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Future healthSustainable places for health and well-being

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Contents

Introduction 4RecommendedreadershipWhyhealthandwhynow?Howtousethisdocument

Chapter 1Challenges and opportunities for our health, 6 well-being and environment

1 Modern healthcare: more than hospitals 8

ImprovinghealthoutcomesTheuserexperience:howdotherapeuticenvironmentswork?Whereareservicesplannedwithincommunities?Anongoinginvestment

2 Well-being, positive lifestyles and the planned environment 12

ImpactofunhealthyenvironmentsPhysicalexercisePositiveinfluencesonmentalhealthPublichealthwithintheplanningprocess

3 The sustainability link 16

EffectsonhealthofclimatechangeandenvironmentaldegradationTheroleofbuildingsandplacesThepotentialoftheNHStoinfluenceplanningTheeconomicincentiveMakinganimpact

Chapter 2Best practice 19

InfluencingthefutureoftownsandcitiesInfluencingtheshapeandhealthofneighbourhoodsRunninganddeliveringhealthcarebuildings

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Chapter 3 What needs to change 28

PlanningProcurementOvercomingsilo-thinkingUsingassetseffectively

Recommendations 30

Appendices 32

1Methodology 33

2Furtherresearchanddetailtosupplementthereport 34 i. Well-being 34 ii. Climatechange 35 iii. TheNHScarbonfootprint 38 iv. ThesizeandinfluenceoftheNHS 39 v. NHSbuildingstock 40 vi. Researchintotherapeuticdesign 41 vii.Effectsofhospitaldesignonnursingstaff 42

3Toolkitsandkeyorganisations 44

4 Bibliography 49

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Introduction

1 Ulrich,R.&Zimring,C.2004:The role of the physical environment in the hospital of the 21st century: A once-in-a-lifetime opportunity,CenterforHealthDesign,Concord,California

2 NaturalEngland2009:Headline Facts: The cost of obesity and physical inactivity [online].

3 DepartmentofHealth2005:Choosing Activity: a physical activity action plan, Cm6374,London,DepartmentofHealth.

4 DepartmentforBusiness,EnterpriseandRegulatoryReform,CommunitiesandLocalGovernment,DepartmentforEnvironment,FoodandRuralAffairs,DepartmentforCulture,MediaandSport&Strategic Forum for Business, 2007: Draft strategy for sustainable construction: a consultation paper.

5 ThisfigureisbasedonemissionestimatespublishedbyDefra(2008),whichcalculatestheUK’scontributiontoglobalcarbonemissionsasapproximately2percent.However,thisfigurehasbeenchallengedbyChristianAid(2007)whichclaimsthatexportedconsumption,intheformoftheinternationalactivitiesofUKcompanies,meansthattheUK’srealimpactonglobalcarbonemissionshasbeenunderestimated.ChristianAidclaimsthatamoreaccuratefigurewouldactuallybearound12-15percentoftheglobaltotal.

6 NHSSustainableDevelopmentUnit2009:Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England,Cambridge,NHSSDU.

7 SustainableDevelopmentCommission&NHSSustainableDevelopmentUnit,2009,Are you a good corporate citizen?Cambridge,NHSSDU.

It is widely recognised that the design of the environment affects the healing process. Evidence shows that design can affect patient health outcomes, staff recruitment and retention, and even the effective provision of care.1 Recently in the UK, major investment in healthcare buildings has resulted in new hospitals, diagnostic and treatment centres and integrated community settings for primary health and social care. Healthcare is in a period of rapid transition as a result of the UK’s ageing population, higher public and policy expectations, technological advances affecting medical procedures and information systems, and the demand for more effective care. The need for the built environment to provide safe, effective and high-quality places that can adapt to changing care delivery patterns has never been as clear.

Thevalueofthephysicalenvironmentinpromotingandimprovingpublichealthisnowbetterunderstood.Withthishavecomecallsfortheplanningprocesstosupporthealthylifestylesthroughhealthiercitiesandneighbourhoods.Evidenceincreasinglysuggeststhatthewiderenvironmentcanreducestress,encourageexerciseandpromotegoodhealth.InEnglandalone,obesityandphysicalinactivitycostthecountry£2.5billionand£8.2billionrespectively.2Bycontrast,regularphysicalactivitycontributestothepreventionofmorethan20conditionsincludingcoronaryheartdisease,diabetes,certaintypesofcancer,mentalill-healthandobesity.3Activetransport,provisionofgoodpublicopenspaceinwhichtoexerciseandopportunitiestofostersocialcohesionareallfactorsthatshouldbeconsideredintheplanninganddesignofthebuiltenvironment.

Withinthiscontext,asustainableplanningapproachthattakesintoaccounttheinfluenceofenvironmentsonhealthisurgentlyneeded.Thereis,forexample,considerablepotentialforthedesignofthebuiltenvironmenttominimisetheeffectsofclimatechange.TheconstructionanduseoftheUK’sbuiltenvironmentinfrastructurecurrentlyaccountsforaround50percentofnationalcarbonemissions4and1percentoftotalglobalemissions.5TheNHS,withthelargestpropertyportfolioinEurope,contributes3percentoftheUK’stotalCO2emissions,6andtheNHSCarbonReductionStrategy(2009)setsgoalsfortheNHStolowerCO2emissionsinlinewithgovernmenttargetsonclimatechange.TheSustainableDevelopmentCommissionhasalsoarticulatedhowNHSorganisations,locallyandnationally,havearesponsibilitytobe‘goodcorporatecitizens.’7

Thisreportexploreshowthedesignofthebuiltenvironmentcanhelptodeliverthreekeypolicyobjectives:modernisinghealthcare,addressinghealthinequalitiesthroughlifestylechanges,andcreatinghealthy,sustainabledevelopment.Whilsteachoftheseisaspecialisttopicinitsownright,herewefocusonthepotentialfordesigntoaddressthemtogether.Weconcludethatthisdesignfocuscanproduceadditionalbenefits.Asingledesigninterventioncanaddresstherequirementsofmorethanoneofthesepolicyobjectives:forexample,locatingservicesinthecommunitywithgoodtransportconnectionsmakesservicesmoreaccessible,reducesCO2emissionsandprovidesintegratedcommunityservicesandactivities.Inthisway,thedesignprocesscanbeacatalystforpolicychangeaswellaspracticalimprovementstothebuiltenvironment.

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Recommended readership

Thisdocumentwillbeusefultothosewhocanaffecthealthoutcomesorwhoshapeenvironmentsthataffecthealthandwell-being,including:

Policymakers:thosedecidingnational,regionalandlocalpoliciesforhealth,well-beingandsustainableenvironments.

Commissioners of healthcare:healthtruststhatrespondtothehealthrequirementsoflocalpopulations.

Providers of healthcare and of environments that impact on health and well-being:

acuteandprimaryhealthcaretrustsandtheirestatedivisionsprojectmanagerswhodeliverbuildingorrefurbishmentprojectswithinthehealthcareestatelocalauthorityplannerswhoinfluencethequalityofthepublicrealm.

Suppliers of healthcare environments, and environments that impact on health and well-being:

designersandbuildingandestatesmanagers.

Why health and why now?

AsthelargestemployerintheEU,theNHShasconsiderablereachandimpact(seeAppendix2,iv,The size and influence of the NHS).Ithasthepotentialtostrategicallyleadtheactionsnecessarytoco-ordinatepolicyanddevelopmentsforhealthcare,well-beingandsustainability:anapproachthatresonateswellwiththeNHSethosofpromotinghealthandwell-beinginthewholepopulation.Atthesametime,thereisgrowingrecognitionofthewayourenvironmentaffectsourhealthandwell-being,withthespatialplanningsystemnowacknowledgingthelong-termimpactsonqualityoflifeandlifestylefactors.Localauthoritiesandhealthcaretrustsareworkingtogethermorecloselytoachievethepositive,long-termoutcomesforhealththatresultfromactiontakentoday.

How to use this document

Chapter 1outlinesthechallengestoourhealthandwell-being,andtheroleplayedbythedesignofplannedenvironmentsandclimatechangemitigation.Italsoexploresthecommonalitiesbetweenwell-designed,therapeuticenvironments,improvinghealthoutcomesandthesustainabilityagenda.

Chapter 2looksattheaddedbenefitsofgooddesignatthescaleofregion,city,neighbourhoodandindividualdevelopments,illustratedwithcasestudiesandpointersforaction.

Chapter 3looksatwhatneedstochange;itexaminestheassetsatourdisposalaswellastheconstraintstobeovercomeinordertoachievethemaximumeffectthroughinvestmentin,andmanagementof,buildingsandenvironments.

Appendix 1outlinesthemethodologyusedinbringingtogetherthismaterial.

Appendix 2providesbackgroundmaterialthatquantifiessomeaspectsofthereport.Aseparatedocument,Future health: further reading,listswidertoolkitsandkeydocumentsandisavailableonrequestfromCABE.

Appendix 3summarisesusefultoolkits.Italsodescribesorganisationsthataresourcesofinformationtohelppeoplemovefromtheoverviewinthisreporttomaterialthatcanhelpinspecificsituations.

Appendix 4listsabibliographyofreferenceworks.

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Chapter 1Challenges and opportunities for our health, well-being and environment

Our view of health is changing to encompass a social as well as a medical model. The social model includes changes that can be made in society and in the lifestyles of individuals to make the population healthier. Illness is beginning to be defined from the point of view of the individual’s functioning within society in addition to monitoring biological or physiological signs. In other words, good health is determined not simply by access to medical care, but by a range of factors, some of which are closely related to the quality of the physical environment.

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‘A positive physical, social and mental state’

TheDepartmentforEnvironment,FoodandRuralAffairs(Defra)defineswell-beingas:‘apositivephysical,socialandmentalstate;itisnotjusttheabsenceofpain,discomfortandincapacity.’12ThisillustratesthebreadthoftheconceptandrelatescloselytotheWHOdefinitionofhealth.

Somehealthproblemsarelongerterm,forexample,oneinfourpeopleareaffectedbymentalhealthconditions.13Preventionofill-health,bothphysicalandmental,iscrucialindevelopingaholisticapproachtotacklinglong-termhealthissues.Thisholisticviewofhealthhasbeensteadilygainingrecognitionandisreflectedacrossacademic,political,clinicalandhealth-relatedfields.Itisanapproachthatseeshealthandwell-beingasinterdependent;itholds‘prevention’asimportantas‘cure’,andlooksforlong-termsolutionsratherthanmoreimmediatelyattainabletreatments.Itis,however,verydifficulttoquantify;rather,well-beingisaconceptimplicitlyunderstoodandappreciated.Acrosstheboard,theterm‘well-being’isusedtogetherwith‘health’asameansofexpressingwhatmightformerlyhavebeenunderstoodas‘publichealth’,withincontextsrangingfromwork,toleisure,tohealthandsafety.Asapopulation’shealthandwell-beingarevitalelementsworthyofinvestmentinanywell-functioningsociety,contributingfactorssuchasplannedenvironmentsmustbeunderstoodasfullyaspossible.

Defining health

8 ForthoseborninEnglandandWalesin1948,theaveragelifeexpectancywas66yearsformenand70yearsforwomen.The2008figuresforthoseborninEnglandandWalesare78formenand82forwomen,adifferenceof12years(OfficeofHealthEconomics2009:Sixty Years of the National Health Service.)

9 OfficeforNationalStatistics2008:UK residents are living longer in good health,London,ONS.SeealsoSustainableDevelopmentCommission2008:Health, place and nature: How outdoor environments influence health and well-being: a knowledge base,London,SDC.

10 ChiefMedicalOfficer2009:‘Thegreatsurvivor:another60years’.InNew Statesman/Pfizersupplement,TheFutureDirectionoftheNHS.9February2009.

11 WorldHealthOrganisation2001:Fifty-fourth World Health Assembly,np,WHO.

12 HMGovernment2009: Sustainable Development: Creating sustainable communities and a fairer world [online].

13 WorldHealthOrganisation2001:Mental disorders affect one in four people [online].

OveralllifeexpectancyfortheUKpopulationisimproving.Onaverage,peoplelive12yearslongerthanwhentheNHSwasestablishedin1948.8Disability-freelifeexpectancyhasincreasedformalesfrom60yearsin2000-02to78in2008andfrom63to82forfemalesinthesameperiod.9Medicaladvancesaccountformuchoftheincreaseinlifeexpectancy.However,theageingpopulation,risinglevelsofobesityandassociatedhealthconditions,burgeoningpoolsofchronicdisease,andgrowingconsumerexpectationsmeanthatthehealthservicefacesneedsanddemandsforhealthcarethatareever-increasingandever-changing.10

Not just absence of disease

TheconstitutionoftheWorldHealthOrganisation(WHO)defineshealthnotonlyastheabsenceofdiseaseorinfirmity,butalsoas‘astateofcompletephysical,mentalandsocialwell-being.’Itemphasisesthatpeopleshouldenjoythehighestattainablestandardofhealth,sayingitis‘oneofthefundamentalrightsofeveryhumanbeingwithoutdistinctionofrace,religion,politicalbelief,economicorsocialcondition.’11WHO’sstatementgivesanegalitarianimpetustoinformourapproachtotacklinghealthissues,onethatisstandardpracticewithinclinicalandhealth-relatedprofessionsinthetreatmentofillnessorinfirmity.Italsohighlightsthefactthathealthisaboutthewholeperson,mentallyandphysically,andtouchesonsocietalinfluenceswhichweknowaffecthealthandhealthinequalities.

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In tandem with these changing perceptions of health and well-being, the provision of modern healthcare is undergoing a fundamental change as a result of more integrated strategic planning on the part of healthcare providers and professionals. This is affecting the type of services offered, how care is provided and the settings in which it takes place.

Whilst predicting future trends comes with great uncertainties, particularly in relation to technological advances, it is likely that the pace of change will be faster than before. This section looks at the changes that can be detected in the health landscape, which in turn will affect the delivery of care.

Improving health outcomes

Oneofthemainchallengesforthefutureisforcaretobeplannedstrategicallyacrossthewholesystem,andinfarcloserintegrationwithotherservices.Otherchallengestowhichthisnewstrategicdeliveryofserviceshastoriseinordertoimprovehealthoutcomesincludesocietalinfluencesuponhealth,theexpectationsofpatients,andthechangingexpectationsofhealthprofessionals.

Social changes Socialchangesaffectbothhowhealthservicesarebeginningtobedelivered—thatis,morestrategicallyandcollaboratively—andperceptionsabouthealthandstayinghealthy.Theyinclude:

1 Greater understanding of health impacts Researchdemonstratestheneedtoaddressnegativeimpactsfromenvironmentalfactorssuchasfoodoflownutritionalvalue,poorairqualityandlackofopportunityforexercise.

2 Changing nature of diseaseTheeffectsofunhealthyeatingandlackofexerciseplaceagrowingburdenonhealth,asdosmokingandexcessivealcoholconsumption,whichareoftentheresultsofsocio-economicinequalitiesandpoorlifestylechoices.Preventativeapproachestothesefactorsneednotbelimitedtopublicitycampaigns;modifyingandimprovingthequalityofoursurroundingscanencourageandenablehealthierbehaviours.

