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Similar to the planning function does more for the cities HEALTH than the NHS
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the planning function does more for the cities HEALTH than the NHS
- 1. The planning function does more for the cities health than the NHS discuss. Greg Fell Director of Public Health, Sheffield Greg.fell@sheffield.gov.uk @felly500 https://gregfellpublichealth.wordpress.com/
- 2. Context. 5 things on my job description 1. Transform PH, from NHS facing to LG facing 2. PH is NOT the PH Grant, but totality of org 3. Stat Duty = to improve health of pop, not to provide some PH services 4. Job - influence the futures that don’t yet exist, often influencing other people’s money 5. Metric = the gap in h life expectancy …..Oh…. And “write a strategy”
- 3. Starting point for PH types……. this working backward? Health ≠ the NHS …………
- 4. Or this working forward The inequitable distribution of this drives demand
- 5. Your job description • If you do your job well, you will create far more health than all the cities doctors put together • To create a city that is less fat, more active, more socially cohesive where well being is the default and easiest option. • Some “built”, some “social”
- 6. Mind the gap. How long will your council survive • social care remand – adult, children, LD • NHS demand • economic productivity – onset of illness age • social justice
- 7. Causes Causes of causes & how far upstream Causes of health inequitable spread of risk Causes of causes Inequitable spread of power neoliberalism Political origins of health inequities: trade and investment agreements http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31013-3/fulltext?rss=yes Joseph Stiglitz Says Standard Economics Is Wrong. Inequality and Unearned Income Kills the Economy http://evonomics.com/joseph-stiglitz-inequality-unearned-income/ Ha-Joon Chang | The economic argument against neoliberalism - https://m.youtube.com/watch?feature=youtu.be&v=ti3rjogF_VU
- 8. The most important public health strategy you haven’t read? • Danger we will all focus on “businesses” and “the economy” • What IS “the economy” • Healthy lives are an economic investment. A bit like HS2
- 9. Reframing transport policy – bike lanes vs more roads vs screening and cancer drugs. How to define “success” in transport policy https://gregfellpublichealth.wordpress.com/2016/10/17/ten-thoughts-on-reframing-transport- policy-as-a-health-investment/ https://gregfellpublichealth.wordpress.com/2016/10/01/parks-and-bike-lanes-and-healthy-folk-on- the-value-of-different-forms-of-investment/ http://publications.arup.com/publications/c/cities_alive_towards_a_walking_world http://lcc.org.uk/articles/healthy-streets-are-cycling-and-walking-streets
- 10. Scotland – getting it wrong Its not the pies and cigs (it might be the booze) • What happened in the 1950, 60, 70s - Catastrophic loss of industry in Scotland - shipyards • Fundamental changes in social structure and patterns • Gorbels -from close knit community to large flats and build new towns. • Men had no jobs, no community facilities, no schools, no shops. http://www.gcph.co.uk/publications/635_history_politics_and_vulnerability_explaining_excess_mortality policy recommendations - http://www.gcph.co.uk/assets/0000/5587/Excess_mortality_-_Policy_recommendations.pdf https://www.theguardian.com/cities/2016/jun/10/glasgow-effect-die-young-high-risk-premature-death
- 11. “planning and health” – here’s some detail you can go over at your leisure • Inequality – creating more equal societies where all have equal opportunity • Transport – air q, activity, carbon and sustainability • walkable environments being the default option and the hierarchy • Obesity – food environment, activity, obesogenic environment etc. hot food outlet density. Concentration. • Open green space – mental well being, activity. building green space, municipal space, parks / playgrounds INTO new developments the default – activity, mental well being, • Play facilities • Housing standards – trip hazards, cold homes and insulation, housing design • location issues (mixed developments, not all posh folk enclaves • Transport / housing / employer links – issues around agglomeration etc Agglomeration - There’s something to be said about building employment zones miles away from residential zones and how this structurally builds in air pollution etc… • Healthy building standards inc Age and disability friendly housing • Demographic stuff and planning health care facilities within developments – • Land use and mix, land density - Social regeneration – and role of planning in this. Not segregated – socially mixed developments. Build on the Glasgow research, referenced at bottom. • living wage type discussions as a default expectation in applications for new retail or industry developments • Noise pollution • Retail Offer – not all takeaways • Stuff around community safety – defensible spaces, planning out crime, reclaim the streets, space for community events and gathering • Housing growth and impact on other policy objectives https://gregfellpublichealth.wordpress.com/2017/02/10/planning-processes-healthy- cities/
