“A sustainable NHS in London needs Londoners that are healthy”

A hospital, possibly in London. Image: Getty.

Labour’s London Assembly health spokesperson on NHS reform.

We need to think again before continuing with the largest experiment that London’s NHS has ever seen. This was the view that was reached this week by the mayor of London on the publication of the King’s Fund’s independent review of sustainability and transformation plans (STPs).

Deeply controversial across the capital because of their radical plans for hospital cuts and closures, STPs have become symbolic of an NHS unable to cope with the demand it faces from the public. In the face of growing demand, the NHS budget isn’t increasing at the same rate, with a £4.1bn shortfall expected to hit by 2021.

Partly driven by finances, the added challenge of Brexit runs the risk of adding to London’s high vacancy rates for medical professionals in almost all areas and specialisms. These are actual posts, budgeted for, that should be filled by doctors, nurses, midwives and allied health professionals, that aren’t filled because there are no qualified people available to fill them.

At the rate of demand, by 2021, London’s hospitals would need to provide an additional 1,700 acute beds. STPs plan to do precisely the opposite: reduce beds, “reconfigure” services, and in some circumstances close hospitals all together.

Whilst the focus on STPs promoting collaboration over competition within the health economy is a welcome shift in emphasis, the lack of system wide leadership and political accountability is damaging, rather than helpful in ensuring the entire health and social care world work together.


Cuts to local government funding and the growing instability of the care provider market have seen the rate of people staying in hospital longer than they need to because of the lack of availability of nursing or care home spaces, doubling since 2012. Over the same period 1,500 more Londoners spent 40,000 more days in hospital after they were medically discharged, because the rest of the system cannot cope with the pressures they face.

Without the kind of decisive leadership Strategic Health Authorities were previously able to provide, quite how the healthcare world will overcome these structural and financial barriers remains unclear. Quite who will be able to unlock the £5.7bn capital investment needed to bring STPs into fruition remains to be seen, leaving proposals open to the accusation that they are a “cut now, pay for it later” sticking plaster.

The crisis that the NHS faces is one of increasing clinical need. The true challenge to its sustainability isn’t the money available to plug the ever-growing financial black hole, but the very ill-health that drives people through the hospital door.

So much of that clinical need is preventable. Rather than forever tackling the consequences of ill-health, keeping people healthier for longer doesn’t just make financial sense, it’s the right thing to do. Despite the cuts to local government public health funding, bigger and better solutions are needed to prevent poor health in the first place.

Setting out this very case, the mayor has recently launched his strategy for tackling the unfair and avoidable health iniquity Londoners face, which sees people living in some parts of London spend nearly 20 years less enjoying good health. 

The strategy is heroic in its attempt to tackle complex social and economic injustices that allow poor health to go unchallenged. Starting at the earliest point, it recognises that the best way of ensuring Londoners lead healthy lives is to ensure our young people get the best possible start in life, and are supported to grow as healthy, resilient children at home, in school and around their communities.

By tackling the growing scourge of mental health problems like stress, anxiety and depression, it will attempt to ensure that the pressures of modern life won’t continue to act as a barrier for people to be able to live, work and enjoy their city.

Through ensuring our streets are walkable, the air breathable and neighbourhoods enable us to make healthy decisions, it will attempt to build a City where healthy living is by design rather than an afterthought. The mayor has ambitions to make London the Healthiest City in the World.

Whilst Londoners may lead busy lives, ensuring that everyone has access to affordable and healthy food; that quitting smoking is always the easier option; that we control our alcohol consumption and it does not control us, will be key in preventing the long-term consequences to ourselves and the NHS we could otherwise bring about.

Over the coming months, both the STPs plans to make the NHS sustainable, and the mayor’s plans to help Londoners lead healthy lives, will be tested. They may be seen at times to engage in their own tough and protracted battles, but they are two sides of the same coin.

After all, a healthy, sustainable NHS in London needs Londoners that are healthy.

Dr Onkar Sahota is a member of the London Assembly for Ealing & Hillingdon, a practicing GP in West London, and Labour’s London Assembly Health Spokesperson. He tweets as @DrOnkarSahota.

 
 
 
 

What’s up with Wakanda’s trains? On public transport in Black Panther

The Black Panther promotional poster. Image: Marvel/Disney.

Black Panther is one of the best reviewed superhero films of all time. It’s instantly become a cultural touchstone for black representation in movies, while shining a positive light on a continent almost totally ignored by Hollywood. But never mind all that – what about the trains?