3 Profound demographic change Olderpeoplenowmakeupthefastest-growinggroupintheUKpopulation.In2007,9.8millionpeoplewereagedover65,andby2032thisfigureisprojectedtoriseto16.1million,equivalenttoalmostoneinfourofthepopulation.Atthesametime,numbersofthe‘oldestold’(peopleaged85andover)willmorethandouble,risingfrom1.3millionin2007to3.1millionin2032.14Longersurvivalratescomewithahigherlikelihoodofco-morbidities,coupledwiththehazardsoffrailty.Thesewillneedtobemetwithforward-lookingdesignsthatidentifyandmitigatehealthrisks.Onagenerallevel,however,theadvantagesassociatedwithmoreinclusiveandaccessibleenvironmentscanbelife-enhancingforall.

14 OfficeforNationalStatistics2008:Benefits and challenges of an ageing population,London,ONS.

1 Modern healthcare: more than hospitals

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Patient expectations and cultural change Astheconsumer-anduser-focusedculturegathersstrength,patientswillbemakingdemandsonthequality,contextandaccessibilitybothofservicesandoftheenvironmentalcomponentsthatencouragegoodhealth.Thiswillbeheightenedbythegenerallyolderdemographicoftheservice-userbase,andcanbesummarisedasfollows:

1 General user awarenessAsawarenessisraisedaboutpersonalresponsibilityforhealth,manypatientsnowexpecttoreceivemorepersonalisedcare,tailoredtreatmentandtoplayagreaterroleintakingdecisionsabouttheircare.

2 Demands of an information society Withincreasedaccesstoinformationthroughtheinternet,peopleexpectreliable,evidence-basedinformationabouttheirhealthandtheirtreatment.Newtechniquesforhealthcareprovisionwillbedevelopedtoexploitcommunicationstechnologies.Thiswillrequirechangesinbothprofessionaltrainingandinplaceswherehealthcareisaccessed.

3 Rising standards of environments for carePatientsarelookingforgreaterprivacyanddignity,suchassinglebedrooms,welcomingambiencewitheaseofaccess,controllablelightingandtemperature,reducednoiseandviewsontoattractiveexternalspaces.Morehospitalityservices,suchascafésandshops,andaccommodationforrelativesandvisitors,arealsoexpected.Healthcarebuildingshavetobedesignedinresponsetosuchdemandsandsothatsuchchangescanbeaccommodatedovertime.

Staff expectationsTheimpactofservicestandardsreststoagreatextentonhowstaffworkandhowtheyarefacilitatedinwhattheydo.

1 A changing workplaceHealthcareprofessionalsexpecttheorganisationstheyworkfortoprovidehigh-qualitycare.Theywanthealthyandefficientworkplacesthatenhancethewell-beingofpatientsaswellasthemselves,allowingconvenientandrapidaccesstomedicalexpertise.15

2 Innovation in delivery Whileacutehospitalsofferincreasinglysophisticatedandeffectivetreatments,thereisalsoapolicydrivetoshiftlessdemandingcareclosertothehome,andtointegrateitwithothercommunityservices.

3 Improving staff recruitment, retention and effectiveness Researchtellsusthattheimpactofworkplacedesignissignificantenoughtoaffectproductivity,attachmenttotheworkplaceandlevelsofstaffretention(seebelow).

The user experience: how do therapeutic environments work?

Academicresearchintothetherapeuticeffectofenvironmentsshowshowtheirdesigncanaffecthealthoutcomesforpatientsandimprovetheperformanceofstaff.Aseriesofinvestigationsintotheimpactoffactorsintegraltothedesignandplanningofahospital—andtheseprinciplesapplyintheirownwaytoprimarycarebuildings—are:

Views seen by a patient:Viewsvisiblefromahospitalbedcanhaveaneffectonthealreadyvulnerablestateofapatient’shealth.‘Notableevidenceofnegativeeffectsofwindowlesshealthcareenvironmentsonoutcomeshasemergedfromstudiesofcritical-carepatients.Studieshavelinkedtheabsenceofwindowsincriticalorintensivecarewithhighratesofanxiety,depression,anddeliriumrelativetoratesforsimilarunitswithwindows.’16‘Comparisonsbetweenpatientswhohadaviewoutontoabrickwallwiththosewhooverlookednaturallandscapesshowedsignificantlylongerpost-operativestaysamongstthosewithpoorviews’.17

Noise levels and acoustics:Highnoiselevelshavebeenfoundtoincreaseperceivedstresslevelsinstaff,andbringaboutanxietyandsleeplessnessinpatients.18

15 Imison,C.2008:Future Healthcare Trends(PowerPointpresentation,TheKing’sFund)

16 Ulrich,R.2000: Effects of healthcare environmental design on medical outcomes, Design & Health: The Therapeutic Benefits of Design.Proceedingsof2ndInternationalCongressonDesignandHealth,KarolinskaInstitute,Stockholm,Sweden,pp.51,52

17 CABE2002:The Value of Good Design, London,CABE.18 Ulrich,R.2000:Effects of healthcare environmental design on

medical outcomes, Design & Health: The Therapeutic Benefits of Design.Proceedingsof2ndInternationalCongressonDesignandHealth,KarolinskaInstitute,Stockholm,Sweden,pp.51,52

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Exposure to natural light and its daily rhythm:Naturallighthasbeenfoundtobeimmenselybeneficialas‘apowerfulregulatorofthecircadiansystemand[stimulating]increasesproductivity,alertnessandhealthandsafetyofpatientsandcaregivers’.19

Privacy and dignity:Thepresenceofotherpatientsinmultipleoccupancyroomsisseenasamajorsourceofperceivedstressorssuchaslossofprivacy.20

Well-designedenvironmentshaveapositiveeffectonhealthcarestaff.Aspartofaresearchproject, The role of hospital design in the recruitment, retention and performance of NHS nurses in England(2004),CABEsoughttodeterminewhethertheworkplaceenvironmentinfluencednursingstaff.Althoughissuessuchaspayandresponsibilityweremoreimportant,theresultsshowedthattheworkplaceenvironmentdoesinfluencenursingstaffandcaninfluenceanindividual’sdecisionaboutwheretowork.Commentsfromhealthstaffincluded:

A hospital that looks modern and clean will attract staff. If you have a dingy looking concrete structure, that will turn you off working there.

When people come into one of the areas which I manage, they comment that they don’t think it looks like a clinical area. This is a bonus.

The environment can reduce violence and abuse against staff. The way hospitals are built should reduce noise. It is at night-time that most problems occur when patients are trying to sleep.21

The design of many hospitals and health buildings now recognises that the quality of the patient and staff environment is a main driver for efficiency in terms of health outcomes, staff performance and integrated service delivery.

Appendix2,vigivesmoredetailsofresearchintotheeffectofenvironmentsonhealthandtable3summarisestherelationshipbetweendesignfactorsandhealthcareoutcomes.Thebenefitsextendbeyondhospitals;section2inthischapterillustrateshowthewiderenvironmentcanhavelong-termpositivebenefits,suchastheeffectonphysicalactivity,andonstresslevelsoftheproximityofgreenspacesandcontactwithnature.

Where are services planned within communities?

Someofthecaretraditionallyprovidedbyacutehospitalscannowbeprovidedinfacilitiesclosertohome,suchastreatmentandresourcecentresandcommunityhospitals.RoutinediagnosticproceduresandsimpletreatmentsareundertakenincommunitylocationsandmanychronicdiseasesarenowmanagedinGPsurgeriesandathome.

Thereareongoingeffortstoimprovethequalityandeffectivenessoftheprovisionofcare,andtotransformthewaycareisorganisedthroughpatientpathwaysfromhometohospitalandback.Moreefficientcaredeliverymeansbringingcaretothepatientinoneplaceatonetime,forexample,the‘one-stopshop’approachtodiagnosisandtreatment.

Forprimaryhealthcareandcommunityservices,thetypeandsizeoffacilitiesareexpandingandthereisgreaterintegrationwithservicessuchassocialcare,leisure,sport,housingadvice,policeandcommunitydevelopment.Integrationisencouragingnewnetworksofcareacrossallhealthsectorsandwithotherpublicandvoluntaryservices.Thesebuildingshavegreatpotentialtobecomeafocusforpublicservicesforlocalcommunities.

Inthisnewlandscape,healthisnotplannedinisolation,butbythehealthsectorandlocalauthoritiestacklingdesiredoutcomestogether.Ittakesaccountofthewiderplanningenvironmentandimprovestheshapeofneighbourhoodstomeetlong-termhealthneeds.

19 Simenova,M.2004:HealthyLightingfortheVisual,CircadianandPerceptualSystems: Business Briefing: Hospital Engineering & Facilities Management,Report 3, Touch Briefings,London,pp.99-102

20 Ulrich,R.2000: Effects of healthcare environmental design on medical outcomes, Design & Health: The Therapeutic Benefits of Design.Proceedingsof2ndInternationalCongressonDesignandHealth,KarolinskaInstitute,Stockholm,Sweden,pp.51,52

21 CABE2004:The role of hospital design in the recruitment, retention and performance of NHS nurses in England,London,CABE.SeealsoAppendix2,vii,table4.

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Location of facilitiesAccessibilityiscrucialforpeopletoreachservices,yetthelocationofhealthcarefacilitiesisoftenabarrierinitself.AccordingtotheDepartmentofHealth,duringa12-monthperiod,1.4millionpeoplemiss,turndownorchoosenottoseekmedicalhelpbecauseoftransportproblems.22Thelayoutofurbanandsuburbanenvironmentsandpatternsofregionaldistributionofhealthcareservicesclearlyplayamajorpartintheeaseofaccesstoservices.Poorlyplannedenvironmentsandpoorlylocatedfacilitiescanaffecthealth.Theeffectsofpoordesignorlocationmaybedifficulttorecogniseduringtheplanningphase,buttheycontinuelongafterdesignandcompletion.

Thechoiceofsitefornewservicesiskeytosatisfyingrisingpatientexpectationsofaccessibilityandqualityofcare.Issuessuchassiteownershipandavailabilityoftenimpactnegativelyonaccessandthereforeonhealthinequalities.CABE’s2008samplesurveyofprimarycarebuildings,completedunderthelocalimprovementfinancetrust(LIFT)programme,foundthatthesitesselectedwerefrequently‘ownedbythehealthsectororthelocalauthorityandwereexpendableintermsoftheiruse,orwerenotwantedbyanyone,ornotalwaysappropriateforthedesignateduse.’23

The opportunities for locating care where it is accessible depend on planning across the whole system, from individual buildings to whole geographical areas, and in close integration with other services. Crucial to the accessibility and efficiency of services are:

communicationbetweenagenciessothatservicesareco-locatedwhereverpossibleandnecessaryappropriatechoiceofsiteandappropriatesizeofdevelopmentforservicesenvisaged,withhealthintegratedwithintheurbanformalongsideotherlocalamenitieswhereverpossibleproximitytopedestrianandcyclingroutes,andpublictransport.

An ongoing investment

Anextensiveinvestmentprogrammehasresultedinnewhospitals,GPsurgeriesandotherhealthcarebuildings,manyofwhichhaveexcellentfeatures(asillustratedinthebestpracticeexamplesofthisreport).

However,withcapitalinvestmentsslowingdown,evenmodernbuildingsneedmodificationtoreflectadvancesinhealthcareandchangingcircumstances.Investmenttorefurbishexistingstockisbecomingincreasinglyimportanttobringfacilitiesuptodateanduptoexpectedsustainabilitystandards.

Frequently,withinbothnewandexistingfacilities,thelonger-termbenefitsofpatientwell-beingandhigh-calibrehealthcareenvironmentsareregardedasoutsidethecoreprioritiesofmeetingtreatmenttargets.Unfortunately,thevalueofinvestinginlonger-termoutcomesisrelegatedduetoimmediatecostconcerns.CommunityHealthPartnerships(CHP)addressesthisissueofvalueformoneyinits2008publicationsubtitledHow to Achieve Value for Money in Health and Social Care Infrastructure.

Sometimes, high expenditure can be good value if it yields a higher benefit per pound than, say, an alternative that requires lower spending. Understanding this issue does not necessarily make matters any simpler. Calculating value gained from health spending is, in any case, notoriously difficult… healthcare is an ‘intermediate good’ – its value is not intrinsic. Its real value depends on the impact that the healthcare has on the health and well-being of beneficiaries.24

Attentionisrequiredateverystagetounderstandthevaluesbeingsoughtandtorecognisewhichoptionsprovidethosevaluestothehighestlevel.

Value for money makes most sense in health terms when considered as the long-term value to be gained from careful investment in the right areas. The environmental levels across which long-term value operates can be defined as:

qualityoftheenvironmentwherecareisprovidedlocationofservicesperformanceoffacilitiesinsupportingeffectiveness,safetyandefficiencyofservices.

22 DepartmentofHealth&NeighbourhoodRenewalUnit2005:Creating Healthier Communities: a resource pack for local partnerships.

23 CABE2008:LIFT Survey Report, London,CABE.24 CommunityHealthPartnerships2008:Firm Foundations for World Class

Commissioning: How to Achieve Value for Money in Health and Social Care Infrastructure,London,CommunityHealthPartnerships.

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25 DepartmentofHealth2009:Tackling Health Inequalities: 10 Years On,London,DepartmentofHealth.

26 CommissionontheSocialDeterminantsofHealth,2009,Summary of Evidence for the Review of Health Inequalities Annex2:EvidencefromtheCommissiononSocialDeterminantsofHealth.

27 Lopez,R.P.&Hynes,H.P.2006:Obesity,physicalactivity,andtheurbanenvironment:publichealthresearchneeds,Environmental Health: A Global Access Science Source5(25).

28 HouseofCommons2004:Third Report of the House of Commons Select Committee on Health[online].

Well-planned environments can help the health service provide improved care. In a similar way, the wider environment can help improve long-term health and well-being.

The impact of unhealthy environments

Healthinequalitiesarepersistent,stubbornanddifficulttochange.25ButevensomeoftheUK’smostpressinghealthchallenges—suchaslifestyle-inducedobesity,childhoodasthmaandtheageingpopulation—canbemitigatedbythequalityofoureverydayenvironments.Inotherwords,theconsideratedesignofspacesandplacescanhelptoalleviate,andevenprevent,poorhealthorphysicalrestrictions.

TheCommissionontheSocialDeterminantsofHealth,initssummaryofevidencefortheReview of Health Inequalities in England post-2010,arguesthat:

The lived environment — urban settings, neighbourhoods, communities — are critical in that they can both promote or inhibit access to goods and services, social cohesion, physical and psychological well being and the natural environment. Health related outcomes as diverse as obesity, depression and injury through violence or accident can all be linked to the way we live.26

Forexample,becauseourenvironmentsdonotalwaysoffertheopportunitytoweavephysicalactivityintoourdailylives,itisnotsurprisingthatwalkingandphysicalactivitylevelsgenerallyaredecreasingamongchildrenandadults.USresearchspecificallylinksthistothequalityofthebuiltenvironment27,andtherearetransferablelessonsfortheUK.Servicesarefrequentlytoofarawayorinaccessibleotherthanbycar,andthequalityofopenspaceinneighbourhoodsmaydiscourageresidentsfromenjoyingitforexercise.

Belowaresomeofthemostpressingchallengesintermsofhealthinequalities,andexamplesofwheretheplannedenvironmentcanplayarole.

