Health and wellbeing

The London Intelligence | Health and wellbeing

Health and wellbeing

Adult obesity

More than half of London’s adult population is classed as overweight or obese – less than the national average.

Obesity poses major challenges both to individuals’ health and to the health services. It can increase the risk of some conditions, including type 2 diabetes, heart disease, some types of cancer and stroke, as well as leading to mental issues such as depression and low self-esteem. Obese children are more likely to be absent from school and to remain overweight in adulthood. This puts pressure on the NHS. At the national level, annual spend on the treatment of obesity and diabetes by the NHS exceeds the amount spent on the police, the fire service and judicial system combined.

In 2017/18, 56 per cent of adults (over 18) in London were classed as overweight (a body mass index (BMI) of over 25) or obese (a BMI of over 30), compared to 62 per cent across England.

However, there are some big differences between boroughs and across London. Six boroughs have a higher per cent of adults classed as overweight or obese than the English average. And some of the lowest levels of adult weight issues are found in central and west London, while outer east London has the boroughs with the highest proportion of adults classed as overweight or obese.

There has been little change over time overall in London and England, but some boroughs have seen large fluctuations over the past two years. Havering (+10 per cent), Barnet (+7 per cent) and Hillingdon (+7 per cent) had the largest increases. Those with the biggest decreases over three years are Tower Hamlets (-9 per cent), Bromley (-8 per cent) and Enfield (-7 per cent). This may reflect London’s mobile population as much as specific changes in policy or local conditions.

Childhood obesity

By contrast to adults, a higher proportion of children are classed as overweight or obese in London, compared to the national average.

38 per cent of London’s 10 and 11-year olds were classed as overweight or obese when leaving primary school in 2017/18 – the highest rate of all English regions – compared to 34 per cent on average across England. In London, the proportion of children classed as severely obese rises from three per cent in reception class to five per cent of those leaving primary school.

At the borough level, proportions of children classed as overweight or obese are the highest in east and north east London (Barking and Dagenham, Newham), whilst the picture is reversed in south west boroughs (Richmond, Kingston).

There has been minimal change in the proportion of children classed as overweight or obese in the ten years to 2017/18 across London and England as a whole – up by two per cent and one per cent respectively. However, some boroughs have seen more change. Redbridge (+6 per cent), Havering (+5 per cent) and Hillingdon (+5 per cent) saw the largest increases in the ten years to 2017/18. Wandsworth (-6 per cent), Kensington and Chelsea (-5 per cent) and Kingston (-5 per cent) saw the largest decreases over the same period.

Every child deserves a fair chance to grow up eating healthily. At present, though, this isn’t the case. London has the highest rates of childhood obesity — not just across the UK, but of any peer global city. From our work we see that food environments are key. Across London, young people are growing up in places saturated with cheap, unhealthy food. Messages to eat fast
food and convenience food seem to come at us everywhere we
turn. Income undoubtably matters. Where you grow up strongly influences your chances of being overweight and obese, and for families on the lowest incomes this correlation has only got stronger over time. It’s easy to put obesity into the ‘too difficult to solve’ box. However, though obesity is a complex problem, the solutions don’t have to be. What is most needed is creativity, a long-term approach and committed leadership.

Kieron Boyle, Chief Executive, Guy’s and St Thomas Charity |
@KieronJBoyle @GSTTCharity

Adult activity

London’s adults face fewer weight problems, but there is no difference in physical activity between the capital and the national average – and there has been no change in the last two years.

Regular physical activity has been found to be hugely beneficial to physical and mental health and wellbeing. In children it can improve learning and attainment. This is why the government sets targets for children and adults to be more active.

Using the Chief Medical Officer’s target of at least 150 minutes of moderate intensity physical activity per week, the same proportion of adults – 66 per cent – are classed as physically active in London and England as a whole in 2017/18.

Adults in east London are the least active, with fewer than half of Londoners in Newham, and Barking and Dagenham achieving the government recommended level of activity. Boroughs south and west of the capital fared a lot better, with many seeing activity levels above 70 per cent.

Activity levels were static across London and England over the two years to 2017/18. However, individual boroughs have seen some large fluctuations, with Hounslow (+18 per cent) and Sutton (-11 per cent) seeing the biggest changes.

