Health Inequalities Strategy Implementation Plan 2021-24

Stark health inequalities continue to blight the lives of many Londoners. At a basic level, this means some groups die much earlier and spend more of their life in ill health than others. This does not happen by chance. These health inequalities result from a range of social, economic and environment factors largely beyond people’s individual control. This is unjust and unfair. However, they are not inevitable and can be reversed. The London Health Inequalities Strategy (HIS) vision is that all Londoners should have the opportunity to live a long life, in good health.

This HIS implementation plan details what actions the Mayor and partners will take to tackle these inequalities over the next few years. The five aims of the HIS remain the core framework for action. This plan also reflects the priorities emerging from the COVID-19 pandemic, including those highlighted through the London Recovery Programme.

COVID-19, far from being ‘the great leveller’, has ruthlessly exposed existing health inequalities and in many cases made them worse. It has shown with devastating effect how the different circumstances of our lives can affect our chances of poor health. COVID-19 has disproportionately impacted London’s Black and Asian communities, disabled people, older people and Londoners living on lower incomes. These groups were more exposed to it through their work and living circumstances. They also suffered higher hospitalisation and death rates from the virus, and consequently more bereavement.

The pandemic affected people’s lives in different ways, depending on their circumstances. It exacerbated existing challenges, such as low income and poor housing. Health and wellbeing declined through spending lockdown in overcrowded housing, experiencing greater social isolation which affected mental health, or being subjected to domestic violence or abuse. Difficulties accessing health and care services may have been compounded by digital exclusion. For young people, missed education, increasing income inequity, and increased loneliness will have impacted on their mental health and wellbeing, and may have contributed to their vulnerability to violence and worsened their life chances overall.

Following extensive community engagement during the pandemic response and in planning for recovery, two overriding themes have emerged. The first is structural racism and a lack of trust and confidence in public services. The second is the many and varied challenges linked to income inequality and poverty. In addition, the vital role played by the Faith, Voluntary and Community sector showed the value of working with communities to develop solutions. Co-produced activities with trusted community leaders meant clearer, more appropriate messages reaching communities and supporting them to take action.

Being united by a clear, common purpose meant that the Mayor, London Councils, the NHS and other partners came together to work in new ways. The focus was on community need and removing unnecessary barriers or bureaucracy. Partners want to build on this experience and not revert to ‘business as usual’.

Early on, all recognised the need to start work on London’s recovery. The London Recovery Board first met in July 2020, with the aim to make London greener, safer and fairer than ever before. It oversees action through nine missions, all of which have potential to make a difference to health inequalities. Chaired by the Mayor and London Councils, Board members include the NHS, boroughs, business groups, community leaders and equality groups. Through a London charter, many members have committed to use their procurement and employment practices to boost jobs and opportunities for young people. Equality, diversity and inclusion as well as health inequalities are integral to the board’s work. The Addressing Structural Inequalities Recovery Sub-Group will publish an action plan in early in 2022.

This Implementation plan closely aligns with London’s recovery plans and the London Health and Care Partnership’s Vision to be the healthiest global city. It sets out action that the Mayor will push forward through the GLA Group and, working with partners. The Mayor has identified six key commitments with clear and measurable goals:

1. Healthy Children: Up to 50 School Superzones supported by 2025 – Healthy Place, Healthy Weight Mission (new)
2. Healthy Minds: By 2025, London will have a quarter of a million wellbeing ambassadors, supporting Londoners where they live, work and play – Mental Health and Wellbeing Mission (new)
3. Healthy Places (1): London will be a net zero carbon city by 2030 and will have the cleanest air of any major world city, meeting legal and health requirements by 2050. In the interim, we want to be on a path to zero pollution, meeting the WHO's interim target for PM2.5 (10ug/m3) by 2030. (continuation)
4. Healthy Places (2): The Mayor will lead the campaign to make London a Living Wage City, targeting accreditation of an additional 1,600 employers, lifting at least 48,000 people onto the real Living Wage and putting £635m in Londoners’ pay packets by 2024. (new)
5. Healthy Communities: Ethnic inequalities – TBC - awaiting the outcomes of the London Recovery Board Addressing structural inequalities programme – (new)
6. Healthy Living: By 2041, all Londoners will do at least 20 minutes of active travel each day (for example, walking, cycling) to stay healthy – (continuation)

The Implementation Plan provides a framework of priorities for London that support and encourage action across the city. Most work to tackle health inequalities takes place locally, in neighbourhoods and at borough level. This plan and supporting documents provide a snapshot of the extensive activity seen across the city.

The Mayor and partners, through the London Health Board (LHB), will continue to oversee and direct the city-level partnership work. In 2020, LHB established the Health Equity Group. Co-chaired by the Regional Director of Public Health and Chief Executive of London Councils’ Health and Social Care Lead, it brings together specialist expertise and community insight to advise and steer action, particularly to address the disproportionate impacts of COVID-19. The GLA’s Health and Wellbeing Team will support partners to share and celebrate good practice, consider shared challenges and develop new ways forward.

The scale of the health inequalities challenge can be daunting. However, the pandemic has shown what is possible when we work together and harness the power of communities, as well as what we still need do. Everyone has a role to play and together we can make a difference.

Sitting alongside this plan are:

• Overview of Mayoral and partnership commitments.
• Data summary
• Examples of local action to tackle health inequalities.

Our health is fundamental to us all. It can affect our wellbeing, our relationships, our ability to study, work and more. The London Health Inequalities Strategy (HIS) envisions that all Londoners should have the opportunity to live a long life, in good health. It focuses on addressing the avoidable, unfair and systemic differences in health between different groups of people. These are health inequalities. The pandemic has highlighted the urgency of this priority for the Mayor and London Health and Care Partnership.