Although 20 per cent of the population are obese, and two-thirds morbidly so, the NHS cannot provide detailed clinical services or intensive clinical services for all of them.28

2 Well-being, positive lifestyles and the planned environment

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TheUKnowhasthehighestobesitylevelsintheEU.29Nearlyathirdofourpopulationisobese,andifcurrenttrendscontinuenearly60percentarepredictedtobeobeseby2050.ThiswouldmeanmorethanquadruplingcurrentUKspendingontreatingobesity-relatedillness(fromaround£10billionto£45.5billionattoday’sprices).30 The means of getting to work, school, or to local services provide an important opening to weave everyday physical activity into our lives and to combat obesity levels.

In terms of respiratory disease, the UK has the highest rates of childhood asthma in the world,withoneineightchildrencurrentlybeingtreatedforthecondition.31Again,thecoststotheNHSarehigh;theestimatedannualdrugcostforasthmatotheNHSinEnglandandWalesinallagegroupsisapproximately£115million,ofwhich£8millionisonchildrenundertheageoffive.32Researchhasshownaclearcorrelationbetweenasthmaandthelevelsofnitrogenoxide(NO2)inairpollutioncausedbytrafficnearthehome,whichresultsinrepeatedhospitalencounters.33Reliance on car use — and environments focused on car use — are driving up noxious emission levels, resulting in some of the worst rates of asthma worldwide.

In terms of an ageing demographic, the UK has more people over 65 than under 16 for the first time ever, and the elderly population is set to grow.34Thisplacesincreasingimportanceontheaccessibilityofservicesandtheeasewithwhicholderpeoplecanmovearoundtheirneighbourhoods.Aswegrowolder,theneighbourhoodbecomesanincreasinglyimportantfactorinthequalityofeverydaylife.CommunitiesandLocalGovernmentnotesinits2008guidanceLifetime Homes, Lifetime Neighbourhoodsthatwhenlocalshops,localservicesorthelocalparkorleisurecentreareinaccessibleorevendangerous,olderpeoplecanliterallybetrappedintheirownhomeswithouttheconfidenceoropportunitytogetout,makefriendsorgetthehelptheyneed.35Problemsinaccessinghealthservicesamongtheover-75sisofparticularconcern.36Health complications in terms of both physical and cognitive decline become greater with age, and opportunities for both daily exercise and interaction with the community come about with improved accessibility around neighbourhoods and to local services.

The design and quality of the built and open environment and the siting of buildings and services have a fundamental impact on the health and well-being of communities. So what steps can be taken to use the planned environment to work towards tackling health inequalities?

Physical exercise

Asdiscussedabove,lackofexerciseisakeyfactorintheepidemicofobesityapparentlydevelopingintheUK.Maintainingphysicalactivitylevelshelpstoavoidcognitivedeclineinlaterlife;astheWorldHealthOrganisationhighlights,physicalactivityislikelytoreducemanyofthepsychologicalandsocialhazardsthatoftenarisewithage.‘Mentalillness,particularlydepression,Alzheimer’sdiseaseandfeelingsoflonelinessandsocialexclusion,[are]loweramongstpeoplewhoarephysicallyactive.’37

Active travel Researchoncommutingsuggeststhatthosewhowalkorcycletoworkaresignificantlynegativelyassociatedwithbeingoverweightandobese.38

Soactivetravelplaysakeyroleincombatingobesityandmakesiteasierforpeopletoundertaketherecommended30minutesaday,fivedaysaweekofmoderatelyintensephysicalactivity.

29 SustainableDevelopmentCommission2008:Health, place and nature: How outdoor environments influence health and well-being: A knowledge base,London,SDC.

30 Foresight2007:Tackling Obesities: Future Choices—Modelling Future Trends in Obesity and Their Impact on Health.

31 MedicalNewsToday2009:Traffic-Related Air Pollution Linked To Repeated Hospital Encounters For Asthma.

32 NationalInstituteforHealthandClinicalExcellence,2008:NICE issues guidance on inhaler systems for under 5s with asthma[online].

33 Edwards,J.,Walters,S.&Griffiths,R.K.1994:Hospitaladmissionsforasthmainpreschoolchildren:RelationshiptomajorroadsinBirmingham,UnitedKingdom,Archives of Environmental Health,49,223-27.

34 OfficeofNationalStatistics2008:Ageing: the fastest increase in the ‘oldest old’.

35 CommunitiesandLocalGovernment2008:Lifetime Homes, Lifetime Neighbourhoods: A National Strategy for Housing in an Ageing Society,London,CommunitiesandLocalGovernment.

36 Ibid.37 WorldHealthOrganisation,2002,World Health Day

– Move for health[online].38 Lidström,M,2007:Meansoftransportationtoworkandoverweightandobesity:

Apopulation-basedstudyinsouthernSweden,Preventative Medicine,46.

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SustranshighlightsthatalthoughtheUKhashistoricallyinvestedheavilyinfacilitatingsedentaryformsoftransport,thebalancemustnowchange,withinvestmentprioritybeinggiventoactive,healthymodessuchaswalkingorcycling.39Almost100organisations,includingallsignificantUKpublichealthbodies,havesignedapolicystatement—‘Takeactiononactivetravel’40—developedbytheAssociationofDirectorsofPublicHealth,whichrecommends‘healthchecks’oneveryland-useandtransportdecisionandthecreationofsafe,attractivewalkingandcyclingpaths.

Green infrastructureEvenproximitytogreenspace41canplayaroleinhowphysicallyactivepeoplearelikelytobe.Initsguidanceonhealthimpactassessmentsforgreenspaces,GreenspaceScotlandreferencesastudywhichfoundthatinresidentialareaswithhighlevelsofgreenery,thelikelihoodofresidentsbeingmorephysicallyactivewasmorethanthreetimeshigherandthechanceoftheirbeingoverweightandobesewasabout40percentlowerthanforareaswithlowlevelsofgreenery.42

Urban fabricLevelsofphysicalactivityarenotjustdictatedbytheproximityofresidentstogreenspaces;otherinfluencesincludethequalityofthesurroundingenvironment,thedensityofresidences,themixoflandusesand‘thedegreetowhichstreetsareconnectedandtheabilitytowalkfromplacetoplace,andtheprovisionofandaccesstolocalpublicfacilitiesandspacesforrecreationandplay.’43

Opportunities for active travel, proximity to, and quality of, green spaces, and the quality and mix of the urban fabric all play their role in determining our levels of casual and active physical activity and the associated health benefits.

Positive influences on mental health

Mood,emotionandpsychologicalwell-beingarepositivelyaffectedbyparticipationinphysicalactivity,sportandexercise,accordingtoresearch.44Itfollowsthatthelocationinwhichactivitytakesplaceisalsogoingtohaveaneffect.Therearenumerousexamplesofhowaccesstonaturecanworkasastressreliever.ADanishstudyfoundacorrelationbetweenthedistancefromhometogreenspaceandstresslevelsforallgroups.Foryoungerpeople,asimilarcorrelationwasobservedbetween

distancetogreenspaceandobesity.45Accesstonaturecanalsohaveamarkedeffectonpeoplerecoveringfromillness.Table1fromastudyinSanFranciscoshowsresponsesfrompeopleactivelyusinghospitalgardensintheirrecoveryprocess.

Table 1: Effect of use of hospital gardens on recovery46

How do you feel after spending time in the garden?

Morerelaxed,calmer 79%

Refreshed,stronger 25%

Abletothink/cope 22%

Feelbetter,morepositive 19%

Religiousorspiritualconnection 6%

Nochangeofmood 5%

What is it about the garden that helps you feel better?

Trees,plants,nature 59%

Smells,sounds,freshair 58%

Placetobealoneorwithafriend 50%

Views,sub-areas,textures 25%

Practicalfeatures,benches,etc. 17%

Don’tknow 8%

143gardenusersatfourSanFranciscoBayAreahospitals

39 Sustrans2009:Active travel and adult obesity.40 Sustrans2008:Take action on active travel - Why a shift from

car-dominated transport policy would benefit public health.41 GreenspaceScotland,2009:Health impact assessment

of greenspace – a guide.42 Ellaway,A.,Macintyre,S.&Bonnefoy,X.2005:Grafitti,greeneryand

obesityinadults:secondaryanalysisofEuropeancrosssectionalsurvey,British Medical Journal331,611-12.

43 Marmot,M.,2008:Closing the gap in a generation: Health equity through action on the social determinants of health,np,WHO.

44 Cavill,N.(ed.),2007:Building Health: Creating enhancing places for healthy, active lives. Blueprint for action,London,NationalHeartForuminpartnershipwithLivingStreetsandCABE.

45 Nielsen,T.S.&Hansen,K.B.,2007:Dogreenareasaffecthealth?ResultsfromaDanishsurveyontheuseofgreenareasandhealthindicators,Health and Place.

46 Cooper,M.C.&Barnes,M,2005:HealingGardensinHospitals, The Interdisciplinary Design and Research e-Publication,1(1).

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Whilethereisnotnecessarilyacorrelationbetweenone’swell-beingandbeing‘cured’,itisplainthathowsomeonefeelsisimportanttohisorherrecovery.Interactingwithnatureandnaturalsurroundingsmakespeoplefeelbetter,accordingtothestudyabove.Thisisacrucialconsiderationforourincreasinglyageingpopulation.

The impact on health could be very great if our planned environments do not allow for access to therapeutic forms of recovery for future, frailer generations.

Public health within the planning process

Theurbanplanningprocessiscrucialtosuccessfulplacesthatenhancepeople’squalityoflife.Theemphasisofplanningusedtobeonseparatinglanduses,suchasthoseforresidential,retail,workandleisurepurposes,withheavyrelianceonroadsandvehicularaccesstoconnectareas.Thathaschangedwiththemovetowardsspatialplanning,whichrecognisesthatthekeytosuccessfulplacesliesincommunicationbetweenservicesandproximityofamenities,fromhealthcaretruststolocaltransportnetworks.

TheimportantroleofhealthwithintheplanningprocesshasbeenrecognisedbytheRoyalTownPlanningInstitute(RTPI)andisclearlydefinedinitsgoodpracticenote5(2009).47Itrecommendstoplanningauthoritiesthat:

neighbourhoodsshouldbedesignedtopromotewalkingandcycling

homesandneighbourhoodsshouldbedesignedtobeflexibleandadaptabletomeettheneedsofthelocalcommunity,includingtheneedsoftheageingpopulation

thereshouldbeco-locationandintegrationofservicesincludingthoseforhealth,education,socialcare,theartsandleisure.

Inmanyplaces,healthcaretrustshavejoinedlocalstrategicpartnerships(LSPs)withlocalauthoritiesinordertotackletogetherhealthinequalitiesatlocallevelandfromseveralperspectives,includinghavingasharedvisionwithintheirsustainablecommunitiesstrategyandlinkingthiswithintheirlocaldevelopmentframeworksandlocalareaagreements(seeexample1:Joiningupacrossadministrativeborderstotacklehealthinequalitiesthroughactivetravelandenvironmentalimprovementsonp.21).

Health needs to be a strategic planning goal within national, regional and local strategic planning. Active and sustainable movement is critical and must be captured in policy. Essential community facilities such as healthcare centres need to be located on key sites. The significant contribution to public health and well-being of green space and high-quality public spaces has to be championed.

47 RTPI2009:RTPI good practice note 5: Delivering healthy communities.

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It follows that in those areas where improvement and respect for the environment are exercised, there is potential for improvement and respect for the public’s health. Government recognises the need for protection of the environment; the Climate Change Act 2008 sets out the required reduction of the UK’s net carbon account for 2050 by 80 per cent from the 1990 baseline.48 But where are the links between the sustainability targets and the benefits to our health of a holistic approach to tackling sustainability?

Effects on health of climate change and environmental degradation

Globalwarmingfromthebuild-upofcarbondioxideintheatmospherehaswidespreadeffectsonhealth.Measuringtheeffectsofclimatechangecanonlybeapproximate.ButaWHOquantitativeassessment,takingintoaccountonlyasubsetofthepossiblehealthimpacts,concludedthattheeffectsofclimatechangethathasoccurredsincethemid-1970smayhavecausedmorethan150,000deathsin2000.Italsoconcludedthattheseimpactsarelikelytoincreaseinthefuture.49

Temperature and humidity fluctuations Short-termfluctuationsinweathercancauseadversehealtheffects,asfollows:

Extremesofbothheatandcoldcancausepotentiallyfatalillnesses,forexampleheatstressorhypothermia,aswellasincreasingdeathratesfromheartandrespiratorydiseases.

Incities,stagnantweatherconditionscantrapbothwarmairandairpollutants,leadingtosmogepisodeswithsignificanthealthconsequences.50

TheDepartmentofHealth,initsHeatwave Plan(2009),concludesthatevenduringrelativelymildheatwaves,excessdeathratesaresignificantly,butavoidably,higher:

Climate change means that heatwaves are likely to become more common in England. By the 2080s, it is predicted that an event similar to that experienced in England in 2003 will happen every year... We have already experienced in the UK some of the direct health effects of global warming, such as mortality as a result of extreme summer heat. In Northern France in August 2003, unprecedentedly high day- and night-time temperatures for a period of three weeks resulted in 15,000 excess deaths. The vast majority of these were among older people. The Office for National Statistics (ONS)

3 The sustainability link

48 HMGovernment,2008:Climate Change Act 2008,London,OfficeofPublicSectorInformation.

49 WHO,2008:Climate and Health Fact Sheet. 50 Ibid.

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The potential of the NHS to influence planning

Alongwithlocalauthorityplanners,theNHScanexertsubstantialinfluenceovertheplanningofbuildingsandtheshapeofneighbourhoodstoachievelong-termhealthimprovements.AsthelargestemployerintheEU,itisnotsurprisingthattheNHShasoneofthelargestcarbonfootprintsat18milliontonnesofCO2peryear(3percentoftheUK’stotalemissions).Thisiscomposedofenergy(22percent),travel(18percent)andprocurement(60percent).Despiteanincreaseinefficiency,theNHShasincreaseditscarbonfootprintby40percentsince1990.AsitrecognisesinitsCarbonReductionStrategy(2009),thismeansthatmeetingtheClimateChangeActtargetsofa26percentreductionby2020and80percentreductionby2050willbeahugechallenge.53

Building on mutual improvements for health and for the environment resonates well with the NHS ethos of promoting health and well-being to the whole population.

The economic incentive

Aswellasmitigatingdamagetoourenvironmentandhealth,thereareeconomicincentivestoacting.Inits2006report, The Economics of Climate Change,theSternReviewemphasisedtheadvantagesofwell-thought-throughprocessesinreducingtheriskofverydamagingandpotentiallyirreversibleimpactsonecosystems,societiesandeconomies.‘Withgoodpoliciesthecostsofactionneednotbeprohibitiveandwouldbemuchsmallerthanthedamageaverted.’Itwarns,however,againstdelayineconomicterms:

‘Reversing the trend to higher global temperatures requires an urgent, world-wide shift towards a low-carbon economy. Delay makes the problem much more difficult and action to deal with it much more costly.’54

reported a 4 per cent increase over baseline mortality (680 excess deaths) in England and Wales between 16 July and 28 July 2006 when compared with the average for the same period from 2001 to 2005. This may be an underestimate. This compares to an excess mortality of approximately 2,000 people, representing 16 per cent of all deaths in the August 2003 heatwave.51

Itisessentialtoconsidertheimplicationsofweatherandtemperaturefluctuationswhendesigningfacilitiesandplacesmeanttoencouragehealingandgoodhealth.Forexample,theHeatwave Planrecommendsshadingwindowsandkeepingthemclosedwhentheoutsidetemperatureishotterthaninside,andopeningwindowswhenitiscooleroutsidethaninside.Wherehospitalwardshavesealedwindowsthatdonotopen,respiratoryproblemsmaybeworsened.