While children tend to be active through play, for many adults physical activity involves formal sports participation or active travel (walking and cycling). Therefore transport connectivity can have a direct impact on people’s activity levels. With lower access to public transport in outer London, residents tend to rely on their cars to a much greater extent, and levels of active travel are lower. According to Transport for London data, the boroughs with the highest proportion of trips made by walking and cycling are City of London (54 per cent), Camden (51 per cent), Hackney (50 per cent) and Islington (49 per cent); while those with the lowest are Havering (22 per cent). Redbridge and Hillingdon (both at 23 per cent) and Bexley (24 per cent).

Physical activity can be particularly restricted for the 13 per cent of Londoners who have a disability, and more could have an impairment or long-term illness that limits their activity. While we lack sufficient data for London, across England people with a long-term limiting disability are twice as likely to be physically inactive (42 per cent) than those without a limiting disability (21 per cent).

Roundtable attendees pinpointed the need to design streets and places that are accessible for all, to enable disabled children and adults to participate in social and physical activities on equal terms.

London is changing but that change can’t come fast enough. The evidence is clear, and the reality is obvious to my colleagues working across London to redesign streets and help Londoners cycle and walk more – children in poorer parts of our city suffer most from the impact of car dependency. Obesity and poor mental health are often hidden but are serious problems. These issues can be attributed in part to how people travel around London and the impact those choices have on the communities they pass through. Streets designed for people, that promote active travel above private car use, generate economic, air quality and health benefits. But, most importantly, they support happier, healthier lives, demonstrated by the recent evidence from Waltham Forest showing life expectancy increasing following their street redesign, and a massive increase in social connections.

Matt Winfield, London Director, Sustrans | @mattwinfield2 @sustrans

Disabled people are half as likely as non-disabled people to
be physically active and they live shorter lives as a result. Our
experience shows cycling not only increases physical activity
levels amongst disabled people, but also social inclusion and
mental wellbeing. Solo, tandem, pedalled or handcranked,
cycling solutions exist, and truly, everyone can cycle. Many
disabled people find cycling easier than walking and use their
cycle as a mobility aid. But this concept isn’t widely understood, as our #MyCycleMyMobilityAid campaign shows. The cost of nonstandard cycles and inaccessible cycling infrastructure are also huge barriers. It’s time we radically rethink the way we represent cyclists and design for cycling, in order to make it inclusive for all.

Isabelle Clement, Director, Wheels for Wellbeing | @Wheels4Well

Childhood activity

Children’s physical activity levels in London are also similar to other English regions, and sports participation has declined slightly over the last few years.

We analysed data for children’s different levels of physical activity by age group and region from the Active Lives survey. In London, only 18 per cent of children in school Years 1-6 and 16 per cent of those in Years 7-11 are meeting the recommended daily 60 minutes of activity or more. Another 26 per cent in Year 1-6 and 27 per cent in Year 7-11 are active an average of 60 minutes or more a day but not every day. Comparing activity levels by region shows very slight variation. The Chief Medical Officer’s latest guidelines suggested children should achieve an average of 60 minutes per day across the week rather than every day. They also recommended children engage in a variety of types and intensities of activity, to develop a well-rounded picture of health.

Examining the proportion of children in school Years 1-11 that are less active (i.e. doing less than an average of 30 minutes of sport and physical activity a day) outside school provides further insight. While an average of 49 per cent of children in London are less active outside school, Havering, Lambeth and Camden have the lowest levels of inactivity, while Tower Hamlets, Newham and Hammersmith and Fulham have the highest.

While the Active Lives survey data is only available for 2017/18, data on sports participation (not available regionally) shows a gradual decline in participation over time, with a slight and short-lived uptick following the London 2012 Games.

Roundtable attendees discussed the challenges of getting older children, particularly girls after puberty, to undertake regular physical activity. Some argued that targets can make exercise seem like “another thing you are told you should
do”; instead parents and practitioners should aim to create a positive relationship with physical activity, as something that is pleasant and enjoyable.

Physical activity is a genuinely life-changing gift for people of
every age, from every background and in every part of London.
The benefits it brings, from increased physical and mental health to improved wellbeing and social connections are of enormous importance to people, and to the city as a whole. While London, seen from a macro perspective, has broadly positive levels of physical activity levels, what this report shows so clearly is that beneath the surface there are serious inequalities at play. With everything we know about the positive impacts of leading a physically active life, it is clear that raising activity levels for all Londoners will provide real benefit to local, regional and national policymakers across a host of issues.

