Sustainable Development: The Key to Tackling Health Inequalities

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Sustainable Developm

ent Comm

ission

The Sustainable Development Commission is the Government’s independent watchdog on sustainable development, reporting to the Prime Minister, the First Ministers of Scotland and Wales and the First Minister and Deputy First Minister of Northern Ireland.

Through advocacy, advice and appraisal, we help put sustainable development at the heart of Government policy.

www.sd-commission.org.uk

Sustainable development:

The key to tackling health inequalities

Sustainable development: The key to tackling health inequalities

Foreword: A call to action 2

1 Summary 5

2 Health inequalities: A timely agenda 9

2.1 Introduction 9

2.2 The Marmot Review (2010) Fair Society, Healthy Lives 9

3 Sustainable development and health inequalities 11

3.1 What is sustainable development? 12

3.2 Healthier people, healthier environment 13

3.3 Preventionandco-benefits:Promotinghealthandsustainabledevelopment 14

3.4 Areainequalities 16

3.5 Bigpictureissue:Climatechange 18

3.6 Bigpictureissue:Theeconomy 23

4 A sustainable approach to tackling health inequalities 27

4.1 Introduction 28 4.2 Foodsystems 30

4.2.1 Foodandsustainabledevelopment 30

4.2.2 Food,healthandinequalities 32

4.3 Transport 35

4.3.1 Transportandsustainabledevelopment 35

4.3.2 Transport,healthandinequalities 36

4.4 GreenSpace 43

4.4.1 Greenspaceandsustainabledevelopment 43

4.4.2 Greenspace,healthandinequalities 43

4.5 TheBuiltEnvironment 47

4.5.1 Thebuiltenvironmentandsustainabledevelopment 47

4.5.2 Thebuiltenvironment,healthandinequalities 47

5 A sustainable health system 51 5.1 Anew,partnershipapproachtoprevention 52

5.2 AmoresustainableNHS 56

Endnotes 57

Contents

2 Sustainable development: The key to tackling health inequalities

Whenitcomestocausinghealthinequalities,environmentalconsiderationsplayasignificantrole.Food,transport,greenspaceandthebuiltenvironment are all factors which can narrow or widenthehealthgapbetweenrichand poor communities. ButtheSustainableDevelopmentCommissionbelieves that the environmental causes of health inequalitiesarestillbeingunder-appreciated. Andthatmeanspolicymakersaremissingtheco-benefitsavailablefromaholisticapproachthatcancreate a better environment and healthier people at the same time. Thisisnotjustwishfulthinking;theevidenceisclear.Drawingonasignificantbodyofresearchfromarangeofdisciplines,thisreportshedslightonthecloselinksbetweenunsustainabledevelopmentandhealthinequalitiesandpromotestheco-benefitsofspreadingresponsibilityforhealthbeyondthehealthcare community. Suchanapproachistheonlywayforward.Aswellas established environmental causes of ill health such asairpollution,noiseandpoorqualityurbandesign,climatechangepresentsaseriousrisktohealthandwellbeingandwillhaveadisproportionateimpactonalreadydisadvantagedgroups.Withoutcareful

Foreword: A call to action

consideration,responsestoclimatechangemayincreasenegativeeffectsonpoorergroups.Atthesame time, traditional income-driven approaches to tacklinginequalitiesmayincreasecarbonemissions. Ifwearetoreducehealthinequalitiesandtackleclimatechange,weneedanewpoliticalapproach,builtaroundtheinsightsofsustainabledevelopment,inwhicheverybodyhasequalchancestoflourish,withintheboundsoffiniteecologicalresourcesandanexpandingglobalpopulation.Economic,environmental and social policies should be co-ordinatedproactivelybygovernmentsotheyworktogethertopromoteasupportiveecosystemandsocialjustice,andreducehealthinequalities. Assooften,preventionandsharedresponsibilityarekey.TheSustainableDevelopmentCommissioncallsuponpolicymakersandpractitionersincentralandlocalgovernment–whetherornottheyhave‘health’ or ‘sustainable development’ in their jobtitle–tostartthinkingabouthowtheirwork canreducehealthinequalitiesandpromotesustainable development We hope this report provides you with the evidenceyouneedtomakethechange,andwewelcomeyourfeedback.