Anotherconsiderationistheurbanheatislandeffect,wheretemperaturelevelsinurbanareasareincreasedbyalackofplantingandshading.TheDepartmentofHealthrecommendsstrategicplanningofthedesignoffacilitiesandplaces,forexample,‘coolroofs’,‘greenroofs’and‘coolpavements’.Creatinggreenspacesisanotheroption.Temperaturesinandaroundgreenspacescanbeseveraldegreeslowerthantheirsurroundings(seeUrban heat islandsinAppendix2,ii)becauseofevaporationandshadingfromtreesandvegetation.

Straightforward design measures can be taken to help mitigate the effects of climate change on health, but they require strategic action, long-term thinking and shared goals.

The role of buildings and places

Transportcontributes21percentoftotalCO2levelsintheUK,whileenergyfrombuildingscontributes65percent.52Alongwithemissionsfromfuelandheating,thereisalso‘embodied’energy,ortheenergyusedinmanufacturing,suchasthematerialsusedforbuilding.

During the development of both local facilities and local spaces, there is a cumulative effect of decision-making around environmental factors, which can either make for incremental improvements in the health and well-being of the people that use them, or exacerbate problems that already exist.

51 DepartmentofHealth2009:Heatwave Plan for England 2009.52 DirectGov2009:The Causes of Climate Change[online]. 53 NHS2009:Saving Carbon, Improving Health: NHS Carbon Reduction

Strategy for England,London,NHSSDU.54 SirNicholasStern,2006:Stern Review on the Economics of Climate

Change, Cambridge,CambridgeUniversityPress.

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TheimportanceofeconomicsustainabilityisalsomadeexplicitintheZagrebDeclarationforHealthyCities,whichwassignedbypoliticiansfromthemajorcitiesofEuropeataconferenceorganisedbyWHOinOctober2008.Oneofthefiveprinciplesandvaluesofactionsays:

Sustainable development: the necessity of working to ensure that economic development — and all its supportive infrastructural needs including transport systems — is environmentally and socially sustainable: meeting the needs of the present in ways that do not compromise the ability of future generations to meet their own needs.55

Making an impact

Anycommitmenttoreducecarbonlevelsmustembracethemanagementanddesignofbuildings,procurementandchoiceoftransport,astheNHSCarbonReductionStrategy(2009)acknowledges.Itoutlinesthehealthbenefitsforpatientsandpopulations,andforthehealthcaresystemitself.Forexample,increasedlevelsofactivetravelleadtoareducedriskof‘obesity,diabetes,heartdisease,andmildmentalillness,aswellasreducingroadtrafficinjuriesanddeaths,andimprovingairquality.’56

Thedatabaseofguidanceandcasestudiesofsustainablehealthbuildingscontinuestoexpand.Amongstthemostsignificant,theSustainableDevelopmentCommission(SDC)workswiththeNHStoclarifythenatureof,andthebenefitsgainedfrom,sustainablehealthcarebuildings.Thesequalitiesinclude:

accessibilitybypublictransport,walkingandcycling

siteanddesignthatpreserveandenhancebiodiversity

adaptabilitytochange,forexample,climate,newwaysofworkingandnewtechnologyusingresourcessuchasenergyandwaterefficientlyinitsconstructionandthroughoutitslifetime.57

SomeofthetoolkitsdescribedinAppendix3,suchasthechecklistfromSHINE,dealwithhowtomeasuretheimpactofdesignideasonsustainableperformance.Theseneedtobeusedthroughoutthelifeofabuildingorpublicplace.

55 WorldHealthOrganisationEurope2008:Zagreb Declaration for Healthy Cities: Health and health equity in all local policies,Policydeclaration,np,WHO.

56 NHS2009:Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England,London,NHSSDU.

57 SustainableDevelopmentCommission2005:Healthy Futures: Buildings and Sustainable Development,London,SDC.

Best practice in environmental management generally involves using simple, well-understood ideas and executing them really well, ensuring that buildings are easy to manage to their optimum performance, with robust systems that can, as far as possible, be handled by non-specialist users. Simpler approaches tend to be more robust, easier to manage and more predictable.

19

Chapter 2Best practice

Revisiting the design of places, spaces and buildings and how they work can be a catalyst for change.

Design can synthesise complex requirements and make sustainable places for health and well-being. Many current developments are driven by a single agenda and satisfy a narrow set of goals. When policy, planning processes, needs assessments and design projects are better co-ordinated, they can succeed in multiple ways. The following scenarios at city, neighbourhood and building scales demonstrate how to resolve complex demands for sustainable environments that also better serve the long-term health needs of populations and enhance physical and mental well-being.

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20

Influencing the future of towns and cities

Planning at town and city scale is a complex activity shaped by many hands. Change is often the result of incremental development on which the health of city populations so depends. In its Healthy Cities initiative, the World Health Organisation defines a healthy city as one that is continually creating and improving the physical and social environments, and expanding the community resources that enable people to support each other in performing all the functions of life and in developing their potential.58

Those who influence development at this scale need to be supported in thinking carefully about how networks of different facilities, including green infrastructure and healthcare buildings, can be deployed over time in optimum locations, where they are accessible through sustainable modes of travel. To do this means bringing people concerned with well-being, illness prevention and healthcare into the discussion of policy development and interpretation at the vital early stages. Communication and common incentive-building between local authorities and health authorities is an essential foundation for this.

Some principles conducive to health, well-being and sustainability that can run though local authority policies at city scale are as follows:

Createurbanformthatiscompatiblewiththecharacteristicsofahealthycity,asdefinedbyWHO.59

Developahierarchyofacuteprimaryandcommunityhealthcarefacilitiesthatjoinupdeliveryofservicesfromhospitaltohome.

Developajoining-uppolicybetweenhealthcareandlocalauthorities(seeexample1:Joiningupacrossadministrativeborderstotacklehealthinequalitiesthroughactivetravelandenvironmentalimprovementsonp.21).

Co-ordinatehealthprojectswithexistingandproposedtransportandpedestriannetworks,withlargerfacilitieslocatedatmajorhubsandmorelocaldeliverywithinwalkingdistanceofthecommunitiestheyserve.

Establishnetworksofgreeninfrastructuretomanageairquality,overcomeurbanheatislandeffectsandreducenoiseandstress(seebestpracticeexample4:Tacklingtheurbanheatislandeffectatcitylevelonp.21).

Integratecity-ordistrict-wideheatingforhousingandlocalcommunityhealthfacilitiessothattheycanbesharedacrossareas(seeexample3:Creatingdistrictheating,includingahospitalwithitsowncombinedheatandpowerplantonp.21).

Useapproachestodevelopmentthatreducespeedandvolumeofmotortrafficandencouragewalkingandcyclingsothatairquality,accessibilityofservicesandopportunitiesforphysicalactivityareimproved(seeexample2:Locatingnetworksoffacilitiesaccordingtopedestrianaccessibilityonp.21).

Trytoanticipatefuturedevelopmentsinhealthcaredelivery,includingtechnologytoimprovetreatmentandprevention,andtheimpactonurbanformandlocationoffacilities(seeexample5:Projectingfuturescenariosforcity-integratedhealthcarenetworksonp.22).

58 WorldHealthOrganisation2005:Healthy Cities and Urban Governance[online].

59 Ibid.seealsoAppendix2.i,fig.1.

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Best practice examples

1: Joining up across administrative borders to tackle health inequalities through active travel and environmental improvementsBuckinghamshirePrimaryCareTrust(PCT)playsastrongroleinBucksStrategicPartnership,thelocalstrategicpartnership(LSP)forBuckinghamshire.AmajorpriorityoftheLSPistheHealthyCommunitiesStrategy,whichisaboutthewiderdeterminantsofhealthandwell-beingratherthanthedeliveryofhealthcareitself.Itpromotesphysicalactivitythroughwalkingandreducingcarbonemissionsforallpublicsectororganisations.Thestrategyrecognisesthat‘improvingthephysicalandsocialenvironmentisessentialifhealthandwell-beingaretobeimproved.’www.buckspartnership.co.uk

2: Locating networks of facilities according to pedestrian accessibilityLiverpoolPCTandLiverpool&SeftonLIFTcohavejoineduptheirthinkingfortheequitableprovisionofhealthcarefacilitiesacrossthecity.Aftersurveyingresidentsandpinpointinganoptimum15-minutemaximumwalkingtimetoanyhealthcentre,anewnetworksitescentresacrossthecitywithin15minutes’walkofeveryresidentialaddress.Thepartnershipalsoprovidesservicesintheeveningsandatweekends.www.lshp.co.uk

3: Creating district heating, including a hospital with its own combined heat and power plant Southamptonhasdevelopedthefirstgeothermalenergyandcombinedheatandpower(CHP)districtheatingandchillingschemeintheUK.ThecitycouncilpersisteddespiteinitialsetbacksandnowhasaCHPgeneratorandabsorptionheatpumps.RoyalSouthHampshireHospitalhasalsoopeneditsownCHPplant.PaulineQuanArrow,ChairmanofSouthamptonCityPCT,says:‘Wearepleasedtobeleadingtheway...carbondioxideandotheremissionsareaseriousthreattoourhealthandwell-being,andthereforetheNHShasamajorparttoplayinensuringthatthisistackled.IwouldencourageotherNHStruststogetinvolvedwithsimilarinitiatives.’

4: Tackling the urban heat island effect at city levelThecityofChicagohasenactedlegislationthatrequireslandscapingaroundparkinglotsandmoreenergy-efficientbuildingpractices.Thecouncilencouragesresidentstouselight-coloured,reflectivematerialsforroofs,toplanttreesonpropertiestoincreasetheshadingofbuildingsandparkinglots,andtoincreasetheamountofvegetationoverall.ProjectsincludearooftopgardenonCityHallwhichhassettheprecedentforgreenroofsinthecity,apermeableandreflectivealleyontheNorthSide,milesofmedianplantersandmanycampusparksthattransformasphaltparkinglotsaroundpublicschoolsintoparks.Chicagoalsousesgreenbuildingtechnologiesandpracticesinallofitspublicbuildingprojects.www.cityofchicago.org

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5: Projecting future scenarios for city-integrated healthcare networks TheHygiopoliscityplanningproject,conceivedbyMedicalArchitectureandArtProjects(MAAP),hypothesisesacityinthefuturewherehealthylifestylesandaccesstohealthcarearepriorities.Itemphasisesactiveandpublictransportsystems,accessiblegreenandbluespaces,adaptablehomessuitableforcareathome,andintegratedservices.A‘neighbourhoodcentre’isproposed,withaprimaryschool,facilitiesforolderpeople,communitymentalhealthnurses,socialworkersandGPsallononesite.

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Development at a neighbourhood scale can range from small-scale interventions in established communities, through to the wholesale redevelopment or regeneration of failing urban areas. Those involved include local planning authorities, health authorities, housing associations and private developers.

Health benefits at this scale of development involve locating appropriate community facilities in the right place and structuring the environment to encourage people to use sustainable forms of travel and take physical activity.

Compact mixed-use developments Provideanappropriatelevelofneighbourhood

healthcarefacilitieswithinwalkingdistanceofthecommunitiesserved(seeexample1:Locatinghealthcareservicesaccessiblyandalongsideotherpublicamenitiesonp.24).

Employapproachesthatdesignoutcrime,suchasbuildingsoverlookingpublicroutesandspaces(naturalsurveillance),andgoodstreetlighting.

Useurbandesigntohelpwayfinding,andsupportthiswithclearinformationonwalking,cyclingandpublictransportoptions.

Sustainable transport solutions Providesafe,legible,convenientandattractive

routesthatencouragepeopletowalkandcycle. Ensurepedestrianandcyclingroutesconnect

healthcarebuildingstoresidentialneighbourhoodsaswellasotherkeyareasofactivitysuchasshops,schools,leisurefacilitiesandworkplaces.

Considertheuseof‘homezones’inresidentialareas,whichlowertrafficspeeds,prioritisepedestrianmovement,andemphasiseplaceovermovementasthemainfunctionofresidentialareas.

Implementmeasurestoreducethespeedandvolumeoftrafficandtherebylowerthefrequencyandseverityoftrafficaccidents.

The potential of green spaces Usetreesandotherplantinginlocalparksto

createcarbonsinks,improveairquality,reducesoilerosion,andprovideshadeinsummer.

Encourageoutdoorexercise,includingactiveplayforchildrenandteenagers(seeexample2:Usinggreenspacetoencourageactivelifestylesandreducepollutiononp.24).

Promotebio-diversityandprovideaccesstothenaturalworldbecausethiscanreducestressandrelievethesenseofovercrowdinginurbanenvironments(seeexample3:Improvingmentalwell-beingthroughcontactwithnatureonp.24).

Championthecreationandupkeepofallotmentsandcontactwithnaturetoencouragephysicalexercise,healthyeating,mentalwell-beingandreductionincarbonemissionsfromfoodmiles.

Wider servicing strategies Makedistrict-wideheatingforhousingandlocal

communityhealthcarefacilitiesapossibilitysothattheycanbesharedacrossareas.

Influencing the shape and health of neighbourhoods

24

Best practice examples

1: Locating healthcare services accessibly and alongside other public amenities LutonWalk-inCentreisafour-storey,patient-focusedfacilityincentralLutonnexttoabusyshoppingstreet.Thereareminortreatmentareasandflexiblespacesfordrop-inclinics.Thevolumeofpatientsishighandthroughputisfast.ThePCTcarriedoutathoroughsitesearchandappraisal,andmadecreativeuseofanexistingbuilding.

2: Using green space to encourage active lifestyles and reduce pollutionBeforeitsrefurbishment,MileEndParkwasableak,fragmented,under-usedopenspaceinthecentreofTowerHamlets,anauthoritywithalargepopulationandlittlegood-qualityopenspace.Theparknowhousesaleisurecentreandgym,andprovidessafeandattractivepedestrianandcycleroutes,significantlycontributingtopollutionreductionwhereneighbouringroadsareheavilyusedandcongested.IthasbecomeaninvaluablegreenchainofopenspaceandtranquillitythroughLondon’sEastEnd.

3: Improving mental well-being through contact with natureWiththeNationalCareFarminginitiative,partnershipsareformedbetweenfarmersandhealthandsocialcareagencies,todevelopthepotentialofindividualsratherthanfocusingontheirlimitations.Commercialfarms,woodlandsandmarketgardensareusedasabaseforpromotingmentalandphysicalhealththroughnormalfarmingactivity.www.ncfi.org.uk

4: Encouraging greater self-responsibility for health and well-beingTheWell-beingWagonissetupunderActivateLondon,agroupofprojectsaimedatpromotinghealthyeating,andphysicalandmentalhealth,supportedbytheBigLotteryfund.Cookerydemonstrationsandnutritionaladvicearegiventoresidents.Staffhelppeopletousetheinternetforhealthylivingwebsitesandinformationonrecipes,exerciseandwaysofalleviatingstress.

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Key issues to address in the design stage include the following.