Tove Okunniwa, Chief Executive, London Sport | @ToveOkunniwa

Obesity and physical activity: factors and policy context

Our analysis revealed some interesting anomalies. For both adults and children, there is no significant difference between London and the England average in terms of physical activity levels but adult Londoners are less likely to be overweight or obese, while children in London are more likely to be overweight or obese than in England as a whole.

Attendees at the roundtable highlighted the fact that, although we know activity has an impact on physical and mental wellbeing, there is currently no empirical evidence of impact of physical activity on reducing obesity.

Our analysis found there is a relatively strong correlation at borough level between weight problems, inactivity and in particular low levels of walking and cycling. For example, Barking and Dagenham, Havering, Newham and Sutton score relatively badly on all these indicators, while most central and southwest boroughs score relatively well. Some, like Haringey and Tower Hamlets, have relatively low levels of adult physical activity, but higher rates of active travel and lower obesity levels.

On the other hand, for children, we can see some similarity between physical inactivity and childhood weight problems for some boroughs, but the datasets are not directly comparable due to the different age brackets.

Diet is also a widely recognised factor in obesity. However, we lack the data to make the connections at the local level. Household expenditure data shows that Londoners spend more than any other region on fresh food and vegetables, and less on soft drinks, suggesting they may have better diets overall.

There is also national data that suggests diet differs by age. In 2017, only 29 per cent of adults across England were eating the recommended five portions of fruit and vegetables a day – averaging 3.8 portions per day. The problem gets worse with youth: 23 per cent of young people aged 16 to 24 eat their five a day, and only 18 per cent of children aged between 5 and 15 hit the target. 11 per cent of children eat less than one portion of fruit and vegetables a day. In addition, children seem to have a high sugar consumption, as sugary drinks account for 30 per cent of 4 to 10 year olds daily sugar intake. While this may explain some of the differences between adults and children, diet alone may not explain weight issues.

We also tested the correlation between boroughs with weight issues and those with high levels of poverty and large ethnic minority populations.

For adults, there was no clear correlation between obesity levels by borough, and either poverty or ethnic diversity. For children, however, there was a clear correlation between childhood weight issues and poverty, with more children classed as overweight or obese in areas of high deprivation (as measured by the 2019 Index of Multiple Deprivation), and fewer in more prosperous places.

Ethnic diversity was also a factor, and we know some ethnic groups are more at risk from obesity, while unhealthy diets and low levels of physical activity are of greater concern in other minority ethnic groups. Our analysis identified a similar correlation between the boroughs with high proportions of children classed as overweight and obese in 2017/18 and the areas with higher proportions of non-white residents (measured by the Annual Population Survey).

Therefore, adult obesity levels appear to be more associated with activity levels, and child obesity levels more linked to local socio-economic and ethnic make-up.

Roundtable attendees agreed that poverty and adverse experiences can harm children’s life chances. With food bank use skyrocketing – one emergency food provider, The Trussel Trust, gave out 166,512 food bank parcels given to Londoners in the past year – some argued obesity and diabetes were directly connected to childhood trauma, including hunger and homelessness. Other pointed to parents providing children with packed lunches making unhealthy choices.

What is being done about it?

All of national, London-level and local government have introduced various policy measures to try and address the obesity “epidemic”. For example, in April 2018, the government introduced a Soft Drinks Industry Levy to reduce people’s sugar consumption, and the revenue raised is being used to fund sports in primary school. Recent research has shown that taxing sugary snack could be a more effective measure to reduce levels of obesity.

At the London level, the Mayor banned junk food advertising on the public transport network in and established a Child Obesity Taskforce in 2018. Its recommendations espoused a “whole-systems approach”, including actions for central government, public health and education professionals, as well as the food industry and retailers. Its Ten Ambitions for London published last month set out their plan to halve London’s level of childhood obesity by 2030.

Local authorities have also taken action in some areas, for example banning fast food outlets in close proximity to schools – Barking and Dagenham was the first London borough to do so. Borough spend on public health also has an impact. Control over public health budgets was passed on to local authorities from 2014/15. While this has been hailed as a positive step, public health grant funding for local authorities across England fell by over £700 million in real terms between 2015/16 and 2019/2020, reducing resources for prevention, even though this can save money for NHS and social care services.

