Independent report

Executive summary and recommendations

Published 12 December 2024

Applies to England

Foreword

Cities provide remarkable places for people to live, work, enjoy cultural and leisure activities and study. A high proportion of the English population live in cities throughout their lives while others come to cities early in their adult lives for work or study before moving out, often after they start a family. The health of our cities is therefore very important for the health of the nation.

Cities have a number of unique qualities from a health perspective. They are home to an extensive variety of often distinct communities living very close together. This includes wide ranges of poverty and affluence, ethnic mix and cultural experience all living within short distances. Populations are generally younger than rural areas with favourable ‘old-age support ratios’ stretching into the predictable future. They tend to be home to the large teaching hospitals and other areas of health and scientific specialisation. Distances between families and healthcare are often short, at least geographically, making provision of health and social care services practically easier. It is possible to find almost every interest catered for in a large city within easy access at least for those with limited disabilities; it is also possible to be very alone with no one noticing. It was striking in getting evidence for this report that many cities feel like a conglomeration of multiple villages next door to one another and with each community often not engaged in the health challenges of the neighbouring communities.

Although affluence and poverty are more likely to be side by side in cities than in other environments, deprivation is often concentrated in specific areas within our great cities with the inevitable concentration of diseases of poverty. Ethnic minority populations, and in particular new arrivals, are much more likely to be in cities than in the country as a whole and their needs must be anticipated. Some risks to health, such as outdoor air pollution, are especially problematic in cities, and space for physical exercise and mental relaxation can be difficult to find relative to less crowded areas where the cost of land is lower, and must be protected, especially in areas of deprivation.

This Chief Medical Officer (CMO) annual report examines the health of our major cities. It looks at the issues affecting the largest cities in the UK and addresses some specific challenges for health seen in cities. Cities provide some of the biggest challenges to health; they also provide some of the widest variety of potential opportunities.

For individual citizens living in cities there is a challenge both to optimise our own and our families’ health, and the health of our neighbours. While cities provide multiple opportunities they also make it easy, and often the default, to live a life that is almost entirely sedentary with a diet that is guaranteed to reduce the period living in good health. It is arguably easier to forget the negative effects of our actions on our neighbours, for example in increasing air pollution, in the relative anonymity of a city.

For policymakers in local and central government it is important to support your first instinct to be brave in support of the health of children and vulnerable people now and in the future. It is possible to design cities in such a way that they enhance health through decisions on transport, housing, schooling, food policy, licencing and pollution. The evidence base is there to achieve this. None of these come without some cost in money or political capital but given the density of the population and the degree of need, the impact of pro-health decisions can be substantial and usually long lasting. Those who oppose specific evidence-based solutions should feel a responsibility to say what they would do instead to preserve the health of their fellow citizens.

For the NHS and delivery of public health interventions we may fail because the variety of communities and the very marked concentration of deprivation and consequent ill health in specific parts of cities is not sufficiently reflected in planning. Spreading the jam evenly (often the easiest way to deliver services) will not get the most effective or efficient outcomes when the potentially avoidable ill health in cities is so heavily concentrated in particular localities and communities.

Cities provide more varied problems, and a wider range of potential solutions because of their scale, size and degree of specialisation. This report explores both, with examples from many of England’s cities. I am very grateful to the many authors from around the country and those who contributed to this report, and in particular, Dr Hannes Hagson and Dr Nileema Patel.

Professor Chris Whitty

Chief Medical Officer for England

Executive summary

Health in cities in England

This report is on the health of cities in England. Cities have no exact definition for health purposes, but there are distinct patterns of populations and health in our large built-up areas (BUAs) which differ from those of smaller towns and more rural areas. Cities are younger, more diverse and offer a wealth of resources, from culture to commerce to specialist healthcare, which can promote good health and wellbeing. They can also have high concentrations of deprivation and poverty, often very close to areas of affluence, with the health effects of deprivation being very apparent.

The following paragraphs highlight challenges and opportunities for improving health in cities.

1. Cities are younger than rural areas and smaller towns

This was explored in part in last year’s CMO annual report on health in an ageing society. This means that cities have an advantage in terms of having a large working-age population, and should be better placed to support the ageing population as ‘old age support ratios’ are favourable and likely to remain so for the foreseeable future. However, the population of cities is ageing too, although at a slower rate than rural areas, and maintaining and improving health as we age presents different challenges and opportunities for older people in cities compared to more peripheral areas. A high proportion of the ageing population lives in cities, given the large number living there, so this needs policy focus.