Making healthcare facilities accessible Selectsitesforhealthcarefacilitiesthatare

well-servedbypublictransportandpedestrianroutesandplanprimarycare,suchasGPsurgeries,tobewithincyclingorwalkingdistanceofthecommunitiestheyserve.

Planhealth-andsocialcarestrategically,todeliverservicesinthemostappropriateenvironment,fromthehospitalthroughtothehome.

Considerbringingotherservicesandactivitiesintohealthcarebuildingstocreateacommunityfocus,allowingawiderrangeofpatientcareandadvicetobeprovidedbyco-ordinatedteamsofprofessionals.

UseICTtoimproveservices.Provideappropriateinfrastructuresforincreasedaccesstohealthcareprovision,inthehome,inhealthcarefacilitiesandothercommunitybuildings.Thiswillincreaseoperationalefficiency,makingservicesmoreconvenientandreducingtheneedtotravel(seeexample2:Adoptingsmarttechnologysystemsonp.26).

Creating therapeutic environments Designinteriorsthatusenaturallightand

exploitviewstoreducestress,aidhealing,helpwayfindingandprovideinspiringlivingandworkingconditions(seeexample5:Atherapeuticcareenvironmentformentalwell-beingonp.27).

Specifymaterialsfromsustainablesourcesthatarerobustanddurable,butensurethesecreateanon-institutionalfeelingcapableofupliftingthespirits(seeexample4:ThemostsustainableGPpractice?onp.27).

Makegooduseofcolour,butbesensitivetotheeffectsofsensorystimulionpeopleinmentaldistress.

Providepersonalisedcareinplaceswithstrongidentityandlocalcharacter(seeexample1:Personalisedcareandcommunityresourcesinaplacewithstrongidentityonp.26).

Providing adaptable accommodation Planthesiteandbuildingformtoallowfor

flexibility,sothatfacilitiescanbeextendedorreconfiguredtorespondtofuturechangesinthedeliveryofhealthservices.

Regardless of their size or function, whether newly constructed or a refurbishment, all building projects can be structured to create a positive impact on people’s health and well-being. The collective decisions of health-service users, design teams, planning authorities and those responsible for the day-to-day provision of services will determine whether projects merely deliver on narrow goals, or whether they contribute in a more holistic way, providing wider health and well-being benefits.

Running and delivering healthcare buildings

26

Ensureallbuildingsareadaptableovertimetoaccommodatenewclimatechangetechnologiesastheybecomeavailable.

Designspacesincommunityhealthbuildingsformulti-functionalusetoallowdeliveryofarangeoftreatmentsandservices(seeexample3:Long-termflexibilityandtheabilitytorespondtoservicechangeonp.26).

Encouraging physical activity Usesitecharacteristics,pathnetworks

andgreeninfrastructuretocreateeasilyaccessibleexercisetrails.

Locateattractivestaircasesinconvenientplacestoencouragewalkingandreducetheuseoflifts.

Best practice examples

1: Personalised care and community resources in a place with strong identity Maggie’sCancerCareCentresofferacommunityofadviceandsupportforcancerpatientswithincarefullydesignedandwelcomingbuildingsthathaveadomesticfeel.EachcentreissituatedbesideanNHScancerhospitalandhasbeendesignedtobeasuninstitutionalaspossible,withlight,spaceandwarmth.Theheartofthecentreisalwaystheinformalkitchenarea(suchashereatMaggie’sInverness).

2: Adopting smart technology systemsAtAkershusHospital,Oslo,amotorisedsystemdistributesmedicationfromapharmacystoreinthehospitaldirecttowardsusingrobots.Clean,sterilisedstaffuniformsaredistributeddailyfromvendingmachinestokeephygienelevelsashighaspossiblebyremovingthenecessityforstafftobringtheiruniformsinandsohelpingtokeepinfectionlevelsdown.

3: Long-term flexibility and the ability to respond to service changeAttheHeartofHounslowLIFTbuilding,twowingscontaininghealthandsocialservicesandofficespacesaresuitableforbusiness,health,socialandcommunityuseandaredesignedtobeflexiblyusedforwhicheverservicemayneedtooperateinthearea.Acoveredcommunalstreetcreatesamall-likeinformalmeetingspaceforthecommunity,andapublicplazasitsatthefrontforthesurroundingneighbourhood.

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4: The most sustainable GP practice?Theaward-winningSwaffhamSurgeryisoneofthebest-performingnewbuildingsintheNHSestate.Thecostimplicationsweredealtwithpragmaticallybythearchitect,thecontractorandNorlifeLIFTco,withthecarbonfootprintreducedthroughsustainablebuildingmaterials,cleverorientationandpassivetemperaturecontrol.

5: A therapeutic care environment for mental well-beingAttheBamburghClinic,StNicholasHospital,Newcastle,amentalhealthunitwasdesignedtoprovideasecurebuttherapeuticenvironmentforpatients,manyofwhomrequirelong-termcare.Thevisionwastoprovideanon-stigmatisingenvironmentbyenablingthenecessaryobservationthroughdesign,providinggooddaylight,viewsandaccesstooutdoorspace.

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Chapter 3What needs to change

By using the planned environment to help nurture a healthier population, we can reduce the burden on the healthcare service. But, in order to achieve this, there are fundamental issues to address in how we plan, procure and approach the narrowing of health inequalities.

28

29

Planning

Althoughvariouspublichealthobjectiveshavebeendesignedtoaddresswideninghealthinequalities,thelong-termhealthandwell-beingimplicationsfortheusersofbothnewandimproveddevelopmentsarenotyetfullyintegratedwithinplanningpolicyandlocalauthoritydevelopmentplans.

Localauthoritiesarestillinsufficientlysupportedintheirconsiderationofthelong-termeffectsonhealthcaredevelopments,forexample,intermsofthevolumeoftrafficduetothesitingofservicesorthequalityofopenspacesforsafephysicalactivity.

Procurement

Thepressurewithinpublicserviceprocurementtodeliverontimeandonbudgetmeansthatholisticthinkingonhealthandwell-beingcanfallbythewayside,evenonprojectsthataresupposedtobepromotinghealth.Forexample,thecreationoftherapeutichealthcareenvironmentsthatusenaturaldaylightandventilationcanbringtheaddedbenefitsofshorterpatientrecoverytimes,andinthelongertermareworththeinitialhighercapitaloutlay.

However,projectteamsarenotalwaysresourcedwiththespreadofskillsneededtoensurethatthisisconsidered.Asaresult,theremaybenoorlimitedcheckstoensurethatthehealth-relateddesignaspirationsofabriefhavebeenembeddedintheschemes.

Overcoming silo thinking

Deliveringwiderpublichealthbenefitsthroughthedesignofthebuiltenvironmentisdependentupongoodstrategicdecision-making.Thisisnothappeningaseffectivelyasitcouldbecausetheagendastodeliveronhealthcare,well-beingandasustainableapproachtoourbuiltenvironmenthavenotyetfullymovedawayfromthesilosinwhichtheytendtoreside.

Toovercomethis,afullerunderstandingofthewidercontextofadeliveryarenaneedstobeencouraged.Agenciescansuccessfullycometogetherearlyinthedevelopmentprocesstocreateasharedpublichealthagenda—example1(onp.21)andexample3(onp.26)showwherethisisalreadyhappening.

Using assets effectively

Acoremessage—thathealth,well-beingandsustainabilitymustallbeconsideredtogether—isemphasisedinavarietyofwaysinmuchoftheexistingguidanceandgeneralinformationavailabletotrustsandthoseresponsibleforenvironmentsthatimpactonourhealth.Manyoftheseexplainhowthedesignprocessprovidesatimewhentheseideascanbeintegrated,andgiveexamplesofhowthiscanbedone.

Guidance,however,canbehardtoacton.Therightinformationmaynotbeavailableatthetimeitisneeded.Itcanbehardtoconvinceabudget-holdertospendmoretimeandmoremoneyinitiallyinordertogetthebestsolutionforthelongterm.Appendix3describessomeofthekeyguidanceandlistssourcesoffurtherhelpandinformation.AmoreextensivelistoffurtherreadingisavailableonrequestfromCABE.

30

Recommendations

Thebenefitsofaholisticapproachtohealthcare,well-beingandsustainabilityareclearandtheskillsandknowledgeexisttoimplementit.Buthowcanwemakeithappen?

Interrogatinghowdevelopmentdecisionsaremadeisafirststep.Betteroutcomesmaycostmore,buttheywilldeliveradditionalvalue.Joined-upthinkingisneededtoensurethatmaximumhealth,well-beingandsustainabilitybenefitsaccruefromeverydevelopmentinterventionormanagementprocess.

For the policy-makerswhosetnational,regionalandlocalvisionsforhealth,well-beingandsustainableenvironmentsthismeans:

Join up the policy initiatives in health, environment and planning, from national to community level.Morecollaborativeworkingbetweengovernmentdepartments,suchasregular,informeddiscussionsandjointinitiativesbetweenthedepartmentsforHealth;CommunitiesandLocalGovernment;Environment,FoodandRuralAffairs;andEnergyandClimateChangewouldhelpdelivermoreefficientlyonsustainablepublichealthpolicy.Theexistingministerialdesignchampionnetworkwouldbeideallyplacedtoleadonthiscollaborativeworkingbetweenofficials.

Encourage joint goals within communities by supporting the available vehicles for strategic service delivery. Jointstrategicneedsassessments(JSNAs)andlocalstrategicpartnerships(LSPs)goaconsiderablewaytowardsinter-agencyworking.Buttheycanonlyworkwelliftheyareproperlyresourcedandefficientlyrun;ifsustainabilityisembedded;ifinformationissystematicallysharedbetweenagenciesandifrolesareclearlydefined.Again,top-levelsupportisessentialifjointinitiativesaretohappenontheground.

Make collaborative work easy by streamlining the impact assessments and best practice standards that protect health, well-being and sustainability.Whereverseparateassessmentsarerequired,aseparatesetofpeopleisneededtocarrythemout.Drawingonthecommonnetbenefitsforcommunitiesbycombiningtoolssuchashealthimpactassessments,environmentalimpactassessmentsandsustainabilityimpactassessmentswillenablehealthy,sustainableenvironmentstobecomeareality.

Set minimum design standards. The2009CommunitiesandLocalGovernmentpublicationWorld Class Placessaysthatallpublicbuildingprogrammesshouldhaveminimumdesignstandards.Designpolicyandminimumstandardsshouldbedefinedforallrelevantgovernmentdepartments.

Explain the market advantages, identifying the mutual benefits that a joined up approach can bring.Theprestigeassociatedwithradical,innovativeinterventionscanbringattractivelong-termbenefitstoprovidersaswellascommunities.

For commissionerssettingoutthehealthandwell-beingrequirementsforlocalpopulations,thismeans:

aimingforchangeandthinkingafreshaboutlong-terminvestment

developingstrategicplansforpublicservicesthatencompasshealthandsocialcare

overcomingsiloworking:engageagenciesforchangeatalocallevelincludinghealthtrusts,localauthoritiesandtheindependentsector

ensuringthatalldevelopmentishelpingtodeliverhigh-qualityenvironmentsforhealthandwell-beinginaresponsibleandsustainablemanner

beingunafraidtoaskforfreshthinkingthatisrigorouslytestedthroughpropositionsanddifferentscenarios.

For providers ofhealthcareandenvironmentsthataffecthealthandwell-being,thismeans:

valuingdesignasacatalystforchange:realisethepotentialfordesigntosynthesisecomplexissuestobestadvantage

gettingthe‘DNA’oftheprojectrightattheoutset:realisethebenefitsofprovidingeffectivecare,improvinghealthoutcomesandrespondingtothechangingclimatethroughdesign

60 CommunitiesandLocalGovernment,2009,World Class Places: The Government’s strategy for improving quality of place,London,CommunitiesandLocalGovernment.

31

makingthequalityofexperienceapriority:createtherapeuticplacestoengagepeopleandsupportwell-being

respondingtothedynamicandchangingnatureofhealthcaredelivery,andcreatingenvironmentsthatarelonglife,loosefit(flexiblydesignedtorespondtoevolvingpatternsofcare)andlowcarbon.

Wherever we may be within the processes that have long-term impacts on people’s health and well-being, we can think beyond our traditional remits by committing to more integrated working methods and collaboration with useful agencies where necessary to achieve common goals. To meet those priorities of environmental quality that can have a lasting effect on our own health, we can make an impact on health inequalities and enable stronger health and mental well-being for future generations.

32

Appendices

32

33

This report is informed by the following resources:

A literature review of evidence and connections between health and/or well-being, and the design of buildings and places.

Fromnationalandinternationalsources.ThisisavailablefromCABEonrequest.

Detailed consultations Specialistswerebroughttogetherina

seriesofworkshopstodebatethecontextforhealthcare,well-beingandsustainabilityacrossthepublicandprivatesectors,andwhereplannedenvironments,includinghealthpremises,canbringtheseagendastogether.

Theseworkshopsweremadeupofspecialistsfrom:

healthcareservicedeliveryandresearch

well-being,inparticularwithrespecttohealthyneighbourhoodsandmasterplanningforhealth

healthcarebuildingdesign

sustainabledesign.

Toolkits and advice on how to carry out projects for healthcare buildings, neighbourhood planning and

successful design and planning projects. Keytoolkits,checklistsandguidancearedescribedinAppendix3.

Appendix 1 Methodology

34

i. Well-being

TheUKSustainableDevelopmentStrategydefineswell-beingas:

A positive physical, social and mental state; it is not just the absence of pain, discomfort and incapacity. It requires that basic needs are met, that individuals have a sense of purpose, that they feel able to achieve important personal goals and participate positively in society. It is enhanced by conditions that include supportive personal relationships, strong and inclusive communities, good health, financial and personal security, rewarding employment and a healthy and attractive environment.61

Theabovedefinitionofwell-beingisverymuchinthespiritoftheWHOdefinitionofhealth,whichstatesthatahealthyandattractiveenvironmentinitselfcontributestowell-being.

We include as an indicator of emotional wellbeing the incidence of low-level mental health problems such as depression, anxiety, stress, panic attacks, phobias and obsessive-compulsive disorders. But emotional wellbeing is broader than just the presence (or absence) of common mental health problems and so we also include life satisfaction and levels of happiness.

Lifeexpectancyhasreacheditshighestonrecordandthe2008figuresforthoseborninEnglandandWalesare78formenand82forwomen.

In rich countries, (e.g. UK) low socioeconomic position means poor education, lack of amenities, unemployment and job insecurity, poor working conditions and unsafe neighbourhoods.62

Appendix 2 Further research and detail to supplement the report

61Defra,2008:SustainableDevelopmentIndicatorsinyourPocket.

62 Marmot,M.2008:Closing the gap in a generation: Health equity through action on the social determinants of health,WHOCommissiononSocialDeterminantsofHealth:finalreport,np,WHO.