Roundtable attendees agreed that a whole-city multiagency approach was needed and pointed to Leeds as an example of a city, which has turned things around through the work of the Health and Wellbeing Board. The board introduced a scheme called Henry, which stands for Health, Exercise, Nutrition for the Really Young and is focused on supporting the youngest children and poorest families. It supports parents in setting boundaries for their children and taking a firm stance on issues from healthy eating to bedtimes. Over four years, obesity has dropped from 11.5 per cent to 10.5 per cent and the decline in Leeds is most marked among families living in the most deprived areas, where the problem is worst and hardest to tackle.

In London, the Healthy London Partnership, comprising the Mayor of London and GLA, London Councils, NHS England and Public Health England has made some important strides with the Child Obesity Task Force and recently launched the London Health and Care Vision, which aims to further strengthen joint working.

Healthy life expectancy

We are living longer, but as we age, long-term illnesses and disability can hamper quality of later life. In recent years, life expectancy and healthy life expectancy have risen in tandem.

While London is the most youthful city in England (with an average age of 35, compared to 40 in other regions), its population is ageing as people live longer. In the period 2015-2017, men in London had a life expectancy of 80 years at birth, whilst for women this figure was 84 years (compared to 79 for men and 83 for women across the UK). Over the same period, men could expect to live 79 per cent of their life in good health, and women 77 per cent (compared to 80 per cent for men and 77 per cent for women across the UK). Both life expectancy and healthy life expectancy increased by the same rate (two per cent for men and one per cent for women) between 2009-11 and 2015-17, meaning the proportion of life spent in good health remains static.

The proportion of life spent in good health varies between London boroughs (ranging from 73 per cent in Hackney to 86 per cent in Sutton for men; and from 69 per cent in Tower Hamlets to 84 per cent in Southwark for women). Some boroughs have relatively high life expectancy but a lower proportion of this is spent healthy – for instance, Kensington and Chelsea has average life expectancy for men of 83 years but only 75 per cent of this is spent healthy, while in other boroughs the reverse is true – for example, Barking and Dagenham has average life expectancy for men of 78 years but 81 per cent of this is spent healthy – meaning that the healthy life expectancy is almost identical in the two boroughs.

Some roundtable attendees highlighted that London-wide and borough comparisons may be masking bigger differences at ward level. While life expectancy had previously had consistent year-on-year improvements, there is now “an alarming trend” of life expectancy declining in some poorer areas outside the capital, and this may well be the case in some of London’s deprived communities

According to a composite measure of five ‘quality of life’ dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), Londoners aged 65 and over have a lower health-related quality of life than those in the surrounding regions (East Midlands, East of England, South West and South East) but better than the North (North East, North West).

This places pressure on social services, and this is likely to intensify. Institute for Public Care projections indicate that the number of older people needing support in London will grow by 50 per cent by 2035. Many families already provide informal care in helping elderly relatives with daily activities, such as washing, dressing or shopping for food. However, this in turn can place great demands on such carers, leading to physical and mental wellbeing issues of their own, including social isolation. It is estimated that eight in ten people caring for loved ones (unpaid carers) have felt lonely or socially isolated. How we should meet the cost of social care in the future is one of the biggest challenges for public finances.

Child mental health

Public awareness around mental health has increased in recent years, with conversations about the importance of good mental health entering the mainstream. But recording its prevalence has not been consistent. The limited data available suggest that London has the lowest rates of mental health issues among children.

There is no regular or consistent record of the prevalence of mental health disorders for children. The most comprehensive survey was carried out in three years: 1999, 2004 and 2017. Regional data is only available for 2017.

In 2017, London had the lowest prevalence of mental disorders (nine per cent compared to 15.6 per cent in the East of England and 12.8 per cent English average) among 5-19 year olds. Emotional disorders (such as depression, anxiety, phobias, post-traumatic stress disorder, obsessive compulsive disorder) were much more prevalent in London than behavioural disorders (such as oppositional defiant disorder and conduct disorders) – 6.5 and 1.7 per cent respectively.

