Planning, transport and health inequalities - a recent history and future progress

A decade into the 21st century debates about health have become dominated by how we live, which in part reflects the rise in so-called ‘lifestyle diseases' such as obesity.

With so much emphasis on individuals and the choices they make, what is the role for professions such as planning and transport. Can they help to create environments in which people can exercise their choices, however limited? By shaping the environment, do planners influence lifestyles and, potentially, help to reduce health inequalities?

A role in tackling health inequalities

At one level the answer is obvious. What an individual can and can't do is affected to some extent by the environment he or she lives in. Blackpool, one of the case studies presented here on transport and health inequalities, is no more than eight miles across and largely flat. Encouraging people onto bikes there is going to be a much easier task than for many parts of its largely rural and more dispersed neighbour, Lancashire.

Recent health guidance has made much of the potential of planning and transport to help tackle health inequalities.

The 2008 Government strategy 'Healthy weight, healthy lives' sets out the important role of planning to literally build in opportunities for people to be physically active through walking and cycling.

More controversially, 'Healthy weight, healthy lives' suggested that planners could do more to improve health by drawing up tighter controls for where fast food outlets open. There have even been calls for planners to think about whether applications for development include public spaces where women would feel comfortable breastfeeding.

Also in 2008 the National Institute for Health and Clinical Excellence (NICE) published guidance on physical activity directed at planners, which is based on a rigorous assessment of current evidence. NICE is building on this initial guidance by conducting a public health review of spatial planning, which is due to report at the end of 2011.

The most compelling recent trawl of evidence that demonstrates the impact of planning and transport policy on reducing health inequalities is the 2010 Marmot Review. Writing about how to tackle the social determinants of health at the local level, Professor Sir Michael Marmot and his review team state that "an important step… would be greater integration of health, planning, transport, environment and housing departments and personnel."

Opportunities and limits for changing behaviour

The case studies presented here are examples of what can be achieved when places use planning and transport to tackle the social determinants of health. But they also highlight the limits of what these environment-focused professions can do. While shaping the built environment creates opportunities for people to live differently, it won't be planners or transport planners that persuade people to walk to the shops instead of driving.

It is more likely to be a GP or a social worker or a catchy advertisement - or, even more plausibly, a neighbour or friend who also saw the catchy advert. What this demonstrates is that reducing health inequalities must cut across every aspect of what the local public sector does. It must, as the 2009 Health Select Committee Report on Health Inequalities put it, "be like a stick of Blackpool rock - the words go through the whole sweet".

For example, the Bristol case study has assembled a very strong evidence base for introducing 20 mph speed limits. Transport and spatial planners are responsible for the physical implementation of the limits. But the council and PCT accept that they need to "change hearts and minds" as well as changing speed limits. So a social marketing campaign will accompany the new signs and have a critical role to play in raising people's awareness about why driving slower is good for health.

The London Borough of Waltham Forest is the first council in England to put the advice of 'Healthy weight, healthy lives' to the test and introduce local planning guidance to limit the opportunities schoolchildren have to buy fast food. But no one is suggesting that this alone will solve the looming obesity epidemic. The borough has also set up a hot food takeaway corporate steering group to ensure that it takes a strategic approach to this issue: this work will feed into an overarching health inequalities strategy that will be published later in 2010.

To reinforce an approach which integrates health inequalities across different service areas, Stoke-on-Trent City Council and NHS Stoke-on-Trent have prepared a draft agreement setting out how the two organisations will work together on planning and regeneration in the town. They are putting this into practice through a range of documents including draft statutory guidance on healthy urban planning (a supplementary planning document - SPD).

Getting the infrastructure right

Nonetheless, transport and spatial planners have an important role to identify and provide different or better facilities and infrastructure that can create opportunities for changing how people live. The Darlington case study illustrates how its approach to planning for and investing in green spaces is based on a belief that if it creates attractive parks, paths and playgrounds, people will use them.