- 12. Raynsford – opportunities 1. Resilience of developments – floods, AQ 2. Climate change – impact of planning policy 3. Long term infrastructure – the drains? Open and green space? 4. Travel choices and spatial planning. 5. Age proof, all ability friendly developments. 6. Socially cohesive communities, not gated developments 7. Privatisation of profit of development, socialisation of risk. 8. Healthy neighbourhoods and dwellings 9. Community involvement in the process 10.Land value in public interest
- 13. There’s a powerful downstream pull We often talk complexity and upstream, but act differently – empowering parents to address obesity. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60813-1/abstract https://gregfellpublichealth.wordpress.com/2018/08/24/complexity-in-public-health-part-1/ • Research, practice, policy • Strong pushback when you try to be upstream – commercial, ideological, other
- 14. Trade offs and flash-points. • Where is one set of values going to clash with another set. • Economy vs well being – GVA vs wider measure. Reframe “the economy” – internalise the externality. It changes things • Air quality vs jobs – Do the maths
- 15. Not just the city, but upwards • Challenge assumptions at heart of govt. • OBR assumptions re NHS & social care costs. • Fair funding review • NPPF – ancient woodland vs well being? • Advocacy for key policies – MUP, fast food advertising, gambling, welfare system • Structural condition for funding the things we need to fund.
- 16. Concluding thoughts • I’m not a planner • I don’t pretend to understand the pressures in your world • What you do DOES matter to the well being of the residents of your place • REALLY matter • That, in turn, matters to the economy of that place • & to the financial survival of local govt
Editor's Notes
- Leading edge DPH
- LG is at bottom funding wise, now demand pressures. Linking healthy life to service demand Not addressing upstream risks sets up demand for our own services Why is there demand in social care, children’s services, LD services Turn it into a performance issue for the organisation Why is it in the interests of a city to improve health and well being Summary points “Health” and “well being” are flip sides of the same coin. There is a whole philosophical debate about the definition of “health” and of “well being”, salotogenesis theory. One for another time We have an approach to this in the city where we have “health” or “well being” as a theme running through all policies. Not addressing well being or health simply sets up demand for services. Demand for NHS and social care is a response to failure to optimise this further upstream and is buying back health that we've already lost via policy choices in other spaces. Social care demand will be the bit that bankrupts any local authority. Thus considering the upstream causes of that demand is a highly legitimate goal. Upstream includes the built environment, green space, transport policy. Thus the role of the Sheffield Plan is critical "We should have a health in all policies approach", or "we should be more preventive". Both are easy to say and the right aspiration to have. How we build our environment and city - built places, social neighbourhoods, the services we provide, what the economy looks like and how it develops and includes all. All of this, and much more, matters and matters a lot for how healthy we are. We underweight the importance and relevance to "health" of changes we make in landing service and policy discussions, we underweight health (by which I don’t mean health care) and inequalities in outcomes in the trade offs we make. We still aren’t landing the rationale for why PH folk hassle others to build bike lanes, parks, not advertise junk, do progressive licencing etc. Here are some thoughts on linking "how healthy we are" it back to demand for our services. Defining "health" and why is matters to service demand Healthy Life Expectancy (HLE) is the standard proxy used for describing years in wellness or illness, or lack of it. Other metrics are available (activities of daily living, functional ability), there are some distinguishing features but they are all sides of the same coin. All have tricky methodological issues with calculation. We have broadly accepted that HLE is the measure. It can be readily linked to NHS demand. More people with more years of less than good health. That demand is inequitably spread - affluent / poor, mental illness / not etc. This leads to demand for NHS and social care (and arguably is THE point of the NHS's newfound enthusiasm for "population health".) Social care demand is related directly to how poorly people are (that’s a medical model construct) or loss of independence (often related to consequence of decline related to illness or broader social factors) It is easy to track that back to interventions to reduce or manage risk, and thus delay complications (and thus loss of functional ability, illness etc). This is easy to do re NHS services, easy