Across England, there was some increase in the prevalence of emotional disorders among 5-15-year-olds, rising from 3.9 per cent in 2004 to 5.8 per cent in 2017. By contrast, behavioural disorders declined very slightly from 6.2 per cent to 5.5 per cent.

Comparing the 2017 English averages for 5-15 year-olds and for children and young people aged 5-19 reveals that behavioural disorders are more common among younger children, while emotional disorders are more common among older teenagers. Some research presents use of social media by young people – and the pressures it creates to present a certain public image – as one possible cause, whilst others suggest increasing exam pressure is to blame.

Several roundtable attendees observed that the data hides significantly higher levels of mental health issues among children and young people, as there is a high threshold for diagnosis and sub-threshold levels of anxiety “are through the roof”, especially for those living in precarious conditions, such as poverty and insecure housing. Some highlighted the need to catch mental health issues earlier and to focus on prevention and early intervention – particularly in a nonclinical setting. There was also a concern about how long it can take from referral to receiving support and that problems may be exacerbated by a transition of responsibility from child to adult mental health services upon turning 18.

There is no doubt that mental health is a growing priority for Londoners – as the stigma reduces, we now understand more about the scale of the challenge to promote good mental health and effectively support people with mental health problems. This data reminds us of the significant variation in prevalence across London, with a strong correlation to deprivation and social isolation. It also tells us that data quality in understanding mental health, especially children’s mental health, needs improvement. The solutions need to be both local and London wide with leadership from the Greater London Authority, Mayor of London, employers, and communities. Most importantly we must hear the voice of people with lived experience of mental health problems so their solutions can become our solutions.

Paul Farmer, Chief Executive, Mind | @paulfarmermind @MindCharity

Adult mental health

In contrast to children, adults in London suffer from higher prevalence of mental health issues than the English average.

A higher proportion of London adults (19 per cent) had common mental health disorders than the England average (17 per cent) in 2014 – the only year for which reliable data is available.

There was variation across boroughs, with inner east London boroughs having the highest prevalence and most outer London boroughs having the lowest.

Social isolation and loneliness are among the main factors affecting mental health. As Londoners tend to live away from extended family members, this is a particular issue in the capital. The recent comprehensive Survey of Londoners showed that, on average, eight per cent of Londoners feel lonely always or often. This decreases with income – 18 per cent of those with a pre-tax household income of £14,900 or less feel lonely often or always, as opposed to three per cent of those earning more than £58,900. Young people are more likely to feel lonely (12 per cent of 16-24 year-olds as opposed to six per cent of over 65s).

Other factors behind poor mental wellbeing are financial pressures, greater competition in the workplace and the general stresses of busy daily lives. Yet, Londoners are lucky in other respects. Access to green spaces has been proven to improve mental health. The capital was recently declared the world’s first National Park City, reflecting Londoners’ access to parks and other green spaces.

With growing awareness of mental health, however, comes increased pressure on services. A survey of NHS trust finance directors found that funding pressures have led to longer waiting times for people who need mental health treatment. Faced with these waits some patients are resorting to costly private practitioners, exacerbating inequalities in the quality of and access to mental health service.

Waiting times from referral to treatment

Waiting times are growing across the NHS for both London and nationally.

Average waiting times from referral to starting consultantled treatment in London have increased from eight weeks in Q2 2013 to nearly 11 weeks in Q2 2019 – going from slightly below the national average to slightly above it.

Both the previous government and the current prime minister have pledged additional funding for the NHS. However, health services in London (and much of the rest of the country) remain under financial pressure, with significant overspend that has built up over time. To help address this, a group of London clinical commissioning groups have controversially urged GPs to manage demand for hospital referrals where this may not be required and find alternative ways of dealing with patients’ needs – which sparked concerns that this may be rolled out more widely.

In addition, workforce shortages remain an issue, particularly for nurses. The Interim NHS People Plan for England, published in June, acknowledged the problem and identified the shortage of nurses as the most urgent staffing challenge facing the health service. The Plan proposed increasing the number of student nurses and reducing the drop-out rate to increase the supply of new trainees. However, roundtable attendees highlighted concerns that the removal of bursaries in 2017 has resulted in big drops of applications to study nursing, and NHS senior managers have called for better incentives for trainees. Some are also concerned about the ability to recruit staff from overseas after Brexit.