Our life circumstances — the conditions we are born, grow, live, work and age in — affect our chance of having a long, healthy life. Factors like our income, housing, jobs, education, relationships, access to green spaces and air quality all impact on our health. These are the “causes of the causes” of poor health – also called the wider determinants of health. It is how these factors are distributed across different groups of people that lead to health inequalities.

London’s health inequalities have been stark for decades. It is a city of great wealth and great poverty. Despite our best efforts, little progress has been made in narrowing the gap in health outcomes between different groups of Londoners. The time for levelling up health in London is now.

The Mayor and partners are striving to make London a heathier, fairer city, where nobody’s health suffers because of who they are, where they live, or what job they do. The pandemic has shown that to make a difference requires working together at all levels - neighbourhood, borough, sub-region, London-wide and nationally. This involves all sectors, including the NHS, local authorities, the public health community, businesses, education, faith groups and voluntary and community sector.

In 2019 the London Health and Care Partnership published the London Health and Care Vision. The aim is to make our capital the healthiest global city and the best in which to receive health and care services. Partners work together to address shared challenges and priority issues that need pan-London action. Our guiding principle is subsidiarity – this means that decision and actions are taken as close to community level as possible. This approach builds on the unique opportunities and strengths at the neighbourhood, borough and sub-regional levels.

Health inequalities are a golden thread running throughout the London Health and Care Vision. The HIS reinforces partnership across the health and care system’s Londonwide priorities. We are now refreshing the London Vision in the light of the pandemic, with an update planned for early 2022.

This new HIS implementation plan describes what the Mayor and partners commit to do over the next few years as we emerge from the pandemic. These actions will support London’s recovery and tackle health inequalities. The five aims of the HIS - on healthy children, healthy minds, healthy places, healthy communities and healthy living - remain the core framework. This implementation plan is informed by the experience of the pandemic and new pan-London commitments developed in response, including those of the London Recovery Programme.

This plan this plan cannot possiblly do justice to or detail the huge range of work happening now and each day by people and organisations across London. Rather, it seeks to reflect and harness the collective efforts of our statutory, voluntary and community sector organisations. The focus is on key commitments where working together will lead to greater impact. Progress on these commitments will be overseen and reported to the London Health Board.

Healthy Children

Every London Child has a healthy start in life

Healthy Minds

All Londoners share a city with the best mental health in the world

Healthy Places

All Londoners benefit from an environment and economy that promote good mental and physical health

Healthy Communities

London's diverse communities are healthy and thriving

Healthy Living

The Healthy Choice is the easy choice for all Londoners

The 2018 HIS is a ten-year strategy for tackling health inequalities in London. It was informed by a strong evidence base on what matters and what works and was developed in consultation with partners and stakeholders across the city. An implementation plan was published alongside the HIS, which set out the Mayor’s commitments to act on health inequalities and the key role of partners.

Since 2018, the Mayor and partners have achieved a great deal together including:

• cleaning up London’s toxic air through the world’s first Ultra Low Emission Zone

• transforming unhealthy environments through active travel, healthier streets, more green and climate resilient spaces, less unhealthy food advertising and building health into the planning system

• creating opportunities to support the health of children and young Londoners, including via the healthy early years and healthy schools programmes

• improving access to mental health and wellbeing support, improving awareness and addressing stigma

• establishing the first Violence Reduction Unit (VRU) in England and Wales, designed to take a public health approach to violence prevention across London

• delivering world leading progress on preventing HIV through Fast Track Cities.

The 2018-21 HIS Progress Report (Aug 21) gives an overview of our achievements to date. It also reflected on the changes to delivery in the context of the COVID-19 pandemic, which continues to have significant implications for health inequalities in London. This new 2022-24 implementation plan builds on that work.

The Mayor and partners are accountable for the London-level commitments in this plan as shown below.

Mayor of London

Reports annually on progress against the commitments set out in this plan. This is scrutinised by the London Assembly.

London Health Board (LHB)

Chaired by the Mayor, it brings together local council leaders, NHS London, sub-regional integrated care systems and OHID. Together, they oversee the progress towards London’s Health and Care Vision and implementation of the HIS.

Health Equity Group (HEG)

Formed in 2020, this group will ensure London’s response to the pandemic’s disproportionate impact on Black, Asian and minority ethnic communities and disadvantaged Londoners is gold standard. In the medium and longer term, it will provide cross partnership leadership to tackle London’s wide health inequalities. It is co-chaired by Prof. Kevin Fenton, Regional Director of Public Health and Statutory Mayoral Health Adviser and Will Tuckley, Health and Care Lead, Chief Executive, Tower Hamlets and Lead Health Advisor, London Councils (CELC).

Members include representatives from:

• London Councils
• local government leaders
• chief executives and professional networks (ADPH / ADASS)
• NHS, London Integrated Care Systems (ICSs),
• Faith, Voluntary and Community Sector (FVCS)
• business
• academics
• young people’s organisations
• the GLA.

HEG was set up by, and reports to, the London Health Board.

Health Equity Delivery Group (HEDG)

A sub-group of the HEG jointly chaired by NHS London region and ADPH London, its purpose is to provide a holistic approach to reducing health inequalities, improving access to health services and preventing ill health. It does this by bringing key stakeholders together from across the system, to work in partnership as, ‘one-group-as-a-whole’ for London’s populations. It aims to support and guide the development of a health equity framework which will be integrated into daily practice and planning infrastructure. It will also be a key vehicle in implementing a standard approach to health equity across London and sharing good practice and insights into effective programmes which can be scaled-up.

Members include representatives from:

• London’s ICS leadership
• borough adult and children services
• London Councils
• Office for Health Improvement and Disparities (OHID)
• the GLA.