After identifying low levels of bike ownership in Blackpool, another case study, the city council realised that it was pointless telling people to cycle more if they didn't actually have a bike to begin with. So it is investing heavily in enabling bike ownership and improving access to bikes.

Signs of the times

Providing new infrastructure costs money. And while planning does have some potential to generate funds for new infrastructure and facilities through financial contributions from developers, most of the case studies featured here have relied on extra grant funding.

However, most of the interviewees are already cutting their cloth to suit the times, and seem to be fully aware that money is likely to be even harder to come by in the foreseeable future. Chastened by narrowly missing out on a potential £5 million of Healthy Towns funding, Sandwell decided to implement a version of the integrated health and planning model it had sought money to develop. The Sandwell Healthy Urban Development Unit (SHUDU) is a model of working that adds to the day job of planners and public health practitioners, but relies on their buy-in by demonstrating the links and potential benefits of working closer together.

This may well be a useful rehearsal for the new arrangements floated in the white paper in July 2010. If public health does find its way back to local authorities then planning and transport are likely to be two of the most obvious existing service areas to benefit.

Back to the future: the prospects for joined-up working between planning, health and transport

The recent slew of guidance on integrating health improvement and reducing health inequalities into planning and transport reflects a renewed enthusiasm from public health experts for using environmental interventions to change behaviour.

Public health practitioners looking to put this into practice may come up against a surprising barrier: planners. It's not that planners dispute these links - it's just that many think they are already integrating health into what they do. One of the case study interviewees from a PCT told how they had been assured that working with planners would be like "pushing at an open door" - but in practice the door "most certainly wasn't open". Why? "Because planners thought they were already doing health".

It is true that planners have been behind some of the greatest public health advances of the 20th century, for example, utilising advances in sewage and sanitation systems to replace urban squalor with hygienic and healthy places.

But planners have also presided over the rapid expansion of towns and cities since the 1960s. This largely car-based pattern of development is now one of the scourges of the modern public health movement. It promotes obesogenic environments, where physical inactivity is literally built into where people live, undermining the idea that all urban planning has been positive for health. In fact, the Marmot Review found that the current planning system "is not systematically concerned with impact on health and health equity."

What these case studies demonstrate, though, is that with patience and persistence doors can be opened - if somewhat prised open to begin with - and that a shared agenda does exist despite the lack of a systemic approach to health from planning.

They highlight that public health practitioners need the support and influence of planners if they are to reduce health inequalities. But they also reveal what public health can offer planning: expert knowledge, useful contacts, an expectation of working in partnership, and an analytical way of thinking that steeps interventions in evidence and evaluation.

None of the case studies presented here boast of quick wins - conceiving, planning and executing changes to a town or city take years, sometimes decades. In that way there is an obvious shared agenda with public health, which plans interventions that may take many years to implement and evaluate.

If towns and cities are to become healthier places to live for everyone, public health practitioners need to continue to find ways of working with local authority spatial planners and transport planners so that villages, towns and cities become environments where all people can choose to pursue good health.


Fair society, healthy lives: the Marmot Review

NICE public health review on spatial planning and health

NICE guidance on physical activity and the environment

Healthy weight, healthy lives

Health Committee report on health inequalities (third report)

Case studies

Blackpool City Council
Tackling health inequalities through cycling

Bristol City Council and NHS Bristol
20 mph limits in areas of high health inequalities

Darlington Borough Council
Using an open spaces strategy to reduce health inequalities

Sandwell Council and Sandwell PCT
Sandwell Healthy Urban Development Unit (SHUDU)

Stoke-on-Trent City Council and NHS Stoke on Trent
Using spatial planning to reduce health inequalities

London Borough of Waltham Forest and NHS Waltham Forest
Planning guidance on hot food takeaways to help reduce health inequalities

About the author

Andrew Ross is a trained planner who writes on the links between the built environment, health and sustainability,



4 November 2016

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