Figure 1, below, shows a population pyramid of all major BUAs, excluding London, and demonstrates a relatively young population with a peak in those aged 20 to 24 years.

Figure 1: population pyramid of all major built-up areas (BUAs) in England (population 200,000 plus, excluding London)

Data source: Office for National Statistics (ONS), Towns and cities, characteristics of built-up areas, England and Wales: Census 2021 and Coastal communities, characteristics of built-up areas, England and Wales: Census 2021.

Figure 2, below, shows a population pyramid of large and medium BUAs. This pyramid is relatively rectangular, with similar proportions of people in each age band until tailing off in older age bands starting at circa age 64 years.

Figure 2: population pyramid of all large and medium BUAs in England (population 20,000 to 199,999)

Data source: ONS, Towns and cities, characteristics of built-up areas, England and Wales: Census 2021 and Coastal communities, characteristics of built-up areas, England and Wales: Census 2021.

Figure 3, below, shows a population pyramid of small and minor BUAs. This pyramid is relatively rectangular, with a bulge in older ages, demonstrating an older population structure.

Figure 3: population pyramid of all small and minor BUAs in England (population 0 to 19,999)

Data source: ONS, Towns and cities, characteristics of built-up areas, England and Wales: Census 2021 and Coastal communities, characteristics of built-up areas, England and Wales: Census 2021.

2. Cities are often places of high degrees of mixing and churn

They are often areas where people migrate to as young adults, for work or study or other reasons, and subsequently may move out of in later life. People living in cities may move several times within cities, especially in their early adult lives. Many interventions such as screening or immunisation are harder to maintain in such mobile populations and rates of take-up of immunisation, screening and other public health interventions are often lower than in the rest of the country.

Figure 4, below, is a map showing coverage of MMR1 vaccine measured at 24 months of age in England for quarter 1 2024 to 2025 by upper tier local authority. It shows that 19 of the lowest 20 local authorities for uptake of MMR1 are located in cities; 14 are in London.

Figure 4: coverage of MMR1 vaccine measured at 24 months of age in England for quarter 1 2024 to 2025 by upper tier local authority

Data source: ONS licensed under the Open Government Licence c.3.0. Contains OS data © Crown copyright and database right 2024. Image via UK Health Security Agency (UKHSA), Quarterly vaccination coverage statistics for children aged up to 5 years in the UK (COVER programme): April to June 2024.

3. Deprivation and poverty, while existing across both rural and urban areas, is highly concentrated in cities

This means that there are neighbourhoods and areas of cities with entrenched and longstanding deprivation where tens of thousands of residents live with limited access to those things which make us healthy, such as good housing, education and work. The risk factors for ill health, such as smoking and living with obesity, are also often concentrated in urban deprived areas. These combine to reduce life expectancy and years lived in good health in those neighbourhoods. While this is true in deprived rural areas, the concentration of people in our large cities means that the absolute numbers of people living in the most deprived areas of the country can be in the tens of thousands in just one small neighbourhood.

Figure 5 demonstrates just how concentrated deprivation is in our large cities, with over a quarter of residents in major built-up areas (BUAs) in England living in the 10% most deprived areas. This concentration brings challenges for health improvement and health protection, but also opportunities as the areas to concentrate most on because they have the worst health outcomes in high density.

Figure 5, below, is a grouped bar chart showing the percentage of population by BUA category and IMD decile. It shows the general trend that the larger the BUA category, the higher percentage of people in the most deprived areas, with 27.8% of those in major BUAs living in the most deprived decile. London stands out as having only 2.1% in the most deprived decile, but otherwise also has higher proportions of population in the more deprived areas compared with smaller BUAs.

Figure 5: percentage of population by BUA category and indices of multiple deprivation (IMD) decile

Data source: ONS, Health inequalities by built-up area and ethnic group, England: March 2021 to May 2023.

The association between deprivation and poorer health outcomes can be seen in figure 6. This demonstrates the gains in health which could be made by reducing the health effects of city deprivation. It is noteworthy that London, the UK’s wealthiest city, shows significantly lower mortality rates than the other built-up areas, particularly in the more deprived deciles.

Figure 6, below, is a grouped bar chart showing age-standardised all-cause mortality rates (per 100,000 person-years) by IMD decile and BUA category. It demonstrates that mortality rates are higher the more deprived IMD decile, and also that London has lower mortality rates than other BUA categories for each deprivation decile. The highest rates by IMD decile tend to be in medium and large BUAs.

