A good transport system is essential for a healthy society. The impact of air pollution on health is well-known, but transport affects the health of people across society, in multiple ways. Investing in transport is one way we can help address widening health inequalities and regional disparities in public health.

The quality of the transport infrastructure and the adequacy of transport services directly affect health by, for example, enabling active modes of travel (such as walking and cycling) that have health benefits or reducing road accidents and harmful emissions. But wider, indirect impacts on health include enabling people to get to work, school, hospital and fresh food shops, as well as social events and leisure activities – aspects of life that are important for good physical and mental health.

The growth in car ownership has revolutionised people’s lives in the UK – providing comfort and increasing the geographical scope of employment and social interactions. But these benefits have not been shared equally across society, with access especially low among young adults and low-income families. Car-centric policies can lead to underinvestment in other forms of transport. While cars are likely to remain the best (or only) option for some people, particularly where health conditions can otherwise limit mobility, a lack of public transport alternatives can mean reduced options for people without a car.

This long read examines the challenges of shifting towards a transport system that better supports health. It sets out:

• how transport affects health
• the consequences of a car-dependent transport system
• the difficulties in shifting towards greater use of public transport
• an overview of transport policy and the effects of COVID-19 on travel patterns.

The modes of transport that people use have changed significantly during the last 70 years. In 2019, the average annual distance people in Britain travelled was three times as high as it was in 1952 (Figure 1). This is predominantly due to the tenfold increase in distance travelled using private transport by road – mostly by car – reaching 11,000 km per person in 2019. Over the same 67-year period, the average distance travelled by bus has decreased from 1,900km to 600km per person. Rail travel increased from 800km per person in 1952 to 1,300 km per person in 2019.

Figure 1

The increase in driving is caused not only by a desire for convenience, but because cars play an increasingly important role in meeting a perceived minimum standard of life. For some, driving is not a choice but a reflection of deteriorating bus services and rising costs, as well as the need to travel further to find suitable work. Some struggle with the cost of driving but have no alternative transport options, resulting in lower quality of life and financial hardship.

Meanwhile, for people unable to drive, public transport policies can make the difference between social participation and exclusion. This is increasingly important today, when transport is one of the biggest components of household spend and public transport fares have increased at much faster rates than the cost of motoring and the general cost of living. 

In a 2019 survey, more than 70% of people polled were in favour of reducing motor vehicle use in urban areas for the sake of public health. But this view is not reflected in the behavioural reality of people in the UK.

Many people say they don’t have an adequate alternative to their private vehicle. Many more who rely on public transport experience at least one problem with their work commute. This affects people’s decisions on what jobs they can accept, how often they can visit friends and family, and which educational or health care facilities they can access. All of these are important factors that affect our physical and mental health, as well as our quality of life more generally.

The government has recognised the role investment in public transport can play in helping to ‘level up’ poorer regions as well as promoting healthier, greener environmental outcomes. Pre-pandemic announcements made in February 2020 included £5bn for improving buses and active travel outside of London over the next 5 years. Of this funding, £250m was allocated to an emergency active travel fund to help councils reconfigure road space for cyclists and pedestrians during the pandemic.

However, given historic trends in use of alternative modes of transport relative to car use, to make real progress in shifting away from cars, a concerted effort is needed to tackle long-term systemic challenges in transport policy and infrastructure.

Transport affects health directly, but also indirectly – through its relationship with the wider determinants of health. This influence occurs through four main channels:

• active travel
• air and noise pollution
• road safety
• social exclusion.

Active travel

Increasing physical activity and minimising time spent sitting down helps maintain a healthy weight and reduces the risk of cardiovascular disease, type 2 diabetes, cancer, and depression. The UK Chief Medical Officers recommend that to stay physically and mentally healthy, adults should do at least 150 minutes of moderate or 75 minutes of vigorous activity per week. Walking and cycling as part of routine travel – whether for an entire journey, part of one, or to access public transport – can help meet these targets.

In 2019, car, vans, motorcycles and taxis accounted for 86% of the total distance travelled in Great Britain, compared to just 30% in 1952. Private motorised vehicles offer great convenience and mobility to some users, but they also contribute to reducing the mobility of others. These unintended consequences include:

• Marginalised road users. Without bus and bicycle lanes, congestion marginalises other road users, making bus services less reliable and contributing to a perception of danger. Every 10% drop in bus speed caused by congestion leads to a like-for-like drop in bus passenger numbers.

• Reduced services. As people abandon public transport in favour of car ownership, it becomes increasingly difficult to sustain unprofitable services. This could lead to higher fares and poorer availability for those who still depend on public transport as their only way of staying connected. While local authorities can subsidise ‘socially necessary’ routes, declining profitability and financial pressures due to austerity can put services at risk. For example, in 2019, local authority funding for buses was £163m lower (in real terms) than in the previous decade, contributing to 3,000 fewer supported bus services in England.

• Reshaped built environment. Car dependence encourages the development of built environments that are predominantly adapted to the needs of drivers, leaving others behind. One study of planned housing communities in England found that most were designed around car use, with little-to-no funding for walking or cycling. It concluded that just 20 new communities would lead to 200,000 car-dependent households, as developments were built in locations far from town centres and local services.

