London's health: a role for the new mayor

London is not a healthy city. Overall mortality is falling more slowly than in the rest of England,¹ and infant mortality compares unfavourably with that of other European capitals.² The city is blighted by pollution,³ and there are particular problems with HIV infection, substance misuse, teenage pregnancy, tuberculosis, and severe mental illness.⁴ The seven million people who live in London are aware of the problems: a poll revealed that they regard their city as an unhealthy place, and they think it is going to get worse.⁵

Last May Londoners voted in favour of establishing a Greater London Authority (GLA), made up of an elected mayor and an elected assembly. The legislation is on its way through parliament, elections will be held in May next year, and the mayor and assembly will start work on 3 July 2000. The new authority will be responsible for “promoting economic and social development in London and improving the environment.” The mayor will have sweeping executive powers and with the exception of the president of France will have the largest direct democratic mandate of any politician in Europe.

The new authority will have a tremendous opportunity to make an impact on the capital’s health. Although it will not be involved in managing or providing health services, it will produce policies on matters that are inextricably linked with health—such as transport, jobs, and housing. There is, however, concern that health considerations will be neglected. A report just published by the King’s Fund notes that although the government was originally explicit about the mayor's “duty” to improve the health of Londoners,⁶ the present bill refers only to the “desirability” of promoting health.⁷ The report calls for health “to be an integral and essential component of all the GLA's policies.”⁷

London's most conspicuous need is to tackle poverty and inequalities. Thirteen of the 20 most deprived boroughs in England are in London, and across its 33 boroughs there is a good correlation between deprivation score and standardised mortality ratios.⁸ The city is divided by extremes of wealth and poverty and the income gap is growing: from 1979 to 1997 the earnings of the highest paid 10% of people increased from 2.8 to 4.5 times that of the lowest paid 10%.⁹ The health divide has followed suit: between 1981 and 1991 the standardised mortality ratio decreased in the most affluent areas and increased in the most deprived.

London has a large and expanding ethnic population, on whom unemployment falls disproportionately, and the accompanying poverty is associated with poor health. Similar problems have been faced elsewhere: Glasgow has responded by targeting education and training initiatives at its most deprived communities as part of a package of economic regeneration. Air quality is another pressing issue for London. Most of the pollution comes from motor vehicles, but car use in London is increasing despite mounting evidence of the dangers to health.¹⁰ By contrast, the mayor of Rome describes his priorities as “traffic, traffic, and traffic” and has taken action to restrict cars, improve public transport, monitor air quality, and convert motor vehicles to make them environmentally friendly.

These are just two examples of the value of integrating health and social policy. The Healthy Cities project coordinated by World Health Organisation’s European office has established an international network of cities dedicated to improving health—from Liverpool in the United Kingdom to Amadora in Portugal and Kuressaare in Estonia.¹¹ Their approach has been to develop partnerships and joint local strategies between all the municipal offices and other organisations that contribute to health to meet challenges such as poverty, inequalities, unemployment, and homelessness and also to encourage public participation in planning and taking action.¹²

The democratic accountability of the GLA may promote meaningful community involvement in decisions that affect people’s health. The authority will hold annual “state of London” debates and a twice yearly “people's question time.” Ultimately, if the public shows enough interest in health related issues this will put them near the top of the mayor's agenda. Hopefully this will mean that the mayor works constructively with the NHS to improve health, rather than simply criticising health services; health professionals in the capital are unlikely to welcome further external scrutiny.

The GLA will need to ensure that it has access to public health advice, either from the new NHS London regional health authority or, as the King's Fund report suggests, from its own public health team. The BMA is also considering lobbying for a chief medical officer for London. But however the public health advice is provided, the capital needs a strong civic leader who is prepared to make an explicit commitment to improving health by incorporating health considerations into all of his or her policies. The mayor must not underestimate the importance of social determinants on health15: the mayor and the assembly have the potential to be a greater influence on London's health than any of its 34 major hospitals.