Sustainable Development CommissionFebruary 2010

Foreword: A call to action 3

InNovember2008,ProfessorSirMichaelMarmotwasaskedtoadvisetheSecretaryofStateforHealthonthefuturedevelopmentofahealthinequalitiesstrategyinEnglandpost-2010.Thereview,entitledThe Marmot Review Fair Society, Healthy Lives1

(TheMarmotReview)establishedninetaskgroupstoidentifyrelevantevidenceintheareasof:

-EarlyChildDevelopmentandEducation-EmploymentArrangementsandWorkingConditions- Social Protection -theBuiltEnvironment- Sustainable Development -EconomicAnalysis- Delivery Systems and Mechanisms -PriorityPublicHealthConditions;and- Social Inclusion and Social Mobility.

This report is not intended to replicate the detailed discussionofhealthinequalitiesandthepolicy context put forward in the Marmot Review. Instead, Sustainable Development: The key to tackling health inequalities is intended to reinforce the relevant messagesdevelopedbytheReview’sSustainableDevelopmentandBuiltEnvironment taskgroupsandsharethemwithawideraudience. Addressingbothnationalandlocaldecisionmakers,andwithrelevancetoUK-wide,notjustEnglish,policydevelopment,thisreportoffersa comprehensive picture of how sustainable developmentandhealthequityarecomplementaryandmutuallyreinforcing.Itemphasisestheimportance of the environmental determinants of health, all too often underappreciated by thosepolicymakerswithnoexplicitenvironmentalremit,andspecificallyhighlightsthechallengeofclimatechange.Anditsetsouttheevidenceforsustainablesolutionstohealthinequalities, providingenvironmentalandhealthco-benefitsat asinglestroke. Much of the material within this report was developed as a submission to the Sustainable DevelopmentandBuiltEnvironmentTaskGroups,whosememberswere:

Sustainable Development Task Group Jonathon Porritt(Chair)–formerlySustainableDevelopmentCommission(SDC)David Colin-Thomé–DepartmentofHealthAnna Coote–NewEconomicsFoundation(nef)Sharon Friel–UniversityCollegeLondon&theAustralianUniversityTord Kjellstrom–UniversityCollegeLondon&theAustralianUniversityPaul Wilkinson–LondonSchoolofHygieneandTropical Medicine (LSHTM)

Research supportMaria Arnold–SDCHelen Clarkson–ForumfortheFutureSue Dibb–SDCJane Franklin–nefTara Garnett–FoodClimateResearchNetwork,UniversityofSurreyJemima Jewell –ForumfortheFutureDuncan Kay–SDCShivani Reddy–SDCCathryn Tonne–LSHTMBen Tuxworth–ForumfortheFutureJames Woodcock–LSHTM

Built Environment Task Group Professor Anne Power(Chair)–LondonSchoolofEconomics(LSE)Jonathan Davis–CommissionforArchitectureandtheBuiltEnvironment(CABE)Paul Plant–DepartmentofHealthTord Kjellstrom–UniversityCollegeLondon&theAustralianUniversity

Research supportCatalina Turcu –LSEHousingHelen Eveleigh–CABE/SDC

This report


TheCommissionhasalwayssoughttomakeclearinitsadvicetogovernmentthathealthcannotbeaddressedin isolation, and as such this report also reinforces materialwithinthefollowingpublications,allofwhichareavailableatwww.sd-commission.org.uk

Stock take: Deliveringimprovementsinexistinghousing

Building Houses or Creating Communities?–Areview ofGovernmentprogressonSustainableCommunities

Every Child’s Future Matters – Why the environment shouldbeakeyconsiderationinchildwellbeing

Health, place and nature–Howoutdoorenvironmentsinfluencehealthandwellbeing:aknowledgebase

Setting the Table – AdvicetoGovernmentonPriorityElementsofaSustainableDiet,(publishedaspartofDefra’s Food 2030 project)

Smarter Moves – How information communications technologycanpromotesustainablemobility.

TheSustainableDevelopmentCommissionistheGovernment’sindependentadviseronsustainabledevelopment,reportingtothePrimeMinister,theFirst Ministers of Scotland and Wales and the First MinisterandDeputyFirstMinisterofNorthernIreland.Throughadvocacy,adviceandappraisal,wehelp put sustainable development at the heart of Governmentpolicy.

Drafting teamThisreportwasdraftedbyMariaArnoldwithsupportfromAnnaAbbott,TessGill,SusanGransden,JamesGreenleaf,TimJenkins,DuncanKay,ShivaniReddy,JakeReynolds,ShirleyRodrigues,KayWest,withadditionaleditorialsupportfromNicoletteFoxandEstherMaughanMcLachlan.