A city should strive to provide:

1 Aclean,safephysicalenvironmentofhighquality(includinghousingquality)

2 Anecosystemthatisstablenowandsustainableinthelongterm

3 Astrong,mutuallysupportiveandnon-exploitativecommunity

4 Ahighdegreeofparticipationandcontrolbythepublicoverthedecisionsaffectingtheirlives,healthandwellbeing

5 Themeetingofbasicneeds(forfood,water,shelter,income,safetyandwork)forallthecity’speople;

6 Accesstoawidevarietyofexperiencesandresources,withthechanceforawidevarietyofcontact,interactionsandcommunications

7 Adiverse,vitalandinnovativecityeconomy

8 Theencouragementofconnectednesswiththepast,withtheculturalandbiologicalheritageofcitydwellersandwithothergroupsandindividuals

9 Urbanformthatiscompatiblewithandenhancestheprecedingcharacteristics

10 Anoptimumlevelofappropriatepublichealthandsickcareservicesaccessibletoall,and

11 Highhealthstatus(highlevelsofpositivehealthandlowlevelsofdisease).

WHO1997:Twenty Steps for Developing a Healthy Cities Project,3rdedn,Copenhagen,WHORegionalOfficeforEurope.

Figure 1: WHO qualities of a healthy city

35

ii. Climate change Table 1: Health effects associated with climate change

Heatwaves Heatwavesareprojectedtobecomemorefrequent.Theveryold,chronicallyillandpooraremostsusceptibletoheat-relatedillnesses.Theadditionaldeathsinsummerwillbeoffsetbyadeclineofapproximately20,000cold-relateddeathseachyearduetowarmerwinters.Intheperiod1971–2003meanannualheat-relateddeathsdidnotriseassummerswarmed.Thisimpliesanincreaseinthepopulation’stolerancetoheat.Inthesameperiodannualcold-relatedmortalityfellbymorethan33percent(DH,2008a).

Improvedtolerancetoheatinthefuturewillreduceimpactofhottersummers,butincreasedfrequencyandintensityofheatwavesarestillamajorconcerntohumanhealth.

By2012,therewillbea1in40chancethattheSouthEastofEnglandwillexperienceaseriousheatwave(averaging27°CinSouth-EastEngland)causingover3,000immediateheat-relateddeathsand6,350furtherheat-relateddeathssoonafterwards(DH,2008a).

Air pollution TheairpollutionoftheUKwillcontinuetochange.Whileconcentrationsofanumberofimportantpollutantsarelikelytodeclineoverthenexthalf-century,theconcentrationofground-levelozoneislikelytoincreaseduetotheprojectedincreasesindry,sunnyweatherinsummerwhichfavourozoneproduction.Thiswillincreaseattributabledeathsandhospitaladmissions.Theincreasesarelikelytobesignificantwithasmanyas1,500additionaldeathsandhospitaladmissionseachyear.

Cold-related illness and deaths

Cold-relatedillness,fallsanddeathsarelikelytodeclineduetowarmer,wetterwinters.

River, coastal flooding and flash floods

Floodsareassociateswithfewdirectdeaths,butthefulleffectonhealth,intermsofindirectmortalityandmorbidityduetoinfectiousdisease,mentalhealth,andinjuries,isnotknown(DH,2008a).

Theriskofmajorfloodingdisasterscausedbyseverewintergales,heavyrainfallandcoastalerosionislikelytoincreasecontaminationofdrinkingwater,increasewaterborneinfectionsandexposuretotoxicpollutants,accompaniedbypsychologicalconsequences,destructioninjuriesanddeaths.Latereffectsoffloodingincludestressandmentalhealthproblems(Tapsell,2002).Riverfloodsorstormsurges,whichcanbeforecastseveraldaysinadvance,havefewercasualtiescomparedtoflashfloodswherethereisnopriorwarning.

Infectious diseases Casesoffoodpoisoning(Salmonellosis)andwaterbornediseases(Cryptosporidiosis)linkedtowarmweatherarelikelytoincrease.A1°Cincreaseintemperaturemightresultinabouta4.5percentincreaseinfoodpoisoning.Theeffectofwarmersummersonfoodbornediseaseincidentswilldependonfuturefoodhygienebehaviourandtherelativecontributionofdifferentpathogens,aswellaschangesintemperature(DH,2008a).

Vector-borne diseases

OutbreaksofmalariaintheUKarelikelytoremainrare,thoughhealthauthoritiesneedtoremainalerttothepossibleoutbreaksofmalariainotherEuropeancountriesandtothepossibilitythatmoreeffectivevectors(differentspeciesofmosquito)mayarriveintheUK.RapidresponsetooutbreaksofmalariawillreducethechancesofthediseasebecomingendemicintheUK.Tick-bornediseases(e.g.Lymedisease)arelikelytobecomemorecommonintheUK,butthisismorelikelytobeduetochangeoflanduseandleisureactivitiesthattoclimatechange.Thelikelihoodthattick-borneencephalitiswillbecomeestablishedintheUKisverylow.

36

Sunburn, skin cancer and cataract

Changesinclimatesuchasincreasesinsunshine,reductionsinprecipitationsandhighertemperatureswillbelikelytofavourpatternsofbehaviourinvolvingmoreoutdooractivity,lighterclothingandgreaterexposuretothesun.Thisislikelytoresultinsunburn,skincancerandcataracts(DH,2008a).Ithasbeensuggestedthatcasesonskincancercouldincreasetoupto5,000casesperyearandcataractsupto2,000casesperyear(DH,2002).

Water and food shortages

Droughtmayincreasetheriskofinfectiousdiseasesduetoreducedpublicandpersonalhygieneandincreasedriskofwatercontamination.Theremaybeanincreaseofcasesofdehydrationduetoinadequatewaterintake.Thereisthechanceofincreasedmentalhealthproblemsduetoanxietyoflossofwatersupplyandintroductionofemergencymeasures.Sealevelrisesmaysalinatecoastalareasleadingtoimpairedcropyields.

Possible ancillary health benefits

Increaseinphysicalactivityduetoextendedwarmweather,butoutcomescouldbeworseduringextremeheatevents.Possiblyhealtheatingifsustainablefarmingandfoodpolicyareadopted.

Extreme weather events

ThedirecthealtheffectsduetochangesinwindstormintensityorfrequencyarelikelytobesmallrelativetootherhealtheffectsofclimatechangeintheUK.However,theincreaseintheoccurrenceofseverewintergalesisstillanareaofconcern.Deathsduringseveregalesarecommonplace,asaresevereinjuries.Thesereflectpeoplebeingsimplyblownover,beingstruckbyflyingdebrisorbeingcrushedbyfallingtreesorcollapsingbuildings.Thelikelylossofelectricalpowersuppliesduringseverestormsaddstotheseproblems.

Source:Haq,G.,Whitelegg,J.&Kohler,M.2008:Growing Old in a Changing Climate: Meeting the challenges of an ageing population and climate change,Stockholm,EnvironmentInstitute.

37

Figure 8.3: Direction and magnitude of change of selected health impacts of climate change (confidence levels are assigned based on the IPCC guidelines on uncertainty, see www.ipcc.ch/activity/uncertaintyguidancenote.pdf)

Negative impact Positive impact

Very high confidenceMalaria:contractionandexpansion,changesintransmissionseason

High confidenceIncreaseinmalnutrition

Increaseinthenumberofpeoplesufferingfromdeaths,diseaseandinjuriesfromextremeweatherevents

Increaseinthefrequencyofcardio-respiratorydiseasesfromchangesinairquality

Changeintherangeofinfectiousdiseasevectors

Reductionofcold-relateddeaths

Medium confidenceIncreaseintheburdenofdiarrhoealdiseases

Urban heat islands Duringaheatwaveitislikelytobehotterincitiesthaninsurroundingruralareas,especiallyatnight.Temperaturestypicallyrisefromtheouteredgesofthecityandpeakinthecentre.Thisphenomenonisreferredtoasthe‘urbanheatisland’(UHI)anditsimpactcanbesignificant.InLondonduringtheheatwaveofAugust2003,thedifferenceintemperaturebetweenurbanandrurallocationsreached9ºConoccasions.ArangeoffactorsvariesbetweenruralandurbanareasandcontributestotheUHI.

Thermalpropertiesofbuildingandroadmaterialsandtheheightandspacingofbuildingsandairpollutionlevelsresultinmoreofthesun’senergybeingcaptured,absorbedandstoredinurbansurfacescomparedwithruralsurfacesduringthedayandaslowerlossofthisenergyatnight,resultingincomparativelyhigherairtemperatures.

Lessevaporationandshading,withaconsequentreductioninassociatedcooling,takesplaceinthetypicallydrierurbanareasasthereislessvegetation.

Greaterinputsofheatasaresultofthehighdensityofenergyuseincities,forexamplefrombuildingsandtransport,ultimatelyendsupasheat.

Strategicplanningisthereforerequiredtotakeaccountoftheabovefactors,particularlyinthecontextofclimatechange.Atalocallevel,thisincludesthemodificationofsurfaceproperties,forexamplecoolroofs,greenroofsandcoolpavements.Plantingtreesandvegetationandthecreationofgreenspacestoenhanceevaporationandshadingareotheroptions,astemperaturesinandaroundgreenspacescanbeseveraldegreeslowerthantheirsurroundings.63

Themagnitudeofhealthimpactsascurrentlyunderstoodaresummarisedinfigure2fromtheIntergovernmentalPanelonClimateChange.Whiletheseareglobalimpacts,theyallhavesomerelevancetothehealthstatusoftheUKpopulation.

Figure 2: Health impacts associated with climate change

Source:IntergovernmentalPanelonClimateChange,2007,IPCCFourth Assessment Report (AR4), Climate Change 2007: Impacts, Adaptation and Vulnerability,chapter8.

63DepartmentofHealth,2009:Heatwave Plan for England 2009: Protecting health and reducing harm from extreme heat and heatwaves, London,DepartmentofHealth

iii. The NHS carbon footprint

Figure3showsthenecessaryreductioninNHScarbonemissionsby2020inordertomeettargetssetoutintheClimateChangeAct2008.Itdemonstratesthehighproportionincomparisonwithemissionsfromothersources.

Figure 3: Carbon dioxide emissions (MtCO2) by source, 1990-2000 and predicted to 2020

38

Total emissions

ThetotalNHSEnglandCO2emissionsfor2004wereestimatedtobe18.61MtCO2.ThiscompareswithoverallUKandEnglandconsumptionemissionscalculatedasfollows:

2.7% oftotalUKemissions(699MtCO2)

3.2% oftotalEnglandemissions(584MtCO2)

88% ofthewholeofNorthernIreland’semissions(21.3MtCO2),whichhas1.7millioninhabitants

58% ofthewholeofWales’semissions(32.0MtCO2),whichhas2.9millioninhabitants

32% ofthewholeofScotland’semissions(58.8MtCO2),whichhas5.1millioninhabitants.64

64 SustainableDevelopmentCommission2008:NHS England Carbon Emissions Carbon Footprinting Report,London,SDC.

CO2emissionsbysource,1990to2020,MtC

MtC

1990 2000 2010 2020

180

160

140

120

100

80

60

40

20

0

TransportIndustryServicesResidentialRefineriesPowerstations

Source:SustainableDevelopmentCommission2008:NHS England Carbon Emissions Carbon Footprinting Report,London,SDC.

iv. The size and influence of the NHS

Atthetimeofwriting,theNHSinEnglandincludes:

147PCTs235NHStrusts10caretrusts10strategichealthauthorities(SHAs)10specialhealthauthoritiesfiveregionaldirectorates.

NHSEnglanddoesnotincludenursinghomes,charities,hospicesandprivatehospitals.65

ThebreakdownofstaffbyroleisshowninFigure4.

OnatypicaldayintheNHS,thereare:

90,000doctors300,000nurses150,000healthcareassistants22,000midwives13,500radiographers15,000occupationaltherapists7,500opticians10,000healthvisitors6,500paramedics90,000porters,cleanersandothersupportstaff11,000pharmacists19,000physiotherapists24,000managers105,000practicestaffinGPsurgeries.

65 SustainableDevelopmentCommission2008:NHS England CarbonEmissions Carbon Footprinting Report,London,SDC.

66 Ibid.

Key facts

Thetotalworkforcefigurehasbeenrisingeachyearsince1997,butfellforthefirsttimein2006,andagainin2007butataslowerrate.

Toplinefigures,2007:

Thereare1.3millionstaffintheNHS.

Ofthese,justover50%(nearly680.700)areprofessionallyqualifiedclinicalstaff,e.g.therearejustover128,200doctorsandabout399,600qualifiednurses.

Theyaresupportedbyaround441,100staffintrustsandGPpractices.

Theremainder(about207,800)areNHSinfrastructuresupportstaff,withnearlyahalf(justunder100,200)ofthemincentralfunctions,justoverathird(71,100)inhotel,property&estatesandjustunderafifth(36,500)aremanagers.

Figure 4: Staff in the NHS 1997-2007 (England)66

2.7%

5.3%

Supporttodoctors&

nurses

Qualifiednursesincpractice

nurses

QualifiedST&Tstaff

QualifiedambulancestaffAlldoctors

Manager&seniormanager

Hotel,property&estates

Centralfunctions

Supporttoambulancestaff

SupporttoST&Tstaff

GPpracticestaff

0.9%

7.1%

21.2%

1.3%9.6%

7.5%

4% 10.3%

30%

39

40

OnatypicaldayintheNHS:

almost1millionpeoplevisittheirfamilydoctor130,000gotothedentistforacheck-up/treatment 33,000peoplegetthecaretheyneedinaccidentandemergency 8,000peoplearecarriedbyNHSambulance1.5millionprescriptionsaredispensed2,000babiesaredelivered 25,000operationsarecarriedoutincluding320heartoperationsand125kidneyoperations 30,000peoplereceiveafreeeyetestdistrictnursesmake100,000visits.67

v. NHS building stock

Thereisstillademandforinvestmentincommunityhealthcarefacilities,andforimprovedenergyperformance.ButunlikerecentPFIprojectsforlargenewhospitals,theseprojectswillbemainlyrefurbishmentsofexistingbuildings.Implementingthemwillrequireimaginativeuseofdesignandmanagementideasinexistingcontexts.

By2010,justafifthoftheNHSstockofhospitalswillpre-datethebirthofthehealthservicein1948.Beforethecurrentgovernment’sbuildingprogramme,itstoodat50percent.

SinceMay1997,89majorhospitalschemes(68PFIand21publiccapital)openedand26areunderconstructionandareworthover£10.5billion.

49capitalLIFTschemesworthover£1billionhavedelivered125newprimarycarebuildingsand74areunderconstruction.

189ProCure21schemesworth£854millionhavebeencompletedand133areindevelopmentwithaprogrammevalueofover£2.3billion.68

67 SustainableDevelopmentCommission2008:NHS England Carbon Emissions Carbon Footprinting Report,London,SDC.

68Ibid.