The COVID-19 pandemic has shown with devastating effect how the different circumstances of our lives can affect our chances of poor health. While the pandemic affected us all, some populations have been hit much harder than others. This includes the risk of catching the virus itself, the impact of mitigation measures, and effect on people’s mental health and wellbeing.

In the first wave, it quickly became clear that those who became ill or died were more likely to be older, from Black, Asian or minority ethnic groups or disabled people. According to the latest data, nationally during the first wave, people from almost all ethnic minority groups had higher rates of death involving COVID-19 compared with the White British population. The rate was highest for Black Africans males, at 3.7 times greater than for the White British males, followed by Bangladesh males who had 3 times greater COVID-19 related death rates than White British males. In the second wave, despite knowing more about the virus and how it transmits, we continued to see an unequal impact. The differences in COVID-19 mortality increased for people of Bangladeshi and Pakistani ethnic backgrounds; the Bangladeshi group had the highest rates, 5.0 and 4.1 times greater than for White British males and females respectively. However, people of Black Caribbean and Black African background, while their risk remained higher, their relative risk was reduced in the second wave compared to White British groups; suggesting that ethnic inequalities in COVID-19 mortality can be improved with concerted effort.

People staying, living, and working in health and social care settings like hospitals and care homes faced greater risk. This was particularly so at the beginning of the pandemic when there was a lack of personal protective equipment and limited understanding about transmission. Public-facing key worker jobs, such as bus and delivery drivers, and those in health and social care, came with a higher risk of exposure to the virus – This was another driver of the unequal impact on certain communities. One example was the impact on the Filipino community in the first wave, who experienced relatively high death rates during the first wave, linked to their being the second largest non-British national group employed in the NHS, as shown in the Filipino Nurses Association UK’s parliamentary evidence submission.

People’s homes and work were important in other ways too. Crowded housing meant some were unable to isolate, and multi-generational homes increased the risk of spread to different age groups. Whether you can work from home, whether your job is secure enough that you can self-isolate without losing it or whether you can access sick pay, all influenced risk. Again, the likelihood of being in a precarious work situation is far greater is some populations than others. For example, 16 per cent of Black workers experience insecure work, compared with 6 percent of White. Overall, workers from an ethnic minority group, women, young workers, low paid workers and disabled workers, have been hardest hit financially, and the intersectionality of these factors means that some sections of the population have been severely impacted.

Measures put in place to tackle the pandemic also had an unequal effect on people’s lives and wellbeing. For some people, restrictions severely affected children’s access to education or adults’ ability to work and their income. Some people were trapped in crowded accommodation, with no access to green space, whilst others suffered domestic violence and abuse. In fact, the pandemic revealed another pandemic of violence against women and girls (VAWG) where cases of domestic abuse soared around the world. London was no different with agencies highlighting an exponential increase in cases and crucially an increase in the severity of the abuse resulting in a need for more intense support.

For some, lockdown periods and beyond, meant considerable isolation, for example if unable to access the support of a local social or family network, or if a vulnerability increased the risk of socialising, or even going to the shops. Some suffered bereavement, sometimes losing multiple family members and friends to the virus. Some were unable to access health services to receive treatment for other conditions. This was due to pressure on the NHS to treat COVID-19 cases or because they struggled to access online services. Some experienced many of these challenges at once or one after the other.

The effects of the pandemic on Londoners’ mental health have been profound and widespread. The Centre for Mental Health predicted that up to 10 million people nationally, 20 per cent of the population, will need new or additional mental health support as a direct consequence of the pandemic. Again, the mental health impacts were felt disproportionately in some groups. These include asylum seekers, children and young people, Deaf and disabled people, LGBTQ+ people, older people and women. This is due to a combination of bereavement; loss of income; lockdown; severe loneliness, and isolation. For children and young people, missed education, increasing income inequity and impacts on mental health and wellbeing may have contributed to their vulnerability to violence.

COVID-19 will have a long-term impact on people’s lives. The pandemic isn’t yet over and will have profound implications for health inequalities in London, as elsewhere. We’ll learn more about these impacts and those of long-COVID on health in the coming months and years. This is already being reflected in life expectancy data in Figure 2.

Figure 2: Life expectancy has fallen, and inequalities have widened

London was hit very hard by the virus. It already had the highest cumulative death rate (after considering population age) from COVID-19 of all the English regions. There were more deaths than expected (excess mortality) across all regions of the UK, but this was highest in London.

After steadily increasing for several years, in 2019 the trends in male and female life expectancy in London plateaued. (as they did nationally). However, Londoners still enjoyed longer and healthier life expectancy than the rest of England. Further inequalities in life expectancy - the gap between the most and least deprived people - were not increasing in London. Yet, they were in England as a whole.

The pandemic has reversed these trends. The most recent interim data on life expectancy shows COVID-19 has reduced life expectancy (between 2019 and 2020) across all UK regions, but the greatest reduction was seen in London.

The life expectancy of those in the most deprived areas has reduced more than those in the least deprived areas. Consequently, inequality in life expectancy in London was greater in 2020 than in any other year in the last decade.

See supporting document Population health data for further information.

Read more about the impact of the pandemic in the first and second waves:

COVID-19: review of disparities in risks and outcomes, Public Health England (June 2020)

Beyond the data: Understanding the impact of COVID-19 on BAME groups, Public Health England

Rapid Evidence Review: Inequalities in relation to COVID-19 and their effects on London, Commissioned by the Greater London Authority (Sept 2020)

The impact of COVID-19 on Londoners’ mental health and wellbeing, Thrive LDN (March 2021)

Community engagement perspectives

The impact of the pandemic has been vividly brought to life by the words of Londoners. Through 2020 and 2021, community engagement focused on hearing directly from Londoners most affected. This provided vital up to date information and allowed us to hear the stories behind the data. It also ensured that we were hearing London’s diverse voices – recognising that many of the communities most impacted by health inequalities and the pandemic are often under-represented in statistics.