Figure 6: age standardised all-cause mortality rates by IMD decile and BUA category (per 100,000 person years)

Data source: ONS, Health inequalities by built-up area and ethnic group, England: March 2021 to May 2023.

4. Cities benefit by having highly ethnically diverse populations

Ethnic diversity in England is country-wide but is much more highly concentrated in cities. People from ethnic minority backgrounds often experience particular health inequalities. Most, but not all, ethnic minority groups suffer on average less good health than the white majority population. This can have many causes including genetic pre-disposition (for example, sickle cell disease) and societal factors, but it can often be largely caused by the relatively higher concentration of deprivation in which many ethnic minority citizens in cities live. Some major diseases more common in some ethnic minority groups have genetic, social and deprivation components – an example might be Type 2 diabetes.

Teasing these apart can be difficult but is important for planning public health interventions and NHS services in cities, which need to serve the many communities cities contain.

Figure 7, below, is a horizontal grouped bar chart showing the percentage of total population in different BUA categories by ethnic group (excluding White British). It shows the general trend that larger BUAs have a higher degree of ethnic diversity, with London standing out as having greater ethnic diversity than other areas. The only ethnic group with a larger percentage in an other BUA category is Pakistani ethnic group in major BUAs.

Figure 7: percentage of total population in different BUA categories by ethnic group (excluding White British)

Data source: ONS, Health inequalities by built-up area and ethnic group, England: March 2021 to May 2023.

5. Cities are unique in their high concentration of buildings, including for accommodation

This presents challenges in terms of access to good housing, green spaces, and a pollution-free environment. Improving the built environment in cities presents an opportunity to significantly improve health for millions of people.

6. The effects of air pollution are mostly faced in large urban areas, in particular, cities

Transport and space heating are areas that need particular action to reduce air pollution.

Figures 8a and 8b, below, are annual air quality maps of mean NO2 and mean PM2.5 over Birmingham for 2021. They show concentrations of NO2 and PM2.5 pollution over more central areas and along major roads.

Figure 8a: annual air quality map of mean NO2 over Birmingham for 2021

Figure 8b: annual air quality map of mean PM over Birmingham for 2021

Data source (8a and 8b): Zhong, J, and others^{[footnote 1]}, as part of the West Midlands Air Quality Improvement (WM-Air) programme.

7. Physical activity is one of the best ways to preserve health

Cities provide both difficulties and opportunities for citizens to build exercise and physical activity into their daily lives. Cities should be ideal places for enabling active travel with shorter distances to the things we need or want on a regular basis, including supermarkets, places of leisure, work or healthcare. Making walking and cycling more practical and safer, and access to green space easier and more equitable, would go a long way toward removing barriers to improving physical activity levels and could significantly improve the health of England’s increasingly urban population. Green space and sporting facilities are at a premium, but transport to them is usually good in comparison to rural areas. Areas of deprivation are often poorly served both for active transport and for sporting facilities.

8. The food and outdoor leisure environment in cities varies between areas of affluence and deprivation

It is often varied and exciting in areas of affluence, but frequently detrimental to public health in areas of deprivation, with a heavy concentration of fast food outlets concentrating on a limited range of products high in fat, sugar and salt, a high density of advertising of unhealthy foods and limited shopping opportunities. While the food system in cities is very complex, this provides an opportunity to improve the health of city populations by enabling better access to healthy food.

Figure 9, below, is an infographic showing the food system. It shows a circle highlighting the following stages: grow and produce, process, transform and package, distribute, sell and purchase, prepare and eat, and waste, recycle and compost.

Figure 9: the food system

Data source: Birmingham City Council Public Health. Birmingham Food Systems Strategy 2022 to 2030.

9. Higher and further education students are largely based in cities

This population needs specific consideration in preserving physical and mental health, due to their transient nature in the area and in some cases relative social isolation.

10. Rough sleeping numbers are highest in cities, especially London

Though absolute numbers are small, people who have to sleep rough face specific challenges in terms of their complex health and social needs.

11. The infectious disease risks in cities are different from those in less highly concentrated areas

The close nature of city living makes respiratory infections and other infections of more crowded environments more likely. The high concentration of young adults leads to a concentration of sexually transmitted infections. As mentioned earlier, vaccination rates are also lower in city populations.

Figure 10, below, is a line graph showing laboratory confirmed cases of measles by week of onset of rash or symptoms reported, in London, West Midlands and England, 1 January 2024 to 21 October 2024. It shows an increase and subsequent decrease in measles cases in London and England from 1 January 2024 to 21 October 2024. In West Midlands it starts at a high level and tails off with time.

