Published: 16/01/2003, Volume II3, No. 5838 Page 18 19

From 17 February, most people driving into central London will have to pay a£5-a-day congestion charge.

Mayor Ken Livingstone will use the money raised by the charge to make desperately needed improvements to public transport in the capital.

Congestion charging is a vital public health service.Why? The health impact assessment commissioned by the mayor from the London Health Commission concluded that it could reduce air pollution and associated hospital admissions for respiratory and heart disease, decrease noise, traffic collisions and casualties and increase physical activity by making it safer and more attractive to walkers and cyclists. These effects will, of course, only occur if congestion charging is successful in reducing car use.

1Transport for London, the mayor's transport body, predicts that the charge will reduce traffic congestion in central London by 10-15 per cent. Others disagree.

But even if car use does not fall appreciably, the mayor has started a vital public health ball rolling by attempting to break the cycle of ever-increasing car use, damage to health and the environment.

This is a global problem that must be tackled.

If it works, other cities around the world will soon follow suit. The congestion charge is expected to raise about£1bn over 10 years for investment in healthier forms of transport. This is no less than a hypothecated tax for health promotion.

Everyone who lives, works, uses or has business in London will benefit. The disbenefits, as shown in the HIA, are very small.

For those with tunnel vision, judgements will be made about the congestion charge in isolation from other transport and economic polices.

But much like other major, modern public health issues, there are no magic bullets that will, on their own, reduce car use in one painless and effective shot.

Reducing car use needs to be tackled like other health behaviours that are damaging to health. In the case of tobacco, it has taken a generation to get commitment to complementary national, local and individual change that is necessary for success.

Counter to what is often said by those with vested financial interests, changing health behaviours - such as dietary habits and exercise - are not difficult with the help of effective long-term policies. Before seat belt legislation, about a third of drivers wore seat belts. After legislation, it increased to 95 per cent, and has remained at this level.We must be patient with congestion charging. The jury hasn't even been chosen yet.

And where is the NHS voice in all this? Mostly absent, and apparently taking an individualistic view. Along with the many thousands of column inches devoted to the finer points of whether mud on the video cameras recording congestion charge fraudsters will make the scheme fail, a district nurse working in central London was quoted as saying, 'I am very much opposed to the charge.

'We have already got terrible difficulties with recruitment of staff.We have been told that what might happen is we pay the charge...and claim it back as an expense. This means the taxpayer will foot the bill.'

2But why are not taxpayers more concerned about the£29m they already pay to foot the medical and social care costs to society of road traffic accidents in London or the£1.4bn cost of the capital's road traffic accidents?

3One expects the road and car lobbies to behave much as the tobacco and alcohol lobbies when their freedom to profit is curbed in the interests of health, but surely we can expect more from NHS professionals?

Perhaps safer streets, reduced traffic volumes and shorter journeys may make it more attractive for community nurses to work in central London - and maybe even to consider other forms of transport.

So what further action should be taken in the long term to ensure the charge is effective?

Many, including the HIA, argued that the congestion-charging zone should be larger and should also become a low-emission zone for cars.

One of the potentially most effective ways to complement the charge might be for the mayor to provide greater financial incentives for central London's workers to use public transport outside the rush hour and for employers to redesign work patterns to allow more flexible working hours.

It will be vital for the mayor and Transport for London to evaluate and make transparent the full impact of the congestion charge over time.

The evaluation should be as objective as possible and the results published in peer-reviewed journals.

Transport For London has already embarked on an intensive piece of evaluation which will assess changes before and after the introduction of the charge. Its main current focus is on travelling patterns and attitudes within and outside the zone.

It must also aim to assess the impact on the indices of health identified in the mayoral HIA.

If it does not, a unique opportunity to demonstrate how much this brave new policy can really benefit health and reduce health inequalities will have been lost.


1London Health Commission. A report of a health impact assessment of the mayor's draft transport strategy www.Londonshealth.gov. uk/pdf/transport. pdf.

2Clark A. Congestion charges: an end to jams or road to nowhere? The Guardian. 3 January 2003.

3 Lowdell C, Fitzpatrick J et al.Too high a price. Injury and accidents in London. London Health Observatory. September 2002. www. lho. org. uk.

Dr Bobbie Jacobson is director of the London Health Observatory.