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No fit state to be in

In the first in a mini-series on planning and health, Ben Willis finds that despite planning's roots in the 19th century drive for public health these principles have fallen by the wayside.

Every day we are told what unhealthy and vulnerable lives we lead. We are fat, depressed, do not exercise enough and breathe in who knows what from the cars clogging our streets, the same vehicles that are responsible for running over nearly 30,000 of us every year. What is often overlooked is that most of these ailments are by-products of the environment in which we live.

A heavyweight report published last month by the Royal Commission on Environmental Pollution concluded that with clear links between the urban environment and obesity, heart disease and poor mental health, planners and the planning system are vital to the nation's well-being. However, with planning and public health often operating in two separate spheres, the report points that out that we are missing a trick in tackling some of society's gravest ailments.

'The planning system offers an important opportunity for a more coherent effort to develop our cities to positively affect the health and well-being of urban inhabitants,' it concludes. 'The system, however, is still unable to deal adequately with complex public health issues. For local health concerns to feature much more prominently in the planning process for urban areas, the wider community as well as health professionals must be involved from the start.'

Planning and health were once closely allied. Indeed planning has its genesis in the 19th century movement to make towns and cities more salubrious places to live. Since then, planning has evolved to suit different agendas and thus moved away from its original ethos, according to the director of the World Health Organisation (WHO) centre for healthy cities at the University of the West of England, Hugh Barton.

'Many authorities think of planning as being concerned with enabling the market on one hand and environmental protection on the other,' he says. 'The fact that its core role may be providing for the health of the community has not quite got through, despite the fact that modern town planning originated from health concerns.'

The links between health and the urban environment are numerous. For example, every year there are 34,000 obesity-related deaths in the UK, most of which could have been avoided if more people took the recommended 30 minutes of exercise five times a week.

At the moment, only 35 per cent of men and 25 per cent of women stir themselves to this extent, which is why obesity is undergoing such a rapid increase. One of the reasons for this is that people often have to go out of their way to take exercise. So planning has a clear role in creating environments where exercise can be built easily into the daily routine, for example through better walking and cycle facilities.

'You make the biggest difference to health by making the healthy option the easiest option,' argues former Royal College of Nursing general secretary Christine Hancock. 'It is not realistic to think that the whole population is going to go the gym three times a week, but if you could build moderate exercise into people's lives it would be much more likely to keep them healthy.'

In her current role as European director of the campaigning body Oxford Health Alliance, Hancock fears that the rhetoric on joined-up government pervading all levels of public service is rarely reflected in reality. While Department of Health officials are well aware of the contribution that planning could make to health, other relevant government departments responsible for transport and planning rarely give much consideration to health in their own policies. The same is true at a local government level, where stretched health and planning authorities tend to operate in isolation rather than collaboration.

The question for planners and health officials, therefore, is this - how can they work together better to bring planning closer to its original ethos and transform the notion of public health into one of prevention rather than cure? The NHS is ploughing billions of pounds into coping with a rising tide of chronic disease that, with some forward thinking, could be prevented at source by changing the way people live their lives.

Experts call for integrated assessments

Among its many recommendations, the report suggests making health impact assessments (HIAs), currently carried out voluntarily by some local authorities, a mandatory part of the planning process. Specifically, it says HIAs should be included in environmental impact assessments (EIAs). Although EIAs are a statutory part of the planning process for new developments, they are not obliged to consider impact on human health. 

Mark Elton, technical director at planning consultancy WSP Environmental, agrees with the commission's view that the best way to integrate health considerations into project planning is via the EIA. 'At the moment there are some HIAs being done but they are stand-alone reports rather than integral to the planning process,' he says. 'It is more valuable if an HIA is done as part of an EIA because then it becomes part of a statutory document that will actually be read. If you are going to integrate health, social and economic issues then the EIA is the perfect place to do it.'

This integration, Elton believes, would by default also lead to the kind of joined-up working advocated by the commission and others. 'It would give planners an opportunity to talk to stakeholders who are not already involved in the EIA process, such as public health directors and NHS trusts,' he argues. 'They would be involved from the start and be a vital part of the process.'

The commission pointed to examples of towns and cities that have successfully integrated health considerations into their planning procedures. Many of these belong to the WHO healthy cities network, an international movement that enshrines the organisation's principles of healthy urban planning. These also closely match the principles of the commission itself for collaboration between planning and health authorities and the use of HIAs.

One of WHO's healthy cities is Brighton and Hove. According to city council head of city planning Rob Fraser, health and planning authorities here have been working together in preparing the local development framework (LDF). 'LDFs expect you to make very strong links back to community strategies,' he explains. 'So the process started with discussions with the community strategy people. They had targets for health, so we took the community strategy headings for the first draft of the core strategy and just copied them. We can therefore make the targets on health in the framework very explicit.'

Although it may sound like one more bit of procedure in the already cluttered bureaucratic landscape of local governance, Fraser claims that the process does not require much extra work. 'It does not involve lots of theory or serious research,' he explains. 'The difficult bit is getting the data. But the primary care trust has got the experts who can get the statistics that we would struggle to find. When we came to putting the documents together, it seemed to fit in naturally with the process of thinking about how we can improve people's lives, which is what planning is about.'

Awareness will help make action a priority

What might be more of a problem for some smaller planning departments is the thorny old question of capacity. Many authorities are already groaning under the burden of the demands that are being placed on them, while in some smaller authorities there is also a shortage of skills.

But Hancock believes that health must quickly become a central consideration in the planning process, as the environment and climate change has done over the past five years. 'Child obesity is to us what the melting glaciers are to the environment movement - a very clear sign that something is going badly wrong,' she says.

'I am not sure that we have yet got to the point where people outside the world of health see it as that serious, whereas environmental concerns are now reaching into all parts of life and people are talking about them,' she suggests. 'That has to be our mission, to get more people understanding not just the scale of the problem but that preventing it also quite easy.'

Belfast Healthy Cities

Belfast is a member of WHO's healthy cities network and has established a partnership called Belfast Healthy Cities to put the issue at the forefront of all decisions made about public service delivery.

To date, the partnership has worked closely with Belfast City Council's planning service on the preparation of the metropolitan plan. 'We work with the planning service to get it to see that it needs to build health considerations into the plan,' says partnership health development officer Maire McCotter.

It has also been closely involved in the regeneration of the Lower Shankill area, where high concentrations of poverty mean that health is a prime concern. 'Here we are working with partners to try to raise the health aspect of this regeneration programme,' says McCotter. 'We are engaging with local people and different agencies, then drawing up a report and presenting it to the housing executive and various government departments. We will then follow it through to monitor whether they are going to rule a proposal out or alter it to make it more beneficial to people in terms of health.'

 The partnership also trains planners, housing executive members and staff from other key public agencies across the city in health impact assessments, McCotter adds.