Figure 10: laboratory confirmed cases of measles by week of onset of rash or symptoms reported, London, West Midlands and England: 1 January 2024 to 21 October 2024

Data source: UK Health Security Agency (UKHSA), Confirmed cases of measles in England by month, age, region and upper-tier local authority: 2024.

12. Cities are often a patchwork of much smaller, distinct communities with strong internal links and support but relatively little interaction with other communities in quite close proximity

This is both a strength because social movements, services and the voluntary sector are often highly engaged in these communities, and a weakness because provision of health and social care services can often feel fragmented and less than the sum of its parts. Health services need to adapt to this reality and not treat a city as a single entity, though still need to function as a cohesive whole.

13. The way the NHS operates in cities is often quite different to smaller towns and rural areas

There may be easier access to specialist services in major hospitals and A&E may more frequently be the first port of call rather than general practice, especially for newer and more transient individuals in certain circumstances.

Recommendations

Overall recommendations

Breaking entrenched deprivation in cities will take a long time, but well-evidenced actions can be taken now to improve health and wellbeing for people living, working and studying in cities. Deprivation is highly concentrated in specific parts of cities. This affects millions of people in England and can lead to worse health and wellbeing. This impacts individuals and society as a whole, with higher health and care costs and lower productivity. National and local government should undertake co-ordinated and concerted efforts to break the cycle of ill health in those areas of cities where it has become entrenched. Concentrating prevention efforts and resources in these areas and adapting to their local communities is likely to be both more efficient and more effective than spreading a uniform service thinly over entire cities.

High smoking rates, obesity prevalence, air pollution, excess alcohol and lack of access to physical activity are more common in areas of high deprivation. Government, both national and local, as well as the NHS, should consider further targeted interventions to improve these well-known risk factors in concentrated urban areas and direct resources in order to do so. Tackling these risk factors is not alone sufficient to remove the stark inequalities in health seen in our cities, but failing to do so because the choices seem difficult is to condemn many people living in deprivation to shorter lives constrained by ill health.

Maintaining good health for the longest possible time can be harder in cities and should be seen as a major priority. In contrast to more rural areas the age-support ratio will remain reasonably stable in cities over coming decades, but the barriers to maintaining health of those ageing in cities can be high. Cities are better at providing curative than preventive services for older citizens. Action to remove barriers and maintain good health for older people in cities can include having age-friendly accommodation and ensuring practical access to places maintaining physical activity and social engagement for those with predictable mobility and sensory impairment of older age.

Cities are areas of high ethnic diversity. Both prevention and curative services need to reflect that. Measures to improve the sustained involvement of local communities in finding culturally competent solutions to local issues are essential. Steady, prolonged engagement rather than stop-start initiatives is key to maximising the chances of effective health improvement.

Specific recommendations

There are specific recommendations throughout this report, but here I highlight 4 important areas that can and should be improved.

The food environment in parts of cities entrenches inequalities in health and promotes obesity

Healthy food deserts combine with junk food advertising to set children and adults up to live a shorter and unhealthier life through obesity and the diseases it causes, particularly in the more deprived areas of our cities. Changes will need to be tailored to local needs and food choices.

To reduce air pollution, transport emissions, including from public transport and space heating (especially solid fuel burners), need particular action specific to cities

Air pollution is a particular risk in cities where the greatest levels of pollution are combined with the highest concentrations of people. It causes significant lung and cardiovascular disease. Many mayors and city authorities have proposed sensible steps to reduce them; those who oppose these should say what they would do to improve air quality instead.

Healthcare service planning and delivery should consider the needs of young adults in cities

The health needs of young adults are concentrated in cities and are often overlooked. Mental health issues generally emerge by or in early adulthood, and current increases in mental health needs for already stretched mental health services therefore fall disproportionately in cities. Similarly, increasing rates of sexually transmitted infections (STIs) and the weakened provision of STI services is particularly a city problem.

We need to account for, and explore solutions to, the itinerant nature of city populations in providing routine immunisation and screening services

Steady engagement with communities with historically lower uptake is also essential. The relatively poor, and falling, rates of routine immunisation and screening in our cities deprive their citizens of effective tools which could prevent major diseases. This needs action.

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1. Zhong, J, and others. Using task farming to optimise a street-scale resolution air quality model of the West Midlands (UK), Atmosphere 2019: volume 12, issue 8, page 983. (This is an open access article distributed under the Creative Commons Attribution License). ↩