Mayors can tackle health inequality

The article originally appeared in the Local Government Chronicle. 

Unaffordability is making us sick.

Across the UK, high housing costs and expensive transport are contributing to worsening public health outcomes and the widening of health inequalities. When people spend more than a third of their income on housing, they often struggle to afford essentials like food, heating and social activities.

Poor housing quality, often linked to unaffordability, leads to cold, damp and overcrowded conditions – risk factors for respiratory illness, cardiovascular disease and poor mental health.

Meanwhile, costly or unreliable public transport can isolate people from healthcare, employment, education and social networks. It can delay or prevent access to medical care, increase anxiety and reduce life satisfaction. These issues are especially acute for low-income households, young adults, and minority ethnic communities.

Strategic authorities, led by elected mayors, are now uniquely placed to take action across the building blocks of health – including housing and transport – to address these inequalities.

Research by Cles and The King’s Fund highlights how affordability cuts across both housing and transport policy. While many strategic authorities are already embedding health outcomes into their strategies, affordability remains a key barrier. And this barrier is often reinforced by private ownership models that prioritise profit.

Municipal ownership offers a promising alternative.

A different path

In housing, strategic authorities are using strategic planning, land commissions and compulsory purchase powers to unlock land for affordable homes. They’re also leveraging the social and affordable homes programme, with some (sub) regions such as Greater Manchester and the West Midlands set to gain full control of this funding stream by 2026, giving them power to direct site selection, set standards and approve scheme funding.

Yet demand far outstrips supply. 90,000 social rent homes per year are needed to end the housing emergency. All the while, dominant investor-led development models  extract profit and value from public land and subsidies while delivering minimal affordable housing.

Municipal housing companies like Manchester’s This City and Salford’s Dérive offer a different path, however. Dérive, builds high-quality, sustainable homes on council-owned land, with rents below market rates. Since 2017, it has delivered over 350 homes, with 1,000 more in development. This model prioritises long-term place stewardship over speculative capital.

In our research, we explored how strategic authorities could scale such models across their (sub) regions. Shared training, strategic partnerships and pooled expertise were all identified as enabling factors. For mayors and strategic authority officers, this means convening local authorities, health systems and other local partners around a shared vision for affordable, healthy housing.

Bus franchising

In transport, affordability is also being tackled head-on.

Strategic authorities function as local transport authorities and are embedding health outcomes into their plans with bus service improvement plan (BSIP) funding and mayoral precepts used to subsidise travel for young people, disabled residents and pensioners.

West Yorkshire CA has also used BSIP funding to support Project Hope – an initiative led by the integrated care system to provide young people that are care experienced with career development opportunities. The integrated care system provides job placements, while the strategic authorities offers free travel cards to those on the programme.

Bus franchising is another powerful tool. It allows strategic authorities to control routes, fares and service standards. Greater Manchester is leading the way, with franchised services rolling out since 2023. Passenger numbers have increased, and fares remain capped at £2 despite a national rise to £3.

Other strategic authorities like Liverpool City Region and West Yorkshire CAs are exploring franchising and we call on all other strategic authorities in our research to follow their lead.

Municipal ownership

But deeper reform is also needed. The UK’s main bus companies are owned by wealthy investors, extracting hundreds of millions in dividends. Public ownership could save £506m annually, reinvested into services and cheaper fares. Reading Buses, a municipally owned network, invests an extra £3m a year into its fleet and services, for example.

The Bus Services Act 2017 currently prohibits new public bus companies. However, the forthcoming Bus Services (No.2) Act is set to reverse this and we call on all local transport authorities to explore a shift to municipal ownership so that transport systems can better support access to care, reducing isolation and promoting wellbeing.

As an alternative to municipal ownership, we also make the case for stronger regulation to ensure that a greater share of profit and surplus extracted by the current main bus providers is instead redirected towards keeping fares lower and more affordable.

Strategic authorities have the tools – and increasingly, the powers – to address the building blocks of health.

By prioritising affordability and embracing municipal ownership models that put people’s health and wellbeing before profits, they can build healthier, more equitable places.

For public health professionals, strategic authority officers and mayors, supporting these local interventions is not just good policy – it’s essential for improving lives and narrowing health inequalities.