aid, mental health interventions and mediation advice to help prevent them losing their homes. The model has been largely successful in preventing evictions – benefitting tenants, landlords and local authorities alike.

6 July 2021