London 2012—What health impact?
=================================

* Fiona Sim

*   Health policy
*   primary care
*   public health
*   public health policy

## Why does it matter?

One might think that the Olympic and Paralympic Games are all about competitive sport and the demonstrable impact of incredible levels of fitness achieved by those selected to represent their countries. One might be glad that athletes of so many of the world's nations can come together in peace or that the status given to the Paralympics means that the stigma of disability can be consigned to history. And then the Games are also about the marketing of London UK PLC and a somewhat incongruous display of economic and political might at a time of national and international austerity.

So while sport is perhaps the most obvious purpose of the Olympic Games, the public health impact of the Games may stretch well beyond the Games themselves or their traditional ambitions. The health impact of any intervention can be either positive or negative or it may have no impact at all. As far as major sporting events are concerned, a systematic review published in 20101 concluded that there was insufficient evidence to propose that future sporting events would impact on the host population's health or socioeconomic status, though the authors were critical of the quality of the previously conducted research with which they had to work. If we commence with an assumption that hosting the Games *should* be good for the health of Londoners—and others, it will be important to see if the efforts made do achieve these ambitions.

If we apply a broad model of health, then virtually every area of human activity can influence human health, and therefore most public or political decisions have the potential to impact on population health, both positively and negatively. We know that the greatest scope for improving the public's health often lies outside the control of the health services, through interventions in economic, housing, agriculture, transport, education and other ‘non-health’ policy areas. This is likely to be very true of the London Olympics and Paralympics. The concept of health impact assessment has been with us for over a decade, and its methodologies have already proved valuable in the context of the 2012 Games.2 HIA provides a flexible and adaptable approach intended to influence decision-makers so that policies, projects and programmes in all areas lead to improved public health or do no harm to population health.3 So HIA is not merely a research tool, it is a political tool to aid decision-making. HIA, as defined by the WHO Europe in 1999, is thus a means of assessing the health impacts within a defined population of policies, plans and projects—such as the Olympics—in diverse economic sectors, using quantitative, qualitative and participatory techniques.

## Potential for benefits and harms

As far as the London Olympics are concerned, that there could be impacts on population health was recognised early in planning, and a rapid screening assessment was published as early as 2004, prior to the outcome of London's twice daily to host the 2012 Olympics.4 This HIA explored the health impact of having versus not having the Olympics in London. It sought ‘to examine the nature and extent of health impacts over the period 2006–2012 and beyond’ on the local community. Many potential health impacts (positive and negative) were identified, and the HIA stakeholder workshop concluded at the time that overall ‘participants considered that risk to health from construction activities, employment impacts and gentrification as being significant. However, the most significant influence on health raised was a potential lack of community involvement.’

Now that the Games are upon us, in the heat of the moment, it would be easy to overlook their legacy in terms of health impacts—during the period of the Games themselves and afterwards, as well as the preparatory period.

So how broadly should the net be cast if we are searching for health impact? Having started with the knowledge that there could be impact on population health, the next step is to scope that impact. To do this, questions need to be asked, for example, the geographical area, the population and the timescales to be covered. Geographically, to limit consideration to London would be too parochial: at least the whole of England may be affected, not to mention the close scrutiny being applied by the Scots as they plan for the 2014 Commonwealth Games in Glasgow. Note, for example, the report published from the North East of England5 and the conference held in the South West in 2011,6 to consider the health impact of ‘2012’ to those regions. Clearly, a positive impact is desirable and regions plan to exploit this. London and the other areas hosting Olympic events have a broader agenda, in that they have to ensure, as far as possible, the immediate welfare—the health and safety—of all athletes and their entourage and Games ticket holders, in addition to planning to benefit from the more generic, largely economic, short-term opportunities offered by an influx of international visitors and the longer term opportunities offered by the association with promotion of healthier active lifestyles.

Ethically, it can be argued that if a positive impact can be assured and a negative impact avoided, these are desirable outcomes. There may be caveats regarding affordability and the possibility that one person's positive impact could be someone else's negative impact, but more of that later. As for the population, why should the impact be restricted to any groups? And as for timescale, the UK health impact of the Games probably started the day the host venue for 2012 was announced and may be expected to continue for many years or decades after their conclusion.

## Where is the capacity to capitalise on positive impacts while minimising the harmful ones?

While much of the responsibility for the health legacy lies with traditional local government departments, such as planning, leisure and environmental services, the public health delivery system has a huge role to play in protecting and promoting population health before, during and after the Games. So, it is of some concern that the public health system in England is, once again, in a state of flux this summer, as the NHS reforms proceed and public health departments move into local government.7 The transfer of funding from the NHS to local government remains to be fully resolved and recruitment to some critical public health roles is delayed. However, the planned transfer of the Health Protection Agency to the new agency, Public Health England, has not yet taken place, so that at least the national leadership and coordination of the specialist health protection function can be maintained for duration of the Games and beyond. Given that coordination and planning for management of health emergencies and outbreaks of communicable diseases are important HPA functions, this stability is reassuring, but the fragility of the mainstream public health function at this time of flux may impede efforts to ensure that all opportunities arising from the Games to improve and protect health are captured. In addition to public health transition, including the creation of Health and Well-being Boards led by local authorities to oversee local health strategy development, the Primary Care Trusts, which oversee healthcare commissioning and quality of services, have also been undergoing reconfiguration, with the NHS East London and the City Cluster of PCTs, which includes the Olympic Park venues, only coming into existence in April this year.