to track back (or forward) to social care. These risks are due to well known risk factors. Downstream and upstream risk factors matter. Upstream always matters a lot more. Not addressing risks sets up demand for our own services. Thus it IS important to set up an environment where people can be healthy, it is an investment in preventing future demand. To use an over simplistic example, if we build a city like Amsterdam more people will walk and cycle, there will be less obesity, less downstream complications of obesity - diabetes, cancer, heart disease, joint pain. And all the NHS demand, and loss of function thus social care demand that ensues. The city will be more connected, likely mental health will improve. Some if this is near impossible to prove in modelling terms, though plenty have done this - see here (Pop benefits of Dutch levels of cycling) for an example directly linking active travel, health status and economic productivity via GDP . Having a healthier set of folk than you would otherwise is probably the biggest, and seemingly as yet untapped by those that "do" the economy, economic lever you can pull at a city level. I’ve written a little on that before – the link between “health” and economy is two way.. Im not only picking on bike lanes here, though there are a neat simple example. The same can be said in almost any area of policy. Thus it IS in the cities interests that we DO use the various levers available to us to get a healthier set of folk than would otherwise be the case. Why don’t we do better. Many obvious reasons. Austerity has led to us stripping out lots of service to maintain statutory. Even before austerity, however, this was an issue. “health (or “prevention”) isn’t my job, its done by someone else, somewhere else, leave me alone I’ve got other stuff to do”. There is something in here about business planning/budget/accountancy We didn’t want to make severe cuts to any of our preventive services. Circumstance dictated that result – we need to balance this budget NOW, we have these stat services we must deliver, something has to go somewhere, etc. We can’t fix the problem of the amount of money available – so will need to affect that decision process in other ways. This is the classic Public Service Reform problem of where returns on investment go – and how long they take to accrue. Given that we cant make the challenge go away, there IS a case to add more information to the frame so it is not just a financial calculation – or can we design a budgeting/business planning approach that exposes the dependencies across the system (so we can model “make this cut now and you will add 5x the pressure to future budgets”). We probably don’t have the data for this sort of approach, or peraps the capacity (and maybe the capability) for the modelling A “business case for cuts” process might be an interesting exercise. Makes it more complex, admittedly. The mechanism/what would need to be in place for someone (cabinet? EMT?) to be able to say “the long-term implications of change x in service y for service z is not something we can ignore – go away and think again” and possibly then look to move some money around the system in response? This might make budget setting even more terrifyingly complex than it is already. More broadly and away from narrow budget view: application of COM-B to this might be useful what is the behaviour we want from colleagues on this – need to define this clearly, something like “decision making with full view of the long term outcomes and implications”? Then from this, do they have capability, opportunity, motivation? Suspect capability and motivation might be a problem, haven’t really thought through opportunity. Knowledge is important but values too. Who are we delivering for? Eg think the evidence on active travel etc is well understood but we are continually under ambitious. Ultimately it needs to be a performance issue for Directors/HoS etc?
- Ten thoughts on reframing transport policy as a health investment https://gregfellpublichealth.wordpress.com/2016/10/17/ten-thoughts-on-reframing-transport-policy-as-a-health-investment/ parks and bike lanes vs cath labs and cancer drugs. https://gregfellpublichealth.wordpress.com/2016/10/01/parks-and-bike-lanes-and-healthy-folk-on-the-value-of-different-forms-of-investment/ http://publications.arup.com/publications/c/cities_alive_towards_a_walking_world http://lcc.org.uk/articles/healthy-streets-are-cycling-and-walking-streets
- Planning processes & healthy cities https://gregfellpublichealth.wordpress.com/2017/02/10/planning-processes-healthy-cities/
- Lets have open dialogue about where the trade offs are?? Recognise flashpoints and trade-offs. Eg - Cars/ economy/ congestion/ AQ/ Active travel (often a false flag when you REALLY stop to think about it) Belief sets and national rules may slow progress – eg DfT and travel budget, preference for cars. Where does “growth” and “economy” clash with “well being” (I often get into reframing the word “economy” at that point) Where does efficiency clash with equity and or community focused approaches….