Engagement included:

• GLA weekly survey of frontline civil society and community organisations from April 2020. The results were used alongside a range of other intelligence to inform the continuing pan-London response to the COVID-19 pandemic.
• The Deputy Mayor for Communities and Social Justice’s virtual roundtable conversations and community meetings convened over 250 civil society, community and faith groups in 2020. The findings were published in the Map of Community Views.
• Professor Kevin Fenton and PHE led virtual Big Conversation events and roundtables with community and faith organisations, throughout 2021.
• A series of events with communities and partner organisations led by PHE with the support of the Health Equity Group, aiming to take stock and reflect on progress since the 2020 PHE Beyond the Data Report was published. Beyond the Data One Year On was published at the end of 2021.

Through this engagement, diverse communities shared their experiences. For example, high levels of bereavement, long-Covid and worsening health, including increasing issues with mental health. The experience of loneliness, social isolation and digital exclusion were common themes, alongside a lack of access to green spaces and opportunities to be active. We also heard about poor access to testing and vaccination, and to health services in general.
Communities highlighted the valuable role of the faith, voluntary and community sector to help with shopping and other daily tasks. This helped to mitigate food poverty, address loneliness and provide a wide range of other vital assistance.
Communities recognised the pandemic’s unequal impacts, highlighting causes including:

• Racism, discrimination, stigma, fear and trust, and feeling judged.
• The impact of social and economic inequalities – poverty, poor and insecure housing, digital exclusion, community support; and
• Communication barriers, including lack of culturally appropriate communications and communications in non-digital formats.

Two themes arose strongly and consistently through the engagement - mistrust of and a lack of confidence in public institutions such as the police and the NHS, and experience of racism and discrimination. These views were reinforced through engagement with the NHS and social care staff.

The issues raised during the engagement need to be explicitly recognised and addressed in partnership work going forward as causes of health and other inequalities, including in this plan and the London Recovery programme.

The pandemic has had a substantial impact on London, Londoners, and our health and care system. The new ways of working developed in response to the crisis delivered achievements London can be proud of. For example, ‘Everybody In’ to bring homeless Londoners off the streets (see Figure 4). The Mayor, London’s boroughs and the NHS are determined to build on these successes and not return to ‘business as usual’. As the first wave subsided, the Mayor and partners came together to start planning London’s recovery. This section offers an overview of London’s approach:

• Leadership through the London Recovery Board

• Missions-based approach to action developed through community engagement

• Maximising opportunities to improve heath and reduce health inequalities across the programme, through the health and wellbeing cross-cutting principle

• Concerted action on the climate emergency as part of the Green New Deal

• Harnessing the power of London’s anchor institutions to benefit local communities

• Addressing Structural Inequalities Group to develop a London-wide partnership response

We have developed this HIS implementation plan recognising the broader landscape of the Recovery programme and the London Health and Care Partnership’s Vision. It complements and mutually reinforces the objectives and priorities across pan-London plans. This helps to streamline priorities, reduce duplication, and maintain a focus on what communities have told us they want to see.

In July 2020, the London Recovery Board set a Grand Challenge to restore confidence in the city, minimise the impact on communities, and create a stronger economy and society. The board is co-chaired by the Mayor of London and the Chair of London Councils. It brings together leaders from local and central government, business and civil society, alongside the health and education sectors, trade unions and police. Together they seek to make London greener, fairer and safer than ever before.

The London Recovery missions and health inequalities

The London Recovery Programme, has two missions focused on health – ‘mental health and wellbeing’ and ‘healthy place, healthy weight’. These have been developed with extensive engagement from Londoners over many months.

All nine of the missions (see below), provide an opportunity to act on the causes of health inequalities. The recovery programme recognises the importance of a ‘health in all policies’ (HiAP) approach to maximise the health impact of a range of policies, through the inclusion of a health and wellbeing “cross-cutting principle”.

The London Recovery Missions

• A Green New Deal - Tackle the climate and ecological emergencies and improve air quality by doubling the size of London's green economy by 2030 to accelerate job creation for all.
• A Robust Safety Net - By 2025, every Londoner is able to access the support they need to prevent financial hardship.
• High Streets for All - Deliver enhanced public spaces and exciting new uses for underused high street buildings in every Borough by 2025, working with London’s diverse communities.
• A New Deal for Young People - By 2024 all young people in need are entitled to a personal mentor and all young Londoners have access to quality local youth activities.
• Helping Londoners into Good Work - Support Londoners into good jobs with a focus on sectors key to London’s recovery.
• Mental Health and Wellbeing - By 2025 London will have a quarter of a million wellbeing ambassadors, supporting Londoners where they live, work and play.
• Digital Access for All - Every Londoner to have access to good connectivity, basic digital skills and the device or support they need to be online by 2025.
• Healthy Food, Healthy Weight - By 2025 every Londoner lives in a healthy food neighbourhood.
• Building Strong Communities - By 2025, all Londoners will have access to a community hub ensuring they can volunteer, get support and build strong community networks.

The relevance of health to all missions is well demonstrated by the Green New Deal mission. This relates to the climate emergency, the greatest global health threat facing the world in the 21st century. For London, the consequences of climate breakdown will be severe, particularly in terms of flooding and extreme heat events. Like the pandemic, the impacts of climate change will not be spread equally or fairly. They will be felt most by vulnerable communities, least able to adapt to overheating, flooding and the knock-on impacts to services and infrastructure. In 2018 the Mayor declared a climate emergency and in 2020, committed to making London net zero carbon by 2030.