Among the concern about public health capacity, there is a risk that the capacity within the ‘wider’ workforce could be unrecognised and thereby wasted. Thousands of ordinary people from all walks of life, including health workers, have been recruited as Olympic and Paralympic volunteers—the ‘Games Makers’. Without doubt, channelling some of their energy into a force for improving health would be an opportunity not to be missed—and dare it be said, a chance to try out the principles of the Big Society on something that matters? The prospect of Games Makers contributing to ‘making every contact count’ (see footnote i) for health and well-being is an exciting one—let's not waste it.

## Optimising health impact

Considerable effort has been made to predict and optimise the positive health impact of the Games and to mitigate the negative. Much of this work has been led by NHS London (the Strategic Health Authority for London) working closely with the office of the London Mayor.8 The development of a collaborative partnership between bodies in London, which have complementary responsibilities, brings about its own legacy, which may be hard to quantify, but bodes well for future collaboration—except, of course, that the latest NHS reforms mean that the Strategic Health Authority will no longer exist after March 2013, and new relationships will have to be built from scratch.

When challenged to identify any likely health impact of the Olympics, people struggle to answer—more people playing sport should be good for their health, they say; regeneration of the largely deprived area of East London that is host to much of the Olympic activity has meant employment for local residents and the resultant increase, hopefully, in availability of decent quality, affordable modern homes: yes, all of this should be good for the health of the population, in the short, intermediate and long term.

In reality, the potential health impacts are complex, vary over time and encompass both good and bad.

By way of example, where a potential impact has been recognised as harmful, substantial planning has taken place to mitigate the impact—so, for example, there have been concerted efforts and targeted resources for emergency planning, which is in itself welcome from the public health perspective—though, as with other effective public health interventions, its impact will be the absence or reduction in harm compared with the impact had the intervention not taken place, which is always challenging if not impossible to quantify.

## Impact on the NHS?

What about the NHS, is the potential impact trivial? Initially, one might think that the influx of several thousand fit young people would have little effect on the day-to-day running of the health service. But a little more probing and we find that hospitals and other healthcare providers in the area of the main events have in place detailed plans to cope with additional demands for their services as well as heightened emergency preparedness. Not only that, but they have to expect that their staff are likely to struggle to reach their workplace for several weeks this summer, as a result of the effect of the Olympic Transport Plan,9 which is also expected to impact adversely on supplies, not to mention patients. It has been described as the equivalent of five rush hours per day during the Olympics.10 In addition, the NHS is likely to prove a valuable resource among those members of the ‘Olympic Family’ who are less young and fit, for all of whom the NHS will be available free at the point of use, though not for intentional health tourism. Estimates of 5+% additional unplanned activity have been made,11 which although that might sound quite modest, will present a real challenge to an NHS already expected to make real savings in 2012/13 in response to the economic downturn and downward pressure on public spending.

Before we leave the NHS, what was that about thousands of young fit people, descending on London? Well, of course, that will present another challenge to the NHS—through the additional demand for sexual health services, including contraception and treatment of sexually transmitted diseases. Indeed, pharmacies in London have been girding their loins (pun intended) in preparation for the increased demand for postcoital contraception, while at the same time worrying that their staff will be unable to get to work. Sadly, the increased consumption of (low price) alcohol and partying are also likely to be associated with violence, accidents and injuries that end up in A&E departments—contributing to the pressure on the acute sector.

## Health and sponsorship

In the context of 2012, it is impossible to consider health impact without consideration of sponsorship. Major sponsors that include manufacturers and retailers of what are now generally regarded as unhealthy foods and drinks are difficult to reconcile with short or longer term improvements in health and well-being. But the arguments were made and seemingly lost years ago12—reminding us that what is a positive economic impact to one multinational corporation may well be a negative health impact for many thousands or millions of consumers. To add some perspective here, there is currently much work being done in preparation for the Commonwealth Games in Glasgow in 2014. It has been noted in that context that ‘in the (London Olympic) Aquatic Centre, the seats are 46–47 cm wide, but since people are getting bigger, most temporary seats in future will be 50 cm wide.’13 That is some legacy.

In the Centenary year since the sinking of the Titanic, we really do have to do some rapid turning to get out of where we are headed. We must wish all the best to Glasgow for 2014 and to Rio for 2016, as they, too, strive to achieve the elusive positive health impact.

The health lobby must find its voice among the world's political leaders, before the stadium seats in Qatar in 2022 are made 55 or even 60 cm wide.

### What is already known on this subject

*   There have been various attempts to predict and to quantify the health impact of the Olympic Games and of other large scale sporting events in different cities. Some of the published and unpublished evidence describes specific aspects of health impact, while others have taken a broader definition of health impact. It has to date been challenging to find evidence of achievement of a positive health legacy, though this is an important aim of the London Olympics.

### What this study adds

*   This paper brings together evidence from diverse sources on which to base consideration of the likely health impact of the London 2012 Olympic and Paralympic Games.

## Acknowledgments

Thanks to Karen Lock, Vanessa Saliba, Lucy Bell and Dan Swerdlow for their creative ideas for this editorial.

## Footnotes

*   Competing interests FS was one of several hundreds of thousands of people who applied unsuccessfully for Olympic tickets in the first round of allocations. She eventually purchased two tickets in May 2012 and so will be attending an Olympic event this summer. Online UK application for Olympic tickets was without doubt one of the most challenging tasks of the past year and the source of as yet unevaluated adverse health impact.

*   Provenance and peer review Commissioned; internally peer reviewed.

*   i Making every contact count (MECC): Source: Steve Field, Chair: NHS Future Forum 2nd Phase Report, January 2012. ‘Every healthcare professional should make every contact count—use every contact with the public to help them improve their health’. … but why not extend beyond healthcare to every type of encounter? [http://healthandcare.dh.gov.uk/forum-report/](http://healthandcare.dh.gov.uk/forum-report/) (accessed 2 Jun 2012).

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