Easing pressures – how work, money and homes can make our cities healthier and fairer

Few places are as diverse as ours. While this vibrancy is an asset, it also involves a deeply unjust distribution of opportunity.

The stark differences in the length and quality of people’s lives in urban areas are not inevitable and so can be improved. We know inequalities in income, employment and housing contribute to health inequity in our place – those who live in more affluent areas can enjoy up to 19 more years of healthy living compared to those in more deprived areas.

Three years on from publishing ‘From one to many‘, the picture for people with health conditions remains the same. People are developing long-term conditions at an early age and underlying inequalities speed up people’s journeys to multiple conditions. On average, people first become ill at the age of 35, five years before the NHS begins offering routine health checks. And, nearly one in three Black adults in Lambeth and Southwark already live with more than one long-term condition; no other ethnicity is so disproportionately affected.

Health conditions related to the pressures of twenty-first century urban living dominate the picture. Chronic pain, hypertension, depression, diabetes and anxiety are common. Of all people developing a second long-term condition, more than half will struggle with their mental health. This is because of the complex and mutually reinforcing ways in which the social, economic and emotional pressures of living with ill health interact – the pressures of life make us sicker and being sick adds to the pressure of our lives.

Yet, none of this is inevitable. Research reinforces what people living in Lambeth and Southwark tell us: that intervening when people are younger would make a significant difference.

Four areas are particularly important: financial health, good work, decent housing and healthy neighbourhoods hold the power to slowing the progression from one long-term health condition to many.

We commissioned research, undertaken by researchers from King’s College London, to analyse healthcare data from interactions between GPs and patients in Lambeth in 2020, as part of a broader study examining 15 years of data. The insights from this research have helped shape our response to this major urban health challenge.

It highlights the true scale and impact of health inequality in our place, observed through the lens of people’s journeys from one to multiple long-term conditions.

The more we learn about the risks that turn one long-term health condition into many, the better we can seize opportunities to guard against them with precision.

Combatting precarity and spotting for moments in people’s lives that trigger a deterioration in health are vital. Common threads that run through all of our work are the need to:

• Address precarity – unstable situations and power imbalances, examples of which run through this report, have a profound impact on our health. This precarity is even harder felt by those that already experience discrimination in society, such as people from Black and ethnic minority communities.
• Champion equity through design, not only access – services and policies need to be designed by and with the people who use them most, not by those with vastly different life experiences. Design needs to be based on an understanding of risk factors and life events that can trigger ill health and progression from one to many long-term health conditions.
• Broaden the case for health – by encouraging decision makers and service designers in housing, finance and employment to understand the impact they make on people’s health and to explore opportunities for cross-sector collaboration.
• Share power and rebuild trust – with communities who experience the starkest health inequities, by sharing the power to make decisions and co-designing services that meet their needs. Without trust, opportunities are missed to connect in the key moments in people’s lives where an effective support system can make the difference between stable health and a deterioration to multiple long-term conditions.
• Influence those who hold power to do things differently – making sure health inequity is an issue they can no longer ignore and raising awareness of the impact mistrust and power imbalances have on people’s health.

With that in mind, there are three examples of change we want to see in cities:

1. Health and wellbeing are a deliberate part of job design, security and conditions in essential urban industries, such as health and care, waste management, early years education, transport and supermarkets.
2. Long-term health conditions are included by default within the vulnerable customer policies of lenders, landlords, employers and other organisations, recognising the additional burdens of living with health and financial difficulty.
3. A viable market for lower end private sector tenancies develops, which shares more characteristics with social housing, leading to accessible, affordable, secure homes that are in good condition and therefore good for health.