Harnessing the potential of London’s ‘anchor’ institutions

An anchor institution refers to a large organisation whose long-term sustainability is tied to the wellbeing of the local community and economy in which it is located and operates. Their size and procurement power, recruitment and estate management capacity mean they can have a major social and economic impact in those areas. In some places, outer London particularly, the council or NHS trust is the largest employer and therefore plays a big part in the local economy. Other anchor institutions include universities and colleges, cultural venues, and large businesses, many of which have been committed for years to making sure they’re having a positive local impact.

Bigger and more positive changes can be made together rather than working alone. The London Recovery Programme has brought the city’s anchors together to reach shared goals. The London Recovery Board created a London Anchors task and finish group to drive action, chaired by Sir David Sloman, NHS London Regional Director. The resulting London Anchor Institutions’ Charter is a commitment to work together to support recovery efforts. The initial priorities are maximising employment opportunities and helping young people to flourish and delivering the capital’s net zero targets. The institutions already signed up to the charter between them employ half a million people and have a combined budget of over £73bn per year.

As one of London’s biggest employers, landowners and procurers, the NHS is leading by example with NHS trusts and other parts of the system driving forward action. At regional level, the NHS London Anchor Systems Network has been created to develop this role and share learning and good practice across London’s NHS. London Councils has also signed the charter, recognising the major anchor role that local authorities play in local communities across the city.

Addressing Structural Inequalities

The London Recovery Board recognizes that structural inequalities led to the pandemic’s disproportionate impacts. To address this requires focused cross-sector action. The Addressing Structural Inequalities sub-group, chaired by Kim Wright, Chief Executive of Lewisham Council, was set up in 2021 to identify what London Recovery Board partners can do to make a real difference. It will publish an action plan in early 2022.

As a first step, it is working with community groups to develop five vision statements. These will set out the changes people want to see for those groups that were particularly hard-hit by the pandemic. These focus on women and girls, older Londoners, race equality, Deaf and disabled Londoners and LGBTQ+ Londoners. Four themes have been prioritised for focus:

• financial hardship
• labour market inequality
• trust and confidence in the equitable delivery of public services, and
• civil society strength.

This important programme of work will shape and influence HIS work plans, in particular on structural racism and addressing ethnic inequalities.

As this document shows, there are many lessons to be learnt from the last two years. This is not only in terms of what we need to focus on, but how we work together - as a system, and with communities and Londoners.

London’s health and care partners

Elements of the COVID-19 response have shown what can be achieved when we are united by a clear, common purpose. Partners worked at pace, collaborated and communicated differently, and shared resources and accountability. Most importantly, they put communities at the heart of service design and delivery, moving beyond traditional sector silos. Figure 4 highlights some examples of how we worked differently together.

The focused approaches taken through the pandemic response and recovery have accelerated place-based partnership. This work has tackled health inequalities through acting together on the social, economic and environmental determinants of health, as well as taking a public health approach rooted in prevention and early intervention to tackle issues ranging from healthy weight to violence prevention. Strong systems leadership has been vital during the COVID-19 response. Rapid action was essential, and the usual procedural and bureaucratic barriers were overcome to focus on getting the best health outcomes for local people. These ways of working built on strong and trusted relationships. Partners are committed to building on the successes of the pandemic to accelerate London’s recovery.

Figure 4: Examples of partners working differently

Vaccination success

"The (webinar) presenters speaking in our native languages made many of us feel that there are professionals who genuinely care about promoting vaccinations in communities that may perceive themselves as a bit distanced from the general population."
- Eastern European Resource Centre (EERC) for migrants.

The COVID-19 vaccination programme has been one of the most successful London vaccination drives of all time. The London programme is led by the NHS, and delivered through partnerships at a London, ICS, borough, locality and hyperlocal level. The programme focused on four key areas:

1. Data and evidence: Regular scrutiny of the London vaccine and case rate data at a granular level to understand where to focus to mitigate inequalities.
2. Practical aspects of vaccination: approaches to increase accessibility included flexible booking; innovative transport and outreach models to reach vulnerable groups; pop up clinics informed by data where people needed them; and using accessible community-based venues. More targetted outreach focussed locally and working closely with faith and community groups worked better for reaching populations with low uptake.
3. Tackling hesitancy: A range of innovative activities were developed to engage with communities to ensure informed choice including: developing vaccine resources through community partnership and insights; pan-London vaccine confidence webinars; tailored and targetted Q&A sessions and establishing the London Community Champion Coordinator Programme.
4. Monitoring, evaluation and system leadership: A public sector and academic led partnership led on a system wide evaluation to learn from what has been effective.

Community Champions

The Community Champions programme sought to address the gap that exists between public services and some communities. To avoid further exacerbating inequalities, innovative approaches were developed locally to counteract the disconnect. Community Champions worked with their community networks and with health professionals to develop and improve messages. Training and information was coproduced by boroughs and Community Champions in response to their needs. Keeping Community Champions updated on policy changes and supported around the vaccination programme was crucial to its success. The champions provided timely grassroots feedback and understanding on the priorities of seldom held communities which further influenced the programme. The London COVID-19 Champions Coordinators network was launched in April 2021 bringing together all London local authorities to share learning and build on the successes. Champions programmes have brought local people and services together to improve health and wellbeing and to reduce inequalities.

