Embedding health in London boroughs

In April 2013, public health was transferred to local authorities under the Health and Social Care Act, 2012. Until then, public health in England and Wales was managed by the NHS, which had taken over responsibility for measures previously administered by local authorities in 1974.

The government saw local authorities as better placed to deliver many of the services which had been previously run by the NHS, because of their strong local knowledge and ability to affect a wide range of influences on health, such as transport, built environment, and licensing.

Government thinking was influenced by the 2010 Marmot Review into health inequalities in England, which established that wide inequality in health exists (both physical and mental), and that this is largely preventable. The review set out actions required across range of social determinants, with emphasis on early intervention and importance of social factors. Marmot identified local authorities as best placed to intervene.

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On Wednesday, 26 March, Future of London kicked off the first in our Delivering Public Health seminar series, kindly hosted by Arup. At the Embedding health in London boroughs session, we heard from a range of stakeholders on how boroughs have been adapting to their new public health responsibilities, and what options are available to them to deliver improvements.

Although London is not unique among British cities, the scale of the challenge here is daunting. With only 50% of Londoners meeting the bare minimum of 150 minutes of physical activity per week, we are seeing increases in related health issues, such as diabetes and childhood obesity. But the picture isn’t all bad. Dr Ruth Wallis, Joint Director of Public Health for Lambeth and Southwark, noted that teenage pregnancies were decreasing, along with instances of respiratory disease, liver disease, and smoking.

When public health funding was transferred in 2013, it was ring-fenced for a year. With this period now coming to an end, and with local authorities under continuing pressure to reduce spending, practitioners are expecting to see their funding cut in line with other departments. In light of this, public health departments are exploring how to deliver better services with fewer resources.

One way this has been addressed is through shared services – for example Lambeth and Southwark’s joint public health services, and interlinked priorities. Helen Macfarlane, of social enterprise Turning Point, highlighted how public health interventions can be effective at reducing costs in other areas, such as social care. Enabling people to be physically active and healthy in their daily lives prevents many illnesses later in life which cost more to treat and put a greater strain on healthcare facilities.

Focusing on built environment interventions could also open up the possibility of developer contributions to fund healthy lifestyle infrastructure such as green spaces. Anna Scott-Marshall outlined RIBA’s position that local authorities should develop Healthy Infrastructure Action Plans, which could be integrated into Local Plans and therefore be funded through CIL contributions. RIBA’s proposals are outlined in more detail in their report, City Health Check: How design can save lives and money.

All speakers reflected on the tendency for public health strategies to be evidence-based, and on the need for long-term strategies to produce results, both of which can be at odds with desires for short-term return on investment and with political cycles. Speakers also mentioned the difficulty in funding measures which have low public profile but which can deliver significant benefits over time, such as early engagement in promoting healthy lifestyles.

Boroughs in part assumed responsibility for public health because of their ability to intervene in a wide range of policy areas, which is appropriate, given health’s multiple determining factors. It was clear that the built environment can play a large role in promoting healthy lifestyles and reducing the burden on the health service. Lucy Saunders, a public health specialist working for the GLA and TfL, noted that of the 68 indicators on which boroughs’ performance will be measured, half were in some way related to transport or the public realm.

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Image taken from TfL’s ‘Improving the health of Londoners’ report

With this in mind, it is clear that to be effective, public health departments need to be able to establish good working relationships with other departments as well as continuing to work with the NHS. TfL’s report, Improving the health of Londoners [PDF], was developed with this in mind, to act as a template for how public health professionals can integrate their work with other departments to make effective interventions in promoting healthy lifestyles. Saunders invited local authorities and health and housing providers to take advantage of the extensive research done for the report, and ‘cut-and-paste’ rather than having to spend on new work.

While the involvement of more agencies opens up possibilities for creative approaches to tackling health problems, it can also make delivery more complex. Good governance and a flexible approach are therefore essential. This flexibility was exemplified by TfL’s whole-street approach and Turning Point’s person-centred approach, both of which look at implementing changes based on local context, rather than taking a one-size-fits-all approach.


The seminar speakers were:

  • Dr Ruth Wallis, Director of Public Health for Lambeth & Southwark
  • Anna Scott-Marshall, Head of External Affairs, RIBA
  • Lucy Saunders FFPH, Public Health Specialist – Transport & Public Realm, GLA and TfL
  • Helen Macfarlane, Acting Head of Research, Community Engagement and Co-production, Turning Point

The session was chaired by Lisa Taylor, Director, Future of London.

The seminar was kindly hosted by:

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Presentations and audio:

Dr Ruth Wallis:  podcast
Anna Scott-Marshall: podcast
Lucy Saunders: podcast
Helen Macfarlane: podcast