Transport's role in creating a fairer, healthier country

Transport can enable everyone, across the social gradient, to benefit from access to schools, colleges, and jobs. It is also critical to enable people to engage with essential services such as doctors, dentists, and hospitals, and to interact with friends and family. However, it is not equally available and can promote, or damage, health. This article explores four key areas where we believe better transport can play a key role in creating a fairer, healthier country.

ACCESS TO THE SOCIAL DETERMINANTS OF HEALTH AND THE NEED TO IMPROVE THE BUS NETWORK

The 2010 Marmot Review described how having access to transport enables access to work, education, social networks, and services that improve people's opportunities and overall community functioning.1 Conversely, not having good transport access increases inequalities in a range of the social determinants of health.2 Yet, in the Marmot review 10 years on,3 we noted the under-investment in a crucial part of our transport system: bus services. The quality of bus services has the greatest effect on the day-to-day travel experience of those without access to a car. In 2021–22, one in four (28 per cent) of the poorest fifth of households did not have access to a car, compared with just 6 per cent of the wealthiest fifth of households.4

In 2018, analyses of the National Travel Survey found that 19 per cent of unemployed people in England either turned down a job or did not apply for a job due to transport problems, compared with 6 per cent of people who were already in employment.5 This followed a sustained decrease in national funding for buses, with a 35 per cent drop in funding between 2008/09 and 2019/20; financial support for buses then increased over the pandemic, but has now fallen back.6 A report published this year notes that bus services outside London, in rural and urban areas, have now halved since 2008, with some areas having reductions of greater than 80 per cent.7 In addition, the cost of bus and coach fares has risen by 69 per cent since 2015, more than rail fares, and average wages, which have increased by 46 per cent.8 Noting the unaffordability of travel, in 2021 the government stepped in with a £2 limit on bus fares, which will rise to £3 in 2025.9

“not having good transport access increases inequalities in a range of the social determinants of health”

For those needing to travel outside of peak times, there has been a significant drop in the frequency and reliability of services. This particularly impacts shift workers without a car, for example those working in the NHS. It also impacts those without a car wanting to travel to socialise or access cultural services.10 Given that lack of quality, affordable transport is a barrier to employment, this will be exacerbating economic and health inequalities and holding back growth. Over half of the working-age population (57 per cent) live in areas with low public transport access to employment opportunities, ie within reach of 45 minutes travel time. Lack of transport does not only impact the ability to engage in work; 66 per cent (7.8 million) of elderly people cannot reach a hospital within 30 minutes by public transport in the UK.11

There is, however, cause for optimism that services could improve. Recognising that the privatisation of bus services has not worked for the majority, the Department for Transport are planning the Better Buses Bill to give new powers to local authorities so that they can decide the ‘details’ of local bus services – that is where they run, when they run and the standards of the services.12 This follows the success of Greater Manchester's takeover of their bus network, the Bee Network, which has resulted in a 5 per cent increase in the number of journeys in the first year and the ability to provide free transport to 16-18 year olds, making it possible for them to take up opportunities in education and work.13 Local authorities should take advantage of these new powers to develop minimum standards for bus services.

IMPROVING CONSULTATION ON LOCAL NEEDS TO REDUCE SOCIAL ISOLATION AND IMPROVE ACCESS TO SERVICES

If public transport is unavailable, because it is too expensive or because of lack of coverage, people will either use cars, or active modes of transportation, or become lonely/isolated. Research has shown that people who are lonely or feel isolated have increased risks for chronic disease, cognitive decline, an inability to perform daily living tasks, and an early death. Social isolation (having few or no social contacts) is a strong predictor of physical decline and early death. Loneliness (the feeling of being alone or disconnected) is even more predictive than social isolation of mental health issues, such as depression or feelings that life has no meaning.14

Understanding local needs is important and consideration should also be given to the diverse ways in which people interact. For example, research has found that individuals from lower income brackets are significantly more likely to interact with family members, and have more frequent and closer social interactions, while those from higher income brackets are more likely to interact with friends.15 The higher level of social interaction in low-income households seen in this study will help to mitigate the damaging effects of poverty and so this is a really positive finding. However, it is worth noting this difference. Those on lower incomes may have greater need for services that connect them with other local homes, which may be at odds with bus services that connect suburbs to town centres, for instance.

“Consulting with users, while retaining a health equity lens, will be a sensible local approach”

At Institute of Health Equity (IHE), we are supporting around a sixth of local authorities in England to improve the social determinants of health in their areas. We are also supporting Scotland and Gwent. In these ‘Marmot’ places, particularly those that are more rural, the topic of transport is not raised in isolation, but usually in the context of the reduction in the availability of local services. To those reliant on public transport, a reduction in local services together with a reduction in public transport is causing considerable distress. There are well documented issues relating to loss of postal, banking, and dental services. There are wider impacts too, with a lack of access to other services, such as domestic abuse services. A route planning exercise may inform where new services need to be provided, and we encourage local authorities to work across boundaries to ensure both the provision of services and routes to them for all their citizens.