Homeless Health

During the first wave of the pandemic, partners built new governance structures and relationships to underpin delivery of an integrated health, care and housing response at pan-London, ICS/Sub-regional and borough levels. This approach was enabled by significant COVID-19 investment and securing national funds for accomodation, mental health, drug and alcohol services, and for hospital discharge. Together, London's boroughs and the GLA have placed at least 9,600 people who were sleeping rough into emergency accomodation, and 6,700 have been helped into settled accomodation. Close partnership working with the NHS ensured that those who were homeless were offered a COVID-19 vaccine and access to Hepatitis C screening and treatment. The response is estimated to have potentially avoided around 7,000 COVID-19 infections, at least 90 deaths and 390 hospital and 115 ICU admissions in the capital.

Building on communities' assets and strengthening our work with communities

An important lesson from the pandemic is that to make a difference on health inequalities, those communities who are most affected need to be central to everything we do. Communities want to be part of London’s recovery from the impact of COVID-19. They can play a vital role, just as they have in the pandemic response.

Working with faith and community organisations and leaders during the pandemic has increased our knowledge and understanding of the drivers of inequality in London. The successes in Figure 4 give a glimpse of how critical their support has been for Londoners throughout the pandemic. Their essential role in tackling health inequalities, before, during and after the pandemic needs to be recognised and built upon.

Working differently and better with communities is a key aspect of the Recovery Missions and must inform all our work. There needs to be continuing engagement with diverse Londoners including ‘inclusion groups’ and people with ‘protected characteristics’. The Building Stronger Communities mission aims to strengthen civic society, and civil society is a focus of the Addressing Structural Inequalities group.

As we tackle health inequalities, we must also address some of the most challenging problems, including sustainability and resourcing, faced by civil society organisations. Only by doing so, can we ensure that they can continue in their vital work, which benefits system partners, our city, and Londoners. The Health Equity Group will progress this work as part of its commitment to champion the priority actions in Beyond the Data - One Year On report (see Figure 5). This includes the need to resource community organisations to support their work.

Community ‘priority actions’ illuminated through engagement activity with Londoners (extract from “Beyond the Data – One Year On”.

Co-production

Involving communities, including young Londoners, in co-production of interventions for the community 

Participatory research

Research by researchers that reflect the community 

Culturally competent care 

Staffing of health and care services to reflect the diverse communities they serve 

The need to resource community organisations 

Adequate resourcing of community organisations to support their work 

Addressing discrimination and racism 

Acknowledge racism as a public health issue 

Improve access to health care and wellbeing services 

Londoners want better experience of health and care services 

Data information and sharing 

Londoners want greater transparency with how their data is used. They want collected data to be fit for purpose 

Further commitments to supporting communities are included under Healthy Communities in the supporting document.

The London HIS continues to provide an evidence-based framework for tackling health inequalities. As outlined above, the pandemic has given us cause to reflect on the priorities it originally set out. While the pandemic continues, we will continue to learn and understand more about its impact on health inequalities. Our community engagement work so far has told us about Londoners’ priorities. Combined with the data, this provides us a clear sense of where we need to focus, and what need to be done.

This implementation plan includes six key Mayoral commitments, which will be prioritised over the next few years. These are the:

• Two health-related Recovery Missions. The key commitment for Healthy Children reaffirms the Healthy Places, Healthy Weight Mission focus on healthier environments for children by creating more school Superzones. The Healthy Minds commitment reaffirms the Mental Health and Wellbeing mission aim to improve access to mental health community support and advice
• Two commitments continued from the previous HIS implementation plan, reflecting the continued priority of tackling the climate emergency. One is the Healthy Places commitment on tackling London’s toxic air and carbon emissions. The other is the Healthy Living commitment to creating environments which support, encourage and enable more Londoners to walk and cycle, and
• Two priorities which have come more clearly into view during the pandemic: ethnic inequalities and structural racism - which have short and long-term implications for people’s health and wellbeing, and action to address income inequalities which result in poverty, deprivation, low income and poor housing. These are also treated as cross-cutting principles. This is because they are relevant across the HIS, relate to each other, and have implications for the risk of poor health.

This plan was developed and exists within a broader context of pan-London partnership working. As stated above, the key commitments incorporate missions from the London Recovery programme, and also align with the London Health and Care Vision. By reinforcing each other they demonstrate the agreement at citywide level of the most urgent and important issues facing London as a whole. This shows how London can act as a system with shared priorities while retaining flexibility around local context.

These key commitments also help deliver the Mayor’s manifesto commitment to champion a health in all policies (HiAP) approach across the GLA Group. This is not a new approach for the GLA, but one is being taken forward with renewed vigour. The GLA has established public health expertise to support this. It also works closely with the wider public health system, to ensure that successes from this approach are built upon. 

There is more detail on the key commitments, their relationship to other work areas and mechanisms for delivery below. You’ll find a full overview of Mayor and partners’ commitments at a London level in the supporting documents.

Action on health inequalities in London happens across different partners and at different geographic levels. Each has its own strategic framing, and an important role to play. At the pan-London level, work on health inequalities is driven by the HIS and implementation plan. This sits alongside the London Health and Care Vision which identifies the major health priorities for London. The London Recovery programme sets out the overarching priorities for London and brings together all of London’s various sectors.

Partners’ priorities

The following provides a high-level overview of some of the priorities of London partners and stakeholders in tackling health inequalities.

Boroughs

Much, if not all, of what local authorities do is relevant to health inequalities. As well as dedicated public health teams, local authorities have core functions which include in adult and children’s social care, regeneration (including housing and planning functions), waste and recycling, environmental protection, parks and leisure services. Health in all polices is fundamental to what boroughs do.

Borough Health and Wellbeing Boards bring together the NHS and local authority with local voluntary and community organisations among others. Board plans focus on wider determinants of health and are highly relevant for health inequalities.

London Councils is working in close partnership with the Mayor and others on the London Recovery programme, prioritising the nine missions and the London Health and Care Vision programme.