To follow up on this report, please contact [email protected]

Summary 5

Whilethehealthofthenation’spopulationhasmarkedlyimprovedoverthelast150years,significanthealthinequalities–definedas‘systematic differences in health status between different socio-economicgroups’–remain.Healthinequalitiesareasymptomofotherformsofinequityandunfairnessinoursociety,andachievinghealthequityisthereforeamatterofsocialjustice. Sustainabledevelopmentprovidesalogicalstartingpointandanessentialanalyticalframeworkforfindingwaystoreducehealthinequalities.Thisreportexplainswhat sustainable development is, why it matters for healthinequalities,andhowitcanleadtopracticalimplicationsforpolicy-making. Sustainable development is understood in terms ofthefiveGuidingPrinciplessetoutbyGovernment.These concern environment, society, economy, governanceandknowledge. Theseguidingprinciplesofferasystemic frameworkwhichisextremelyrelevantfortacklinghealthinequalities.Itisconsistentwiththe‘social model’ofhealth,butextendsandstrengthensitbyemphasising:

A• long-termperspective,drawingattentiontotheneedsandclaimsoffuturegenerationsandinter-generational equity

Afocusonthe• environmental determinants of healthandhealthinequalities,especiallytheeffectsofclimatechange

1Summary

Aconcernwith• alternatives to today’s economic growth inordertoachievelong-termsustainability,equityandimprovedwellbeing

Opportunitiesforinvestingin• synergistic measuresorco-benefitsthatreduceenvironmentaldamage,promotesocialjustice andnarrowhealthinequalitiesatonestroke

Policies and actions that improve life for the •poorest peopleintheglobalpopulation

Theimportanceofhavingaclear• vision of where we want to be by 2025.

Againstthebackgroundofthe‘bigpicture’challengesofclimatechangeandanunsustainableeconomy,this report provides detailed evidence for the health equityandsustainabledevelopmentco-benefitsavailableinfoursectors:food,transport,greenspaceand the built environment. The report concludes with recommendationsforcentralandlocalgovernmentand an outline of the way ahead for a prevention-driven health system in the future.


Unhealthyliving,noisy,pollutedand‘obesogenic’environments create a vicious circle of chronic ill-health, which reduces individual and collective wellbeing.Theseissuesalsoservetoincrease thecarbonfootprintofindividualsandtheNHS andunderminethelong-termviabilityofthe health system. In the developed world, healthcare services tend tobehighlyresource-intensive.Ifpeopleinlowersocio-economicgroupsenjoyedthesamelevelofhealthasthoseinhighergroups,therewouldbefewerpeopleleadingunhealthylivesandrequiringhealthcare. This would help to reduce healthcare costsandthecarbonfootprintoftheNHS,andsavemoneyfortreatingunavoidableillnessandtacklingthecausesofhealthinequalities.Anapproachtohealthcare which, for example, favours community-based primary care and embraces the principles of goodcorporatecitizenship,canhelptoaddresstherootcausesofinequalitiesandthusinthelongtermlower the resource intensity of healthcare. Investingpublicfundsinmeasuressuchasactivetravel,promotinggreenspacesandhealthyeatingwillyieldco-benefitsforbothhealthandcarbonemissions. But opportunities for healthy, low-carbon livingshouldbedistributedinwaysthatfavourpeople with low incomes and so help to reduce their vulnerability to ill-health. Successrequiresstronglocalpartnerships,a broader sense of responsibility for health and wellbeingandsystematicengagementbetweentheNHSandregionaldevelopmentagencies,localandregionalgovernmentandsocialcare.

Area inequalities Areainequalitiessuggestthatwhereapersonlivesaffects how well that person lives now and in the future, and even their life expectancy. Aneighbourhood’sphysical(pollution,traffic,noise,access to amenities) and social (individual and

collective attitudes and behaviours) infrastructures all impact on health. There is a powerful relationship between local measuresofdeprivationandreducedlifeexpectancy;thegapbetweenrichandpoorareasincreasingin the1980sand1990s.Vulnerablegroupssuchaschildren and ethnic minorities suffer particularly inurbancommunities,asdopeoplelivingin deprived rural areas.