41

vi. Research into therapeutic design

NoiseStudieshavefoundthathospitalnoiselevelsareoftenhigh(65-85dB),andproducewidespreadannoyanceamongpatientsandperceivedstressinstaff.Someresearchhasinvestigatedtheeffectofnoiseonoutcomes,particularlyincriticalorintensivecareunits.Mostfindingssuggestthatnoisedetrimentallyaffectsatleastsomeoutcomes,e.g.producingsleeplessnessandelevatingheartrate.69

WindowsNotableevidenceofnegativeeffectsofwindowlesshealthcareenvironmentsonoutcomeshasemergedfromstudiesofcritical-carepatients.Studieshavelinkedtheabsenceofwindowsincriticalorintensivecarewithhighratesofanxiety,depression,anddeliriumrelativetoratesforsimilarunitswithwindows.70

AstudyinasuburbanPennsylvaniahospitalexaminedtherecordsofpatientsrecoveringfromcholecystectomy.Itcomparedpatientswhoseroomshadwindowsoverlookingnaturallandscapeswithpatientswholookedoutontoabrickwall,andfoundthatthepatientswithopenviews:hadshorterpost-operativestays(7.9dayscomparedwith8.7),hadfewernegativeevaluationcommentsfromnurses,tookfewerstrongandmoderateanalgesicdosesandhadlowerratesofminorpost-surgicalcomplications.71

Sunny roomsFindingsfromtwostudiesraisethepossibilitythatpatientroomslookingoutontosunshine,ratherthancloudyordrabconditions,fostermorefavourableoutcomes.72

Multiple occupancy versus single patient rooms[There is] limited evidence that infection rates in critical care units can be lower in single rooms than open wards... The presence of other patients in multiple occupancy rooms [is seen] as a major source of perceived stressors such as loss of privacy.73

Flooring materialsElderlypatientswalkmoreefficiently(longersteps,greaterspeed)andfeelmoresecureoncarpetedcomparedtovinylsurfaces.Ulrich(2000)foundthatfamilyandfriendsmadelongervisitstorehabilitationpatientswhenpatientroomswere

carpetedratherthancoveredwithvinylcompositionflooring.Employees,however,overwhelminglyfavouredvinylcomposition(83%)mainlybecauseofgreatereaseincleaningupspills.74

LightingResearchinlightandhealthhasconfirmedthatlightnotonlyservesthevisualsystembutisalsoapowerfulregulatorofthecircadiansystemandincreasesproductivity,alertnessandhealthandsafetyofpatientsandcaregivers.75

Access to natureItisimportanttorecognizethat‘healing’isnotsynonymouswith‘cure’.Agardencannotmendabrokenlegorcurecancer,butitcandothefollowing:

Facilitatestressreductionwhichhelpsthebodyreachamorebalancedstate.

Helpapatientsummonuptheirowninnerhealingresources.

Helpapatientcometotermswithanincurablemedicalcondition.

Provideasettingwherestaffcanconductphysicaltherapy,horticulturaltherapy,etc.withpatients.

Providestaffwithaneededretreatfromthestressofwork.

Providearelaxedsettingforpatient-visitorinteractionawayfromthehospitalinterior.76

69 Ulrich,R.2000:Effectsofhealthcareenvironmentaldesignonmedicaloutcomes,Design & Health: The Therapeutic Benefits of Design49-59.

70 Ibid.71 CABE,2002:The Value of Good Design,London,CABE.72 Ibid. 73 Ulrich,R.2000:Effects of healthcare environmental design on medical outcomes,

Design & Health: The Therapeutic Benefits of Design49-59.74 Ibid.75Simenova,M.2004:HealthyLightingfortheVisual,Circadianand

PerceptualSystems.Business Briefing: Hospital Engineering & Facilities Management, Report 3, Touch Briefings.

76 Cooper,M.C.2005:HealingGardensinHospitals,The Interdisciplinary Design and Research e-Publication,1(1),1-27.

42

Sin

gle

bed

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s

Acc

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to d

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ht

Ap

pro

pri

ate

ligh

ting

Vie

ws

of

natu

re

Fam

ily z

one

in p

atie

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oo

ms

Car

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No

ise

red

uci

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hes

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loo

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Dec

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alis

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up

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Acu

ity

adap

tab

le r

oo

ms

Reduced hospital acquired infections

Reduced medical errors

Reduced patient falls

Reduced pain

Improved patient sleep

Reduced patient stress

Reduced depression

Reduced length of stay

Improved patient privacy & confidentiality

Improved communication with patients & family members

Improved social support

Increased patient satisfaction

Decreased staff injuries

Decreased staff stress

Increased staff effectiveness

Increased staff satisfaction

=Indicatesthatarelationshipbetweenthespecificdesignfactorandhealthcareoutcomewasindicated,

directlyorindirectly,byempiricalstudiesreviewedinthisreport.

=Indicatesthatthereisespeciallystrongevidence(convergingfindingsfrommultiplerigorousstudies)indicatingthatadesigninterventionimprivesahealthcareoutcome.

vii. Effects of hospital design onnursing staff

Table3showstheeffectonvarioushealthoutcomesofhospitaldesignfactorssuchasqualityoflayout(wherestaffcanbothfindtheirwayroundinstinctivelyanddonotoftenhavetorespondtovisitorsaskingtheway),thepresencethattheserviceshavewithinthecommunityasexpressedbythearchitecture,andthedetailofampleandwell-designedstorage.Table4(onp.43)showstheirimpactonnursingstaff,wheretheyprovetohaveastronghandinrecruitment,retentionandperformance.77

Table 3: Effect of design factors on health outcomes

77 Ulrich,R.,Zimring,C.M.,Zuemei,C.,DuBose,J.,Seo,H.,Quan,X.,&Joseph,A.,2008,AReviewoftheResearchLiteratureonEvidence-BasedHealthcareDesign,HERD: Health Environments Research & Design Journal

Source:CABE2004: Healthy Hospitals Campaign,London,CABE.

43

Table 4: Design factors affecting nurses

Factors identified as part of this research

Factors identified in CABE’s ‘Healthy Hospitals’ campaign

Recruitment Retention Performance

External space Exterior&publictransport

Landscapedesign

Internal environment Entranceandfoyer

Layout

Signage – –

Interior

Storage

Functionality Designofconsultingrooms

Versatility

Civic value Integrationofarchitecture

Facilities –

=Limitedevidence =Moderateevidence =Strongevidence

Source:CABE2004: Healthy Hospitals Campaign,London,CABE.

44

ToolkitsAnindicationoftherelevantthemesandprofessionaldisciplinesaremadenexttoeachofthesesummaries.

MC=moderncareSD=sustainabledevelopmentQD=qualitydesignHN=healthyneighbourhoodsD=designerPl=plannerC=clientPo=policy-maker

Achieving Excellence Design Evaluation Toolkit (AEDET)D,CAEDETisatoolforevaluatingthequalityofdesigninexistingandplannedhealthcarebuildings.TheNHSworkedwiththeConstructionIndustryCouncilandthe UniversityofSheffieldtodevelopthetoolkit,whichallowsuserstocreateadesignevaluationprofile.

Advice to trusts on the main components of the design brief for healthcare buildingsPl,D,C Advicenotefortrustsinvolvedinhealthcarebuildingprojects.StrategicprojectbriefinganddesignqualitybriefingalongthecriteriaofAEDET(seeabove)arecovered.

Association of Public Health Observatories (APHO)MC,Po,Plwww.apho.org.ukAPHOrepresentsanetworkof12publichealthobservatories(PHOs)workingacrosstheUKandIreland.Theyproduceinformation,dataandintelligenceonpeople’shealthandhealthcareforpractitioners,policy-makersandthewidercommunity.Theirexpertiseliesinturninginformationanddataintomeaningfulhealthintelligence.

Architects for HealthQD,Dwww.architectsforhealth.comArchitectsforHealthcampaignsforbetterhealthcareenvironmentsbybringingtogetherindividualsandorganisationswhoshareaninterestinexcellenceintheplanninganddesignofhealthcarefacilities.Itisanon-profit-makingorganisationforanyoneinterestedinthedesignandplanningofhealthcarefacilities.Itsinceptionin1992wasaresponsetoconsiderablestrategicchangeinthehealthsector.

Building Research Establishment Environmental Assessment Method Healthcare(BREEAM:Healthcare)D,CBREEAM:Healthcareisusedtoassesstheenvironmentalsustainabilityofhealthcaredevelopments.TheDepartmentofHealthrequires,aspartoftheoutlinebusinesscaseapproval,thatallnewbuildsachieveaBREEAMExcellentandallrefurbishmentsachieveaVeryGoodrating.Allprojectsarerequiredtohaveasustainabletravelplan.

Appendix 3 Toolkits and key organisations

45

Campaign for Greener HealthcareSD,Po,Pl,D,Cwww.greennhs.orgTheCampaignforGreenerHealthcarefocusesonclinicaltransformationforasustainablehealthservice.Itperformsgreenaudits,andisdevelopinganationalevidence-baseforsustainablehealthcare.Itworkswiththepublic,privateandcommunitysectors,andputsgreenwordsandtargetsintotangibleandsustainableaction,primarilywithintheNHSandassociatedindustries.

Care Quality CommissionMC,Po,Pl,D,Cwww.cqc.org.ukTheCareQualityCommissionistheindependentwatchdogforhealthcareinEngland.ItseekstoimproveservicesprovidedbytheNHSandindependenthealthcareorganisations.

The Climate ConnectionSD,Po,Pl,D,Cwww.theclimateconnection.orgTheClimateConnectionisapartnershipnetworkforactiononpublichealthandlearningonclimatechange.ItisfundedbytheDepartmentofHealthandco-ordinatedbytheUKPublicHealthAssociation(UKPHA).

The Climate and Health CouncilSD,Po,Pl,D,Cwww.climateandhealth.orgTheClimateandHealthCouncilisanot-for-profitinternationalorganisationthataimstomobiliseandinformhealthprofessionalsacrosstheworldtotakeactiontolimitclimatechange.Anyhealthprofessionalorhealthcareorganisationcanbecomeamember.

Commission for Architecture and the Built Environment(CABE)QD,Po,Pl,D,Cwww.cabe.org.ukCABEisthegovernment’sadvisoronarchitecture,urbandesignandpublicspace.CABEworkswitharchitects,planners,designers,developersandclients,offeringthemguidanceonhowtoachievewell-designedbuildingsthatmeettheneedsofusers.

Community Health Partnerships (CHP)HN,Po,Pl,D,Cwww.communityhealthpartnerships.co.ukCHPdevelops,createsinvestmentinandhelpsfindandimplementinnovativewaystoimprovehealthcareandlocalauthorityservices.Ithasdeliveredthelocalimprovementfinancetrust(LIFT)initiative,providingpurpose-builtpremisesforhealthcareandlocalauthorityservices.Itisanindependentcompany,whollyownedbytheDepartmentofHealth.

Department of HealthMC,PoPl,D,Cwww.dh.gov.ukTheDepartmentofHealth(DH)isthegovernmentdepartmentresponsibleforprovidinghealth-andsocialcarepolicy,guidanceandpublicationsforNHSandsocialcareprofessionals.

Designed with care: design and neighbourhood healthcare buildingsMC,QD,C,DCABEreportexamining15ofthebestneighbourhoodhealthcarebuildingsinthecountry,fromadoctor’ssurgerytoanNHSwalk-incentre.Thecasestudiesshowhowhigh-qualitydesigncreatesahuman,inclusiveandreassuringenvironment.

European Health Property Network(EuHPN)QD,Po,Pl,D,CEuHPNisaninternationalnetworkofgovernmentaldepartmentsandresearchcentreswithacommoninterestinallaspectsofhealthfacilities,butespeciallyintheirfinancing,design,managementandorganisation.

Fit for the FutureSD,MC ReportfromtheNHSSustainableDevelopmentUnitarguingthattheNHSmusttakeurgentactionnowtoplayaleadingroleintheresponsetoclimatechangeifitistoprovidethebestqualityhealthcare.Itdetailsasetofscenariosandrecommendsfivekeystepstocreatingasustainable,low-carbonhealthcaresystem.

Guide to town planning for NHS staff GuidefromtheDepartmentofHealthexplainingtheplanningsysteminEnglandwithreferencetoissuesspecifictotheNHS.Itaimstoensurethattheneedsofthehealthservicearetakenintoconsideration,andmet,fromplanningpolicythroughtoplanningapplications.

Natural England: Our Natural Health Service Campaignaimingtoensuregoodaccesstogreenspaceforall,andsothathealthservicesmakebetteruseofgreenspaces,forexamplebyeveryGPorcommunitynursesignpostingpatientstoanapprovedhealthwalkoroutdooractivityprogramme.

46

Open space strategies: best practice guidance PracticalguidancefromCABEtolocalauthoritiesand theirstakeholdersonhowtoprepare,deliver,monitor andreviewanopenspacestrategy.

Health and Care Infrastructure Research and Innovation Centre(HaCIRIC)MC,Po,Pl,D,Cwww.haciric.orgHaCIRIC’sfocusisontheunderlyingbuiltandtechnicalinfrastructureforhealth-andsocialcare,andtheinteractionbetweenthisinfrastructureandchangeandinnovationincareservices.ItisacollaborationbetweenexistingresearchcentresatImperialCollegeLondonandtheuniversitiesofLoughborough,ReadingandSalford.

Healthy hospitals: radical improvements in hospital designResearchbyCABEandPricewaterhouseCoopersshowinghowimportantclinicalstafffeelthedesignofhealthcarepremisesisandwhy.ItoutlinesCABE’s10pointsforawell-designedhealthcarebuilding.

Health impact assessment of greenspace – a guide AdvicefromGreenspaceScotlandonhowtoassessthehealthandequityimpactsofgreenspaceprojects;andminimiseanynegativeandmaximisepositiveimpacts.

The Health Practitioner’s Guide to Climate Change: Diagnosis and Cureeds.JennyGriffiths,MalaRao,FionaAdshead,AllisonThorpe,2009Anintroductionforhealthpractitionerstoclimatechangeanditscurrentandfuturehealthimpacts,describingtherelationshipbetweenhealthandtheenvironment,andsettingoutthehugebenefitstohealthofactingonclimatechangeandhowtodesignhealthy,sustainablecommunities.

Health Protection AgencyMC,Po,Pl,Cwww.hpa.org.ukTheHealthProtectionAgencyprovidesanintegratedapproachtoprotectingUKpublichealththroughtheprovisionofsupportandadvicetotheNHS,localauthorities,emergencyservices,governmentdepartmentsandthepublic.

Health and Sustainability NetworkSD,Po,Pl,D,Cwww.healthandsustainability.netTheHealthandSustainabilityNetworkwasoriginallycalledtheConvergenceofHealthandSustainableDevelopmentNetwork.Itspurposeistoenablepeopleandorganisationsinthehealthcarecommunitytoworktogethertogiveamuchhigherprioritytosustainabledevelopment,andinparticularactingtopreventtheworsteffectsofclimatechange.

The health and urban planning toolkit NHSLondonHealthyUrbanDevelopmentUnit(HUDU)guidesettingoutastep-bystep approachtoimprovingworkingbetweenprimarycaretrustsandlocalplanningauthorities.

Integrating health into the core strategy HUDU’sguideshowshowPCTscaninfluencethespatialplansthatcouncilsneedtoprepare.

King’s FundMC,Po,Pl,D,Cwww.kingsfund.org.ukTheKing’sFundisanindependentcharitablefoundationthatundertakesresearchtoinformbetterhealth,especiallyinLondon.Ithelpsdevelopinformedpolicy,effectiveservicesandskilledpeoplebyfosteringinnovation,andbuildingunderstanding.Ithelpsdevelopcapacityandleadershipthroughoriginalresearchandobjectiveanalysis.

London Health Commission (LHC)HN,Po,Pl,C TheLHCworksinpartnershipwithagenciesacrossthecapitaltoreducehealthinequalitiesandimprovethehealthandwell-beingofallLondoners.Itaimstoinfluencekeypolicy-makersandpractitioners,supportlocalaction,anddriveforwardspecificpriorityissuesthroughjointprogrammesofwork.