All boroughs must meet their obligations under the Equality Act 2010 including the Public Sector Equality Duties. Over and above this, councils typically work through the Equality Framework for Local Government, through an approach grounded in:

• Understanding and Working with Communities
• Leadership and Organisational Commitment
• Responsive Services and Customer Care
• Diverse and Engaged Workforce

Boroughs have been at the forefront of community engagement. This includes leading-edge work on Community Champions, communications, collaborating across London and hyper-local activity. One example of the latter is targeting of testing and vaccination activity to the best locations through their deep local community knowledge. They have worked tirelessly to ensure people with care needs are supported, and mobilised housing options for rough sleepers and vulnerable households throughout the pandemic.

Aligned with boroughs is the Association of Directors of Public Health London (ADPH London). This network enables Directors of Public Health and their teams to work together to address issues which must be successfully tackled on a pan-London basis. In addition, those which enhance the ability of boroughs to meet their responsibilities locally. This includes sharing of best practice, reducing duplication, delivering efficiencies, and improving coordination of related work.

Through its members, ADPH London agrees several areas where it sees benefits in collaborating at a London level. These areas have potential to maximise positive impacts on population health and reduce health inequalities. They can also add value locally and respond to the political, economic, and social environment effectively.

Alongside the established core programmes of work that ADPH London delivers, the network has prioritised two more recent areas:

1. Supporting Black, Asian and minority ethnic communities during and beyond COVID-19

In February 2021, ADPH London released a position statement in supporting Black, Asian and minority ethnic communities during and beyond the COVID-19 pandemic. This statement highlights racism as a public health issue, given the immediate and structural factors that have impacted on London’s communities It highlights five themes where they are developing actions so as to mitigate any further widening of inequalities.

• Trust and cohesion 
• Improving ethnicity data collection and research 
• Diversifying the workforce and encouraging systems leadership
• Co-production with communities 
• Embedding public health work in social and economic policy.

ADPH London published its Action Plan 2021-26 in December 2021.

2. Climate change emergency and health

In November 2021, ADPH London released a position statement declaring a climate and health emergency. Climate change and health are inextricably linked and already affecting Londoners. Importantly, the impacts of climate change do not affect us all equally but put the heaviest burden on those who are most vulnerable, including people on low-income, minoritised, disabled and marginalised groups.

London Association of Directors of Children’s Services (ALDCS)

London’s directors of children’s services work collaboratively through the London Innovation and Improvement Alliance (LIIA) to tackle the priorities affecting London’s children. ALDCS priorities address key health inequalities and include adolescent safeguarding and improving the provision for children with special educational needs and disabilities.



LIIA supports a range of work across London to promote these priorities. This includes drawing together partnership initiatives through the London Adolescent Safeguarding Oversight Board (LASOB) which is working to promote consistent approaches to the safety and wellbeing of children experiencing extra-familial harm. LASOB is currently overseeing the implementation of the Your Choice violence reduction programme which is delivering a multi-systems approach, using cognitive behavioural tools and techniques, to engage young people affected by violence in every London borough.



All of ALDCS’s work is underpinned by a determination to address racial disparities in outcomes for children and to promote equality of opportunity in the children’s workforce. Each of the LIIA work programmes has a specific focus on racism and disproportionality. In the last year the Leadership in Colour programme has been developed to tackle organisational barriers to the advancement of Black, Asian and minority ethnic staff and support individuals in their own development.





London ADASS brings together all Directors of Adult Social Services in London with the aim of improving social care across London and finding ways of doing this more cost-effectively. The network shares good practice and helps sustain effective communications across London’s Directors of Adult Social Services and their teams. Through its Improvement Programme, London ADASS is working with adult social services and other bodies committed to improving the health and wellbeing for all Londoners, encouraging collaboration through various networks and focused projects.



London ADASS priorities include:

• Equality Diversity and Inclusion

• Commissioning and market development

• Workforce

• Integration

• Safeguarding



Current work programmes include carers, dementia and mental health.



Two key initiatives are highlighted below:



Proud to Care

• Around 238,000 people work in adult social care in London. The lowest paid staff are those who support people on a day to day basis in their homes, in supported accommodation and in residential homes. London has particular challenges in retaining staff and turnover and vacancy rates are both high.

• Proud to Care –takes a comprehensive approach to improving recognition, retention & recruitment in adult social care. It is led by those who use services and those who provide care and support. Proud to Care London links people into crucial jobs in care, in partnership with councils across London.



Equality, Diversity and Inclusion

67 per cent of the adult social care workforce are from minority ethnic group backgrounds. The recent Covid-19 pandemic has highlighted the increased risk and disproportionate impact the pandemic is having on Black, Asian and Minority Ethnic (BAME) communities (Disparities in the Risk and Outcomes of COVID-19).



In July 2020 London ADASS issued a Black Lives Matter Statement highlighting the urgent need expose and eradicate all forms of racism within our capital. Members, as leaders of social care services in London have committed to:

• continue to remain fully committed to putting social justice and inclusion at the centre of everything we do.

• champion and continue to shape a diverse social care workforce within the capital as well as ensuring support offered to those in receipt of adult social care is bespoke and tailored to individual need.

• do everything possible to continue to expose and eradicate systemic racism.



Following a series of safe space discussions during Race Equality Week (1-7 February 2021) London ADASS has developed it’s Big Promise action plan to address the issues raised. A wide range of initiatives are taking place across London coordinated and supported by the small London ADASS team.