Meeting government targets on waiting times continues to be a major challenge for the NHS in London and elsewhere. There’s been progress on some measures, but the overall number of people waiting for planned care is still rising. What’s changed, however, is the balance of factors responsible. Rather than funding, the main constraint now is the availability of trained staff. With nearly 40,000 vacant nursing posts across England and more than 9,000 vacant medical posts, meeting rising demand for care will continue to be difficult even as the financial outlook for the NHS begins to improve.

Chris Naylor, Senior Fellow in Health Policy, The King’s Fund | @chrisbnaylor @TheKingsFund

Delayed discharge

Total days of delay have been declining over the long-term – perhaps reflecting efficiencies implemented.

Delayed transfers of care measure the number of days of delay in discharging patients who are occupying a bed and ready for discharge – but require further arrangements to be made for follow-up health or social care (or both). These delayed transfers are unhelpful for patients, and also add to pressure on scarce NHS resources.

In the quarter to June 2019, delays attributed to the NHS declined by two per cent, while delays attributed to social care remained static, compared to the previous year. The NHS remains responsible for the most delayed transfers of care.

All London boroughs have their own statutory Health and Wellbeing Board, an outcome of the Health and Social Care Act 2012 – tasked with enhancing integration between bodies, though lack formal decision-making powers.

Air pollution

Air pollution has been declining – and has now dropped below legal limits – but it still poses major public health concerns.

In addition to personal choices and healthcare provision, there are external factors that affect people’s health and wellbeing. One of the most critical in London is air pollution. Two million people in London are living with illegal air pollution, according to the most recent data. Roadside air pollution –generated mainly by vehicles on the roads – has been a particular concern in London, as many areas have greatly and consistently exceeded legal limits set for the concentration of the main pollutants.

In April 2019, the Ultra Low Emission Zone (ULEZ) came into effect – penalising the most polluting vehicles entering central London. Recent analysis showed the measure has reduced the number of polluting vehicles by a third. This seems to have had a palpable impact, with all the main pollutants dipping below the legal limit in June 2019. NO2 pollution had a particular improvement – its concentration in July 2019 was 20 per cent lower than the same month last year.

However, we know that there are seasonal variations, with concentrations lower in the summer than they are in colder months. Winter will be a real test of policy interventions and the impact of a move to cleaner vehicles that the ULEZ has encouraged.

In addition, measurement of pollutant concentrations as an average across London may be deceptive, and many of the areas most affected remain outside the ULEZ boundary. In fact, as with obesity, deprivation and ethnic background determine exposure to air pollution. It has been demonstrated that Londoners from low income and non-white backgrounds are disproportionately affected, as they are less likely to own a vehicle and are more likely to live in areas of high pollutant concentrations. In addition, young children suffer disproportionately from the health consequences associated with poor air quality – including respiratory and cardiovascular conditions. Prior to the introduction of the ULEZ, more than 400 London schools were in areas exceeding legal limits for NO2. This number may now have reduced but it may not be until the ULEZ extension to the North and South Circular Roads planned for 2021 that we see more widespread benefits.

London’s polluted air is unsafe for everyone. Toxic air can increase the risk of developing lung cancer and stunt the growth of children’s lungs – leaving them vulnerable to a lifetime of health problems. Evidence shows charging zones for polluting vehicles are the quickest way to clean up polluted air in urban areas. London’s Ultra Low Emissions Zone (ULEZ) is a great example of this and has already delivered significant results in a short time. Every London borough has unsafe levels of air pollution. We need to see the ULEZ expanded across Greater London so everyone living, visiting, working and growing up in the UK’s capital can breathe clean, healthy air.

Sarah MacFadyen, Head of Policy and Public Affairs, British Lung
Foundation | @smacfadyen11 @lunguk

Global heath will increasingly be determined by cities. Today, over half of the world’s population live in cities and by 2050 this will increase to two thirds. Whilst London, like other cities, has some of the best health and healthcare, as demonstrated by this report, they also have a disproportionate share of the worst. This is a social injustice and unacceptable. London is leading the way internationally with initiatives such as the Ultra Low Emission Zone – which is already showing a positive impact. Partners across London must continue to work together, at pace, to reduce inequalities and improve the health of all Londoners.

Shaun Danielli, Director, Healthy London Partnership | @shaundanielli @HealthyLDN