These problems illustrate how the transport and infrastructure planning decisions we make today risk locking in higher car use for the future. The right planning approach can encourage a shift towards a wider range of transport options that can help support a healthier and more environmentally sustainable transport system. But car-centric decision making could reinforce problems that have high costs to society – both today and in the future.

Access to cars is limited for some groups in society

Our analysis shows that in 2017/18, around 33% of households in the lowest income quintile did not have access to a car, compared to just 5% of households in the highest income quintile (Figure 3). Providing high quality public transport is important – especially for low income individuals and other population groups less likely to have access to a car, such as young adults, members of black and minority ethnic groups, and people with no qualifications.

Figure 3

Bus use

In most parts of England, bus usage has been on a long-term decline for the past seven decades. Since the 1980s, bus passenger journeys have declined in most UK regions (with London being the key exception, where such journeys have increased). Figure 7 highlights this trend, showing the change in bus journeys per head of population for UK regions since 1991/92.

Figure 7

The coronavirus pandemic has inevitably had a disruptive impact on travel patterns. During the first lockdown in April 2020, car use collapsed to a third of pre-pandemic levels and public transport use fell even more sharply. Unsurprisingly, car traffic normalised more quickly than public transport use during the summer months. While restrictions were in place, there was a clear rise in walking and cycling activity.

In January 2021, during the most recent lockdown, transport use has also been low relative to the pre-pandemic period in January 2020, although it is higher than in the first lockdown because restrictions in some sectors are less stringent. Social distancing measures, perception of danger and restrictions on travelling to work are likely to reduce public transport use while measures remain in place.

The social distancing measures disproportionately disadvantage people who rely on public transport as their only means of commuting – and for whom working from home is not feasible. While many people with high incomes depend on public transport for commuting, the jobs available to them are more likely to enable homeworking than the roles of lower earners. Analysis of the UK Household Longitudinal Study shows that 69% of adults in the top income quintile said that they worked from home at least some of the time in June 2020, compared with only 37% of those in the bottom income quintile.

Figure 8 shows how public transport use varied during the first wave of the pandemic across different household income bands, depending on whether people were working from home at least some of the time or not at all. It highlights that members of lower income households were more likely to use buses. Among households with the lowest 40% of incomes, the share of people using buses at least once or twice per week and never working from home was 8–9%, compared to 5% in higher income bands.

Figure 8

Pandemic restrictions have led to significant shifts in transport use. The reduction in car dependency and increases in cycling and walking have led to greener and healthier travel. Restrictions on public transport have (necessarily) been a step backwards. However, the coming recovery phase for the UK represents a clear opportunity for transport to build back better – and build back fairer.

Even before restrictions altered travel patterns, there were clear indications of greater public support for progress on transport that better supports health. More environmentally friendly modes of transport, safe spaces for more active modes of transport and better-quality public transport were all in demand before the pandemic, and must remain a high priority now.

Ensuring that people – particularly those from more deprived areas, or sectors hit hardest by COVID-19 restrictions – are connected to jobs can help economic recovery and support the ‘levelling up’ of economic outcomes. It can also aid social recovery by preventing social isolation and enabling people to access services and participate in social activities. This is why, when assessing new policy plans, their value for wellbeing and health must be considered. New initiatives should not be prioritised for their economic benefits alone.

The government have already announced plans for increased funding for buses and active transport over the next 5 years, but will need to go further with greater investment over a longer time period to enable the UK to significantly shift away from car dependence. While the coming fiscal climate is likely to be tough, the (currently) low cost of borrowing should be taken as an opportunity for greater capital investment.

Increased investment in our transport infrastructure now and in the next decade can have long-term benefits – from the health gains of lower pollution levels through to access to better jobs for young people who are particularly likely to experience a difficult time in the labour market in the next few years. It is crucial to ensure that transport considerations are factored into other initiatives which are already underway, such as the UK Shared Prosperity Fund, the Towns Fund and new house building projects. Committing to a programme of long-term improvements will also be key.

Transport patterns have changed dramatically over the past 70 years. Today’s two-pronged need – for a recovery plan and for an environmentally sustainable economy – presents an important opportunity for the government to invest in a greener, higher quality, more active transport system that enables healthier lives for all.

A commitment of this nature could underpin a range of existing policy drives that extend beyond direct commitments to improve health and reduce air pollution, supporting the recovery efforts, and levelling up the economy.

To do this effectively, it will be essential that the government incorporates the following priorities into its planning:

• Greater coordination of new infrastructure projects with transport policies, to reduce car dependency and improve community connectedness.
• Increased safe cycling and walking facilities (such as segregated cycle lanes and secure bicycle parking facilities).
• Supporting public transport reliability by introducing traffic management measures such as priority bus routes.
• Increasing the availability, reliability and affordability of public transport services to improve wellbeing and shift travel behaviour away from cars.

Disruptions of the magnitude seen in 2020 and into 2021 have the power to trigger permanent shifts in behaviour towards more environmentally sustainable transport modes. However, concerted political will is required to enable long-term change.