NHS and Integrated Care Systems (ICSs)

London’s five ICSs are setting out how they’ll develop the structures, processes, relationships, capabilities and governance to take on statutory responsibilities from April 2022. This is in order to best meet their local population’s needs. They have four key objectives, which recognise the importance of addressing the long-standing health inequalities that exist within London’s population. They also recognise the broader role the NHS in London can play as anchor institutions within the communities they serve. These objectives are:

• Improving outcomes in population health and healthcare

• Tackling inequalities in outcomes, experience and access

• Enhancing productivity and value for money

• Helping the NHS support broader social and economic development

As they develop, we know the integrated care partnerships (the health and care organisations within a borough footprint) will be key vehicles. They will be used to address health inequality, COVID-19 recovery and engage with local communities. Through these partnerships, we will strive to deliver services in new ways, combining collective resources to provide more tailored care for local communities.

Some of the core areas for alignment between the HIS and NHS London priorities include:

• Becoming net carbon zero by 2040 for the emissions the NHS controls directly. By 2045, this will extend to the emissions they influence for example through supply chains. NHS aims to be the first national health service in the world to agree net zero commitments. To be formally adopted by the NHS at national level, these goals require enabling legislation. However, much local action is underway across London’s NHS supported by the NHS London Sustainability Network.

• Supporting more people to achieve a healthy weight to prevent related long-term ill health and disability

Businesses

Many businesses in London recognise their vital role in supporting Londoners’ health – as employers, and as part of local economies and communities. The pandemic has brought key issues such as employee well-being and health to the forefront of business priorities. As a result, many organisations are responding positively to make a difference. Businesses stand ready to support the Mayor. The London Recovery Board has representatives from the Confederation of British Industry (CBI), London Chamber of Commerce (LCCI), Federation of Small Businesses (FSB), London Economic Action Partnership (LEAP) and London First. The CBI is also represented on the London Health Equity Group. Business groups (collectively known as The London Business Board) are keen to work with the Mayor and their membership to take this agenda forward.

Many businesses are already leading the way, through:

• Ensuring their staff and those in their procurement chains get a decent wage through the London Living Wage programme
• Creating healthier, better quality work through the London Good Work Standard
• Working to increase racial and ethnic participation in senior leadership and at board level, such as the CBI ‘Change the Race Ratio‘ campaign
• Addressing gender pay inequalities through transparent pay reporting.

Some are also acting on wider health inequalities issues, as part of the community, through work on Sustainability and decarbonisation.

Faith, Community and Voluntary organisations

Faith, Community and Voluntary organisations have always played a crucial role in addressing London’s health inequalities by supporting diverse groups of local Londoners, often with complex needs. The experience of the pandemic has made clearer the sector’s vital contribution. The sector was able to reach Londoners (including those shielding) that others could not, mobilise quickly, and provide essential support and advice. Its involvement in tackling London’s health inequalities will remain important going forward. However, we must recognise the challenges organisations face, not least in terms of resourcing. As cited above, the Health Equity Group will prioritise this. It will ask how we can further build on and support the work of Faith, Community and Voluntary partners.  

Infrastructure organisations operating at both borough and pan-London levels, play a key role in bringing together this diverse sector. Their role includes building and running networks to strengthen delivery to tackle health inequalities, to access learning and be heard.  HEAR Equality and Human Rights Network, Faiths Forum for London, London Youth and London Plus also contribute through the Health Equity Group.

Infrastructure organisations and networks support the sector through activities including:

• Improving understanding of the needs of Faith, Community and Voluntary organisations around collecting and presenting intelligence, enabling small community organisations to be heard.
• Supporting organisations to deliver across all communities, including those most disadvantaged. For example, through peer support, advice, sharing good practice, learning, data, and evaluations.
• Linking frontline organisations across sectors, developing and promoting understanding and intersectional approaches to tackling health inequalities.
• Enabling small and grassroots organisations to raise their priorities around health equality in decision making forums to achieve real change.

This plan sets out the direction of travel. It restates commitments of the Mayor and partners to tackling health inequalities and outlines priorities and activities over the next few years. It also begins to set out how we will work together to deliver on our ambition to reduce health inequalities in London.

Most action on health inequalities happens locally, not regionally – the Mayor, and other London–level partners seek to support and enable that local work. The statutory requirement for the Mayor to develop a Health Inequalities Strategy provides a valuable lever for the city. It offers a framework for action and an opportunity to collaborate on issues that matter to Londoners. While the Mayor’s role includes some delivery – for example through TfL – for action on health inequalities, other core aspects of his role are:

• Champion: Speak out on key issues, celebrate and support sharing of good practice.
• Challenge: Fight for what Londoners and London partners need.
• Convene: Bring partners together to consider ways forward in difficult, complex and challenging issues.
• Collaborate: play a leadership role in London wide partnership and deliver through the GLA Group.

The Health Equity Group will ensure London’s response to addressing the disproportionate impact COVID-19 had on Black, Asian and minority ethnic communities and disadvantaged Londoners is of gold standard. In the medium and longer term, it will also tackle the wide health inequalities that exist. The group’s role is key to London becoming the healthiest global city.

Next steps, supported by the GLA’s Health and Wellbeing Team:

• Consolidating learning from the pandemic to tackle health inequalities.
• Develop the health inequalities narrative for London.
• Promoting the plan and sharing opportunities to get involved.
• Working with a wide range of organisations to consider opportunities for action.
• A series of stakeholder workshops focused on working in partnership to address challenging health inequalities priorities.
• Collaborating with other cities and regions in the UK, and internationally, to make London the healthiest world city.

London has set an ambitious vision to become the healthiest global city and the best city in which to receive health and care services. The pandemic hit London hard, and hit those already experiencing the effects of health inequalities hardest. In building back better and fairer London’s recovery partners are acting on what Londoners said and designing solutions in partnership. They will build on the lessons from responding to the pandemic – including innovative partnership working. This plan provides a framework for partnership working at all levels from neighbourhood and place to sub-regional and citywide. Health inequalities are not inevitable and can be reversed by working together.