Consulting with users, while retaining a health equity lens, will be a sensible local approach. If it is needs based, improved services will be rolled out first to those who are least well connected. Some organisations have already called for certain standards. For instance, CPRE has called for every village of 200-300 people to be guaranteed at least an hourly bus service from 6am to midnight, seven days a week.16

TRANSPORT POLICY TO IMPROVE AIR QUALITY AND REACH NET ZERO

Poor air quality harms health, including raising risks of mortality and morbidity. Most deaths related to air pollution are due to heart disease, stroke and chronic obstructive pulmonary disease, and air pollution has also been linked to cancer and childhood and adult asthma.17 Pollution levels are, on average, worse in areas of highest deprivation compared with areas of lowest deprivation.18

Policies aimed at reducing emissions from vehicles, such as promoting the use of electric vehicles and investing in public transport, are associated with a significant decrease in air pollution levels and improved health outcomes among residents and should be expanded.19 However, it is not just these local area impacts that are important. Reducing emissions from transport will be essential on the journey to net zero.

“this fall in domestic transport emissions has been almost entirely offset by the growth in international aviation and shipping emissions”

Domestic transport emissions (ie greenhouse gases) – surface transport plus domestic aviation – have fallen by 14 per cent since 1990. The Climate Change Committee has recommended a gradual reduction up to 17 per cent of total car miles by 2050, with 9 per cent of car miles reduced (eg through increased home-working) or shifted to lower-carbon modes (such as walking, cycling and public transport) by 2035. They primarily see the switch to electric vehicles as the route for decarbonising transport. A larger shift would clearly enable deeper cuts in carbon emissions, greater beneficial impacts for air quality, the liveability of urban areas and reduced congestion.20

However, this fall in domestic transport emissions has been almost entirely offset by the growth in international aviation and shipping emissions, which are now 66 per cent above 1990 levels emissions and continue to rise. There are many factors that are related to this increase, and the answers are beyond the scope of this article, but there are interesting questions – are we reducing our domestic miles, at the expense of getting global goods delivered to our doors? A more integrated approach to reducing our total ‘air miles’ may be required.

PROMOTING ACTIVE TRAVEL TO IMPROVE HEALTH AND REDUCE EMISSIONS

Active travel as an alternative to using a vehicle reduces carbon emissions, which is important for climate change mitigation, and reduces air pollution. Active travel also improves physical health and mental health as a result of the physical activity.21

Action to promote an increase in active travel can work. For example, integrated land use and transportation planning has been associated with a significant increase in physical activity levels and improved health outcomes. Another systematic review also found that policies that prioritise pedestrian and cyclist safety, as well as the development of mixed-use neighbourhoods with good access to public transportation, were associated with a significant increase in physical activity levels and improved health outcomes.22

“Importantly, increases in cycling were consistent across socioeconomic groups”

For example, in Waltham Forest, London, a mini-Holland scheme included slowing vehicles on residential streets and adding protected spaces to cycle. An analysis over one year found of people living in areas with the mini-Holland initiative, 24 per cent more were likely to have cycled in the previous week compared to non-mini-Holland areas. Importantly, increases in cycling were consistent across socioeconomic groups.23 In addition, studies have shown that 20mph zones can reduce inequalities in traffic casualties between the most and least deprived wards by 14 per cent.24

Focussing on equity is critical when designing active travel schemes.25 For example, initially the London Bike Sharing Scheme increased cycling among more affluent people more than among the less affluent; it was only after placing bikes in more deprived areas that cycling began to increase among poorer people.26 Active travel policies should apply an equality impact assessment to ensure that interventions are equitable and do not worsen inequalities.

FINAL WORDS

There are clearly opportunities for good equitable transport policy to create a fairer, healthier society by improving access to services, work and friends and family. Greening transport is both highly possible and necessary to help us reach net zero and deal with the existential threat of climate change. Choosing to walk or use a bicycle can significantly improve our health and reduce inequalities.

One area that we have not considered in depth in this article is affordability. The affordability of transport is in the same bucket as the affordability of food or heating, and we would advocate for the real living wage to be paid and an uplift in universal credit to ensure that it covers the essentials.27 Whilst universal credit, covers just 70 per cent of needs then transportation will be largely unaffordable, and more needs to be done to ensure that those accessing it can get to health services, cheaper food shops, afford to go to an interview and work for a week or a month before being paid.