Manchester Joint Health UnitHN,Po,Pl,Cwww.manchester.gov.uk/health/jhuTheManchesterJointHealthUnitfocusesonstrategicplanningandpartnershipworkingforhealthimprovement,andtacklinghealthinequalitiesinManchester.Partofitsremitistobetheleadonbuildingnewhealthcarefacilitiesinregenerationareas.

47

Manual for StreetsGuidefromtheDepartmentforTransportemphasisingthatstreetsshouldbeplacesin whichpeoplewanttoliveandspendtime,andarenotjusttransportcorridors.Itaimstoreducetheimpactofvehiclesonresidentialstreetsbyaskingpractitionerstoplanstreetdesignintelligentlyandproactively,andgivesahighprioritytotheneedsof pedestrians,cyclistsandusersofpublictransport.

National Heart Forum(NHF)HN,Po,Pl,D,Cwww.heartforum.org.ukNHFisanallianceofmorethan50nationalorganisationsworkingtoreducetheriskofcoronaryheartdiseaseandrelatedconditionssuchasstrokeanddiabetes,andcancer.Membersincludecharities,andnon-governmentalandprofessionalmedicalorganisations.

National Institute for Health and Clinical Excellence(NICE)MC,Po,Pl,D,Cwww.nice.org.ukNICEistheindependentorganisationresponsibleforprovidingnationalguidanceonthepromotionofgoodhealthandthepreventionandtreatmentofill-health.

New Health NetworkMC,Po,Pl,D,Cwww.newhealthnetwork.co.ukTheNewHealthNetworkisanindependent,multi-professionalnetworkthatpromotessustainablemodernisationoftheNHSandfocusesexclusivelyonpatientinterestsandpublichealth.

NHS ConfederationMC,Po,Pl,Cwww.nhsconfed.orgTheNHSConfederationistheindependentmembershipbodyfororganisationsthatmakeuptheNHS.Itrepresentsmorethan95percentofNHSorganisationsaswellasagrowingnumberofindependenthealthcareproviders.

NHS Institute for Innovation and ImprovementMC,Po,Pl,D,Cwww.institute.nhs.ukTheNHSInstituteforInnovationandImprovementsupportstheNHSintransforminghealthcareforpatientsandthepublicbyrapidlydevelopingandspreadingnewwaysofworking,newtechnologyandworld-classleadership.

NHS London Healthy Urban Development Unit (NHSLondonHUDU)HN,Po,Pl,D,Cwww.healthyurbandevelopment.nhs.ukHUDUpromoteshealthimprovementandthenarrowingofhealthinequalitiesinLondonthroughpursuingthealignmentofhealthandspatialplanningstrategies.Itsupportstheintegrationofhealthintolocaldevelopmentframeworks,andfacilitateseffectiveengagementbetweenthehealthandplanningsectorsandaccesstomodernhealthcare.

NHS Sustainable Development Unit(SDU)SD,Po,Pl,D,Cwww.sdu.nhs.ukSDUgivesleadership,expertiseandguidanceonsustainabledevelopmenttoallNHSorganisationsinEngland.Itraisesawarenessastotheresponsibilitiesof,andactionsfor,theNHSonsustainabledevelopmentandclimatechange.Itensuresthatbestpracticeandinnovationareevaluatedandcosted,andthatthemechanismsforimplementationaremadefullyavailabletoallNHSorganisations.

PeabodyHN,Po,Pl,DCPeabodyhousingassociationaimstoensurethatasmanypeopleaspossibleacrossLondonhaveagoodhome,asenseofpurposeandastrongfeelingofbelonging.PeabodyrunseventsforLondonresidentstoencouragehealthandwell-being,focusingonmentalhealth,healthyeatingandexercise.

SHINESD,Po,Pl,D,Cwww.shine-network.org.ukSHINEhelpsNHStrustsimproveonthesustainabilityoftheirestatesthroughalearningnetworkofguidance,casestudies,eventsandtraining,includingachievingsustainabilitythroughNHSprocurementprocesses.ItissupportedbytheDepartmentofHealth,theLondonNHSandCommunityHealthPartnerships.

Sustainable Development Commission(SDC)SD,Po,Pl,D,Cwww.sd-commission.org.ukSDCisthegovernment’sindependentadvisoronsustainabledevelopment.Itprovidesadvocacy,adviceandappraisaltohelpputsustainabledevelopmentattheheartofgovernmentpolicy.Itusesevidence-basedpublicreportsonenvironmental,socialandeconomicissues,andexpertopiniontoadvisegovernment,invitesdebatesoncontroversialsubjectsandgiveswatchdogappraisalsofthegovernment’sprogress.

Sustainable Development Unit(SDU)SD,Po,Pl,D,CThegovernment’sSDUsitswithintheDepartmentforEnvironment,FoodandRuralAffairs(Defra).ItreportsonandmonitorssustainabledevelopmentacrossWhitehallandtheUK.ItimplementstheUK’sSustainableDevelopmentStrategyandensuresthesustainabilityofnewcommunities,andDefra’sinterestsinplanningsystems,housingsupply,sustainablebuildingsandconstruction,strategictransportissuesandtheOlympics.ItsponsorstheSustainableDevelopmentCommission.

Twenty Steps for Developing a Healthy Cities ProjectPo,PlPublicationfromtheWorldHealthOrganisationRegionalOfficeforEuropeoutlininganactionplanforimplementingWHO’squalitiesofahealthycity(SeeAppendix2,iFigure1).Itisaimedatlocalgovernment,communitygroups,healthcareprovidersandneighbourhoodassociations.

UK Green Building Council(UK-GBC)SD,Po,Pl,D,CTheUKGreenBuildingCouncil(UK-GBC)bringsclarity,purposeandco-ordinationofsustainabilitystrategytotheconstructionsector.Itbringstogetheranyoneinvolvedintheprocessofplanning,designing,constructing,maintainingandoperatingbuildings,inacross-sectoralapproach,providinginformation,facilitatinglearningbetweenmembersandhelpingtheindustrytaketheactionrequiredonsustainability.

Working tool on city health development planning: concept, process, structure, and contentPo,Pl,D,C GuidancefromtheWorldHealthOrganisation,referringtophaseIIIoftheWHOHealthyCitiesprojectinEurope.Itsgoalistobuildandmaintainstrategicpartnershipsforhealth.Itdescribesindetailaseven-stepprocessthatcanbefollowedtodevelopalocalhealthplan.Thismodelalsoprovidesthebroadframeworkforcityhealthdevelopmentplanning.

World Health Organisation(WHO)MC,Po,Pl,D,Cwww.who.int/en/WHOisthedirectingandco-ordinatingauthorityforhealthwithintheUnitedNations.Itisresponsibleforprovidingleadershiponglobalhealthmatters,shapingthehealthresearchagenda,settingnormsandstandards,articulatingevidence-basedpolicyoptions,providingtechnicalsupporttocountries,andmonitoringandassessinghealthtrends.

49

CommunitiesandLocalGovernment,2009,World Class Places: The Government’s strategy for improving quality of place,London,CommunitiesandLocalGovernment.

CommunityHealthPartnerships,2008,Firm Foundations for World Class Commissioning: How to Achieve Value for Money in Health and Social Care Infrastructure,London,CommunityHealthPartnerships.

Cooper,M.C.&Barnes,M,2005,HealingGardensinHospitals,The Interdisciplinary Design and Research e-Publication,1(1).

DepartmentforBusiness,EnterpriseandRegulatoryReform,CommunitiesandLocalGovernment,DepartmentforEnvironment,FoodandRuralAffairs,DepartmentforCulture,MediaandSport&StrategicForumforBusiness,2007,Draft strategy for sustainable construction: a consultation paper,London,DepartmentforBusiness,EnterpriseandRegulatoryReform.

DepartmentforEnvironment,FoodandRuralAffairs,2008a,Sustainable Development Indicators in your Pocket[online].

DepartmentforEnvironment,FoodandRuralAffairs,2008b,UK climate change sustainable development indicator: 2006 greenhouse gas emissions, final figures.Statisticalrelease25/08.

DepartmentforEnvironment,FoodandRuralAffairs,2009, e-digest statistics about climate change: UK Emissions of Carbon Dioxide, Methane and Nitrous Oxide by National Communication Source Category [online].

DepartmentofHealth,2005,Choosing Activity: a physical activity action plan,Cm6374,London,DepartmentofHealth.

DepartmentofHealth,2007,Rebuilding the NHS: A new generation of healthcare facilities,London,DepartmentofHealth.

DepartmentofHealth,2009a,Heatwave Plan for England 2009,London,DepartmentofHealth.

Allen,J.,2008,Older People and Wellbeing, London, Institute for Public Policy Research.

Cavill,N.(ed.),2007,Building Health: Creating enhancing places for healthy, active lives.Blueprintforaction,London,NationalHeartForuminpartnershipwithLivingStreetsandCommissionforArchitectureandtheBuiltEnvironment.

Donaldson,L.,2009,‘The great survivor: another 60 years’.InNewStatesman/Pfizersupplement,TheFutureDirectionoftheNHS,p.4.

ChristianAid,2007,Coming clean: revealing the UK’s true carbon footprint.[online]

CommissionforArchitectureandtheBuiltEnvironment,2002,The Value of Good Design: How buildings and spaces create economic and social value,London,CommissionforArchitectureandtheBuiltEnvironment.

CommissionforArchitectureandtheBuiltEnvironment,2004a,Radical improvements in hospital design: Healthy hospitals campaign report,London,CommissionforArchitectureandtheBuiltEnvironment.

CommissionforArchitectureandtheBuiltEnvironment,2004b,The role of hospital design in the recruitment, retention and performance of NHS nurses in England,London,CommissionforArchitectureandtheBuiltEnvironment.

CommissionforArchitectureandtheBuiltEnvironment,2008,LIFT Survey Report,London,CommissionforArchitectureandtheBuiltEnvironment.

CommissionforArchitectureandtheBuiltEnvironment,Case Study: Mile End Park, Tower Hamlets[online].

CommissionontheSocialDeterminantsofHealth,2009,Summary of Evidence for the Review of Health InequalitiesAnnex2:EvidencefromtheCommissiononSocialDeterminantsofHealth.

CommunitiesandLocalGovernment,2008,Lifetime Homes, Lifetime Neighbourhoods: A National Strategy for Housing in an Ageing Society,London,CommunitiesandLocalGovernment.

Appendix 4 Bibliography

50

IntergovernmentalPanelonClimateChange,2007,IPCCFourthAssessmentReport(AR4),Climate Change 2007: Impacts, Adaptation and Vulnerability.Cambridge,CambridgeUniversityPress

Lidström,M.2007,Meansoftransportationtoworkandoverweightandobesity:Apopulation-basedstudyinsouthernSweden,Preventative Medicine,46.

Lopez,R.P.&Hynes,H.P.,2006,Obesity,physicalactivity,andtheurbanenvironment:publichealthresearchneeds,Environmental Health: A Global Access Science Source5(25).

Marmot,M.,2008,Closing the gap in a generation: Health equity through action on the social determinants of health,np,WorldHealthOrganisation.

Mason,T.,2006,Designed with Care: Design and neighbourhood healthcare buildings,London,CommissionforArchitectureandtheBuiltEnvironment.

MedicalNewsToday,2009,Traffic-RelatedAirPollutionLinkedToRepeatedHospitalEncountersForAsthma[online]Medical News Today 17February.

NationalInstituteforHealthandClinicalExcellence,2008,NICE issues guidance on inhaler systems for under 5s with asthma[online].

NaturalEngland,2009,Headline Facts: The cost of obesity and physical inactivity[online].

Nielsen,T.S.&Hansen,K.B.,2007,Dogreenareasaffecthealth?ResultsfromaDanishsurveyontheuseofgreenareasandhealthindicators,Health and Place 13(4): 839-50.

NHS,2009,Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England,London,NHSSustainableDevelopmentUnit.

DepartmentofHealth2009b,Tackling Health Inequalities: 10 Years On,London,DepartmentofHealth.

DepartmentofHealth&NeighbourhoodRenewalUnit,2005,Creating Healthier Communities: a resource pack for local partnerships[online].

DirectGov,2009,Causes of Climate Change [online].

DesignBriefWorkingGroup,NHSEstates&DepartmentofHealth,2002,Advice to Trusts on the main components of the design brief for healthcare buildings,London,DepartmentofHealth.

Edwards,J.,Walters,S.&Griffiths,R.K.,1994,Hospitaladmissionsforasthmainpreschoolchildren:RelationshiptomajorroadsinBirmingham,UnitedKingdom,Archives of Environmental Health,49,223-27.

Ellaway,A.,Macintyre,S.&Bonnefoy,X.,2005,Graffiti,greeneryandobesityinadults:secondaryanalysisofEuropeancross-sectionalsurvey,British Medical Journal331,611-2.

Foresight,2007,Tackling Obesities: Future Choices—Modelling Future Trends in Obesity and Their Impact on Health,London,DepartmentofInnovation,UniversitiesandSkills.

Haq,G.,Whitelegg,J.&Kohler,M.,2008,Growing Old in a Changing Climate: Meeting the challenges of an ageing population and climate change,Stockholm,StockholmEnvironmentInstitute.

HMGovernment,2009,Sustainable Development: Creating sustainable communities and a fairer world[online].

HouseofCommons,2004,Third Report of the House of Commons Select Committee on Health,Norwich,TheStationeryOffice.

Imison,C.,2008,Future Healthcare Trends,PowerPointpresentation,London,TheKing’sFund

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SustainableDevelopmentCommission,2008b,NHS England Carbon Emissions Carbon Footprinting Report,London,SustainableDevelopmentCommission.

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52

WorldHealthOrganisationCentreforUrbanHealth,2001, A working tool on city health development planning: Concept, process, structure, and content,Copenhagen,WorldHealthOrganisationRegionalOfficeforEurope.

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Future health explains how good design makes healthy places. It brings together what CABE knows about sustainable, health-promoting design with the latest thinking about individual health and well-being. Drawing on examples and research, it shows how good planning can have a positive impact on public health, how health trusts can cut carbon and costs by co-locating services, and how designers can influence peoples’ well-being. The publication will be of interest to health trusts, planners, policymakers and premises providers. This full report offers the detailed research behind a summary version, available online and to order from CABE.

CABE1 Kemble StreetLondon WC2B 4ANT 020 7070 6700F 020 7070 6777E enquiries@cabe.org.ukwww.cabe.org.uk

CABEisthegovernment’sadvisoronarchitecture,urbandesignandpublicspace.Asapublicbody,weencouragepolicymakerstocreateplacesthatworkforpeople.Wehelplocalplannersapplynationaldesignpolicyandadvisedevelopersandarchitects,persuadingthemtoputpeople’sneedsfirst.Weshowpublicsectorclientshowtocommissionprojectsthatmeettheneedsoftheirusers.Andweseektoinspirethepublictodemandmorefromtheirbuildingsandspaces.Advising,influencingandinspiring,weworktocreatewell-designed,welcomingplaces.

Publishedin2009bytheCommissionforArchitectureandtheBuiltEnvironment

CABEwouldliketothankJonathanMillmanattheDepartmentofHealth

ResearchbyAlexiMarmotAssociates

GraphicdesignbyDraughtAssociates

Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,copiedortransmittedwithoutthepriorwrittenconsentofthepublisherexceptthatthematerialmaybephotocopiedfornon-commercialpurposeswithoutpermissionfromthepublisher.Thisdocumentisavailableinalternativeformatsonrequestfromthepublisher.