Climate changeClimatechangepresentsseriousriskstohealth andwellbeingforall,ashighlightedrecentlyby theLancetandtheWHO.Poorersocialgroupsaremorelikelytobemoreexposedtotheserisks,to have fewer resources to cushion their effects, and tolackinsuranceagainstthem. Responsestoclimatechangemustbecarefully considered, since they may affect health positivelyornegatively.Poorergroupswillsufferdisproportionatelyfromregressivetaxingandpricingregimes,andtheyoftentendtobelessabletorespondreadilytocampaignsthatencouragebehaviourchange.Measuresintendedtorespond toclimatechangemustnotwidenhealthinequalities.Similarly,effortstoreducehealthinequalitiesshouldseektoreducecarbonemissions.

Sustainable economyAsustainableeconomycannotbeachievedthroughcontinuingeconomicgrowthasweknowit, at least not in developed countries such as the UK.Animmediatetransformationinthenatureofgrowthandconsumptionisrequired.Growthcannotbesufficiently‘decoupled’fromitssocialandenvironmental externalities, and from emissions of C02inparticular.Thesetwoaspectsofachievingasustainableeconomyposeimportantchallengestoeconomic policy.

A preventative approach to health

Summary 7

AspreviousworkfromtheSustainableDevelopmentCommissionhasargued,prosperitydoesnotdependonconstantincreasesineconomicgrowth,butisbestdefinedbypeople’scapabilitytoflourishphysically,psychologicallyandsocially.Prosperityhasundeniablematerial dimensions, but the current culture of consumptionactsasabarriertoenablingpeopletoflourishinlessmaterialisticways.Tacklingthesebarriers can help to reduce many of the social and economicvariablesthatdeterminehealthinequalities. Routestoimprovinghealthandreducinghealthinequalitiesarefoundthroughcreatingconditionsthatalloweveryoneequalopportunitytoflourish,withinlimitssetbyfiniteecologicalresourcesandanexpandingglobalpopulation.Social,environmentaland economic policies are interdependent and mutuallyreinforcing,andneedtobeco-ordinatedproactivelybygovernmentsothattheyworktogethertoreducehealthinequalitiesandpromotesocialjustice at national and international levels.

Food Foodisakeycontributortohealthinequalitiesandcarbonemissions.Poorersocialgroupsarelesslikelyto have access to a healthy diet. Food accounts for 19 percentoftotalconsumption-relatedgreenhousegasemissionsintheUK.Energy-intensivefoodstendtohavemorenegativehealthimpacts.Reducingtheenergyintensityofproductionsystemsandsupplychainswillhelptoaddressclimatechange,increase food security and reduce vulnerability to priceincreasestowhichpoorersocialgroupsareparticularly exposed. Sustainable food policy can thereforebringmultiplebenefitsinregardtohealthandtoclimatechangemitigation. Issues of affordability and physical accessibility are alsoimportantwhenconsideringhealthinequalities.Corporatepracticeswithinthefoodsystemandgovernmentpoliciesmustencourageandenablehealthyandsustainablefoodchoices–throughpublicprocurementbutalsousingfiscalandotherpolicy mechanisms. Local food initiatives should beencouraged.Asustainablefoodsystemthatcan

supplysafe,healthyfoodwithpositivesocialbenefitsand low environmental impacts is vital for increased healthequity.

TransportModern society’s dependence on motorised transport isdetrimentaltohealthandwellbeing,healthequity,andtheenvironment.Transportaccountsforapproximately29percentoftheUK’scarbondioxideemissions,andcontributessignificantlytosomeoftoday’sgreatestchallengestopublichealthinEngland.Theseincludetheburdenofroadtrafficinjuries;physicalinactivity,withalltheconsequenteffects on obesity, chronic disease and mental illhealth;theadverseeffectoftrafficonsocialcohesiveness;andtheimpactofoutdoorairand noise pollution. Recent analysis in Sweden shows howdrasticallythenegativehealthimpactsofroadtransport systems are currently underestimated. Manyoftheserisksarestronglylinkedtosocio-economicstatus.Roadtrafficinjurieshaveoneofthesteepestgradientsinrelationtopovertyandunemployment, and many of the environmental impacts,includingairpollutionandcommunitydislocation, tend to fall disproportionately on poorer populations. Because of this, national or city-wide initiativesmustbedesignedtobenefitthewholepopulation, but prioritise those from lower socio-economicgroups. Therearemanyothermeasuresofprovenefficacywhichmayhelptoreduceinequalitiesifappropriatelytargeted.Urgentandprofoundchangesinthetransport sector therefore represent an opportunity to improvepublichealthandreducehealthinequalities,whilereducingbothcarbonemissionsanddependenceoncontinuedeconomicgrowth.