The film takes place in the fictional African country of Wakanda, a small, technologically advanced nation whose power comes from its main natural resource: huge supplies of a magical metal called vibranium. As is often the case in sci-fi, “technologically advanced” here means “full of skyscrapers and trains”. In other words, perfect Citymetric territory.

Here’s a mostly spoiler-free guide to Black Panther’s urbanism and transport.

City planning

It’s to the credit of Black Panther’s crew that there’s anything to talk about here at all. Fictional cities in previous Marvel films, such as Asgard from the Thor films or Xandar from Guardians of the Galaxy, don’t feel like real places at all, but collections of random monuments joined together by unwalkably-wide and sterile open spaces.

Wakanda’s capital, the Golden City, seems to have distinct districts and suburbs with a variety of traditional and modern styles, arranged roughly how you’d expect a capital to be – skyscrapers in the centre, high-rise apartments around it, and what look like industrial buildings on its waterfront. In other words, it’s a believable city.

It’s almost a real city. Image: Marvel/Disney

We only really see one area close-up: Steptown, which according to designer Ruth Carter is the city’s hipster district. How the Golden City ended up with a bohemian area is never explained. In many cities, these formed where immigrants, artists and students arrived to take advantage of lower rents, but this seems unlikely with Wakanda’s stable economy and zero migration. Did the Golden City gentrify?

Urban transport

When we get out and about, things get a bit weirder. The narrow pedestrianised sand-paved street is crowded and lined with market stalls on both sides, yet a futuristic tram runs right down the middle. The tram’s resemblance to the chunky San Francisco BART trains is not a coincidence – director Ryan Coogler is from Oakland.

Steptown Streetcar, with a hyperloop train passing overhead. Image: Marvel/Disney.

People have to dodge around the tram, and the street is far too narrow for a second tram to pass the other way. This could be a single-track shuttle (like the former Southport Pier Tram), a one-way loop (like the Detroit People Mover) or a diversion through narrow streets (like the Dublin Luas Cross City extension). But no matter what, it’s a slow and inefficient way to get people around a major city. Hopefully there’s an underground station lurking somewhere out of shot.


Over the street runs a *shudder* hyperloop. If you’re concerned that Elon Musk’s scheme has made its way to Wakanda, don’t worry – this train bears no resemblance to Musk’s design. Rather, it’s a flying train that levitates between hoops in the open air. It travels very fast – too fast for urban transport, since it crosses a whole neighbourhood in a couple of seconds – and it doesn’t seem to have many stops, even at logical interchange points where the lines cross. Its main purpose is probably to bring people from outlying suburbs into the centre quickly.

There’s one other urban transport system seen in the film: as befitting a major riverside city, it has a ferry or waterbus system. We get a good look at the barges carrying tribal leaders to the ceremonial waterfalls, but overhead shots show other boats on the more mundane business of shuttling people up and down the river.

Transport outside the city

Unfortunately there’s less to say here. Away from the city, we only see people riding horses, following cattle-drawn sleds, or simply walking long distances. This is understandable given Wakanda’s masquerading as a developing country, but it makes the country very urban centric. Perhaps that’s why the Jabari hate the other tribes so much – poor transport investment means the only way to reach them is a narrow, winding mountain pass.

The one exception is in freight transport. Wakanda has a ridiculously developed maglev network for transporting vibranium ore. This actually follows a pattern seen in a lot of real African countries: take a look at a map of the continent and you’ll see most railways run to the coast.

Image: Bucksy/Wikimedia Commons.

These are primarily freight railways built to transport resources from mines and plantations to ports, with passenger transport an afterthought.

A high-speed maglev seems like overkill for carrying ore, especially as the film goes out of its way to point out that vibranium is too unstable to take on high-speed trains without careful safety precautions. Nevertheless, the scene where Shuri and Ross geek out about these maglevs might just be the single most relatable in any Marvel movie.

A very extravagant freight line. Image: Marvel/Disney.

Perhaps this all makes sense though. Wakanda is still an absolute monarchy, and without democratic input its king is naturally going to choose exciting hyperloop and maglev projects over boring local and regional transport links.

Here’s hoping the next Black Panther film sees T’Challa reforming Wakanda’s government, and then getting really stuck into double-track improvements to the Steptown Streetcar.

Stephen Jorgenson-Murray tweets as @stejormur.

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