Earlier this week, a group of leading medical groups and charities wrote a letter to The Independent, saying the NHS and social care are at a breaking point, with a predicted deficit of £30bn in 2020. Certainly, the future funding and sustainability of the health service is likely to be a major issue in the run-up to next year’s UK general election. What is sometimes neglected in these debates is what we can do to reduce healthcare costs through preventative action, as most health issues have a strong preventable component. Without prevention, the financial cost of healthcare will become unsustainable for formal health systems but also societies more generally.
The third Planning Horizons paper, Promoting Healthy Cities, which was published this Tuesday at the RTPI Scotland Annual Conference in Glasgow, argues that ‘health’ is not limited to hospitals and genetics: the environment in which we live, work and spend leisure time – both the physical nature of places and the social environment of communities – has an enormous impact on our health and wellbeing. Health and wellbeing need to be at the core of how we design and develop urban environments and part of a wider preventative and proactive approach to health. For too many people, cities are still failing to deliver positive health outcomes.
Urbanisation is taking place on an unprecedented scale, especially in the developing world. By 2050, seven out of every ten people will be living in towns or cities – more than six and a quarter billion people. Globally, the urban population is growing by around 70 million a year, with 200,000 more people living in urban areas every day. This means that cities will be the places that help to determine the health and wellbeing of the majority of the population in the twenty-first century, one of the most pressing challenges facing our societies.
In addition, in both the developed world and the developing world there remain significant and in some places growing inequalities in health and wellbeing. In England, the so- called 2010 Marmot Review showed that there is a ‘social gradient’ in health: those living in the most deprived neighbourhoods die earlier and spend more time in ill health than those living in the least deprived neighbourhoods. In Scotland, the Ministerial Task Force on Health Inequalities launched the ‘Equally Well’ report in 2008, which highlighted the health inequalities in the country and the actions needed face to this challenge.
Promoting Healthy Cities summarises these issues and our increasing understanding of how the urban environment shapes our health. It includes case studies drawn from the UK and the rest of the world where planners and other professionals are leading responses to health challenges. Health problems such as obesity, chronic heart disease, stress and mental health issues are intricately linked to the environments in which people live and work. Transport, access to green space, access to healthcare, pollution, housing quality, access to food, community participation, and social isolation are all shaped by social inequality and in turn have significant implications for health. We also now need to recognise that climate change may be the biggest health threat facing our societies, including the impact on safe drinking water, sufficient food and secure shelter.
Taking housing as an example, it is estimated that three in ten people live in bad housing (3.6m children, 9.2m working age adults and 2m pensioners) and that poor quality housing costs the NHS at least £760m per year in the UK. Poor conditions such as overcrowding, damp, mould, indoor pollutants and cold have been shown to be associated with poor physical and mental health.
A lack of effective and proactive planning for urbanisation can result in places which are poorly connected, overcrowded and polluted, with inadequate access to housing, services and employment, exacerbating inequality, social exclusion and poor health. For example, the number of people living in informal settlements could triple to three billion by 2050. If well-planned, however, cities can not only prevent many unhealthy outcomes but also promote better wellbeing, quality of life and opportunity for all. In this way, better cities can be a major part of preventative health and planning is an often neglected ‘lever’ to promote healthy cities – it can help to create successful places that enhance people’s lives.
Promoting Healthy Cities argues that in the twenty-first century, we need to create cities that maximise health alongside economic growth, by making health and wellbeing one of the primary factors in how we design, develop and manage urban environments. For this, we need a new, wide-ranging urban health agenda. This urban health agenda needs to be part of a broader agenda for sustainable urbanisation. In July 2014, a specific urban goal was included in the proposed Sustainable Development Goals, which will replace the current Millennium Development Goals from 2015. This aims to “Make cities and human settlement inclusive, safe, resilient and sustainable”, supported by targets such as eliminating slum-like conditions, reducing urban sprawl and ensuring universal access to safe and sustainable urban transit.
While planners and public health specialists will be central to this, other policy areas will also need to be integrated into this. The social determinants of health include not only neighbourhoods and the built environment, healthcare and public health, but also education, economic development and transport infrastructure. The possibility of a wider and more integrated urban health agenda is not only undermined by institutional division between planning and public health, but fragmented further between formal healthcare, social services, housing, education and regeneration as well as the private sector. Planning needs to be a critical part of our collective responses to the urban health challenge in the twenty-first century.