Green spaces Accesstogreenspaceswilldirectlyandindirectlybenefithealthandwellbeing,especiallyforlowersocio-economicgroups.Proximityto,andtimespentin,thenaturalenvironmenthasastrongpositive impact on factors such as number of health


complaints,perceivedgeneralhealth,stress,bloodpressure, mental health and rates of recovery from surgery.Thepresenceofgreenspacealsohasindirectbenefits,byencouragingphysicalactivity,socialcontactandintegration,andchildren’splay;byimprovingairquality;andbyreducingurbanheatisland effects. Greenspacesareunequallydistributedacrosssocio-economicgroups,withpoorersocialgroupshaving,ingeneral,loweraccess.Recentresearchsuggeststhat,acrossEngland,income-relatedinequalityinhealth(fromall-causemortalityandmortality from circulatory disease) is less pronounced inpopulationswithgreaterexposuretogreenspaces.The types of health determinants and conditions thataremostinfluencedbygreenspace(suchasphysical activity, obesity, mental health, circulatory diseaseandasthma)areverysignificantforhealthinequalities.Moreequalaccesstogreenspacecouldthusbekeytoreducinghealthinequalities–apreventativeandsynergisticapproachthathassocial,environmentalandeconomicbenefits.

The Built Environment Inadditiontotransportandgreenspace,afocusonthebuiltenvironmentoffersparticularhealthequityandsustainabledevelopmentco-benefitsthroughimprovingdomesticenergyefficiencyandotherhouseholdconditionse.g.damp.Retrofittingexistinghomes will improve heart and respiratory illness, lower the number of cold-related deaths, lift poor peopleoutoffuelpoverty,improvewellbeingandhelp reduce carbon emissions. Accessiblelocalfacilities,suchasshops,pubs,schools and libraries, can provide opportunities for social interaction, help create a sense of community and provideemployment,allfactorsinhealthinequalities.Evidenceconsistentlyshowsthatpeoplewhohaveeasyaccesstofacilitiesforphysicalactivity–cyclepaths,localparksandothergreenspaces,beaches,orrecreationcentres–aremorelikelytobeactivethanthosewhodon’t.Theparticularaccessrequirementsofdisabledpeople should also be considered. Thedesignofthebuiltenvironmentcaninfluencelevelsofcrimeandfeelingsofsafetyandthereisastrongcorrelationbetweencrime,povertyandillhealth.Landscaping,streetlightingand

improvementstolocalparksandplaygroundsallencouragepeopleontothestreet,increasingnaturalsurveillance and social cohesion. A Sustainable Health SystemAsustainablehealthsystemmustembracetheframeworksetoutinthispaperandfocusonprevention, with a broader accountability for health atalllevelsofdelivery.TheEnglishhealthservice,inpartnership with other public, private and voluntary sectororganisations,canworktoreversethetrendtowardsobesogenicenvironmentsandinsteadencouragesustainablecommunities.Thiswillbringmultiplebenefitsforclimatechangeaswellasotherenvironmental issues such as air pollution which influencehealthandwellbeing,andhealthinequalities. Thereisastrongrelationshipbetweenprimarycare,incomeinequalityandmortality,andlevelsofprovisionarecurrentlyunequallydistributed.Thereisapowerfulcaseforcommunity-basedservicesgainingmuchmoreprominence,leadingtoimprovedaccessto health services, increased social capital, low carbon pathwaysandarobustmodelintermsofensuringthelong-termviabilityofthehealthsystem.Self-care also represents a low carbon care pathway with verystrongevidenceforhealthbenefitsresultinginreductioninvisitstoGPsandinuseofmedicines. NHSorganisationscanshowthewiderpublicsector–indeed,allsectors–howtoembracesustainabledevelopmentandtacklethedeterminantsofhealthinequalitiesthroughtheirday-to-daybusiness–anapproachknownas‘goodcorporatecitizenship’.Successfuloutcomeshavebeendemonstrated,forexamplethroughemploymentprogrammes,localfoodprocurementandGPreferraltotimebanks. Asustainablehealthsysteminasustainable,low-carboneconomywillpromotewellbeingforall,focusonprevention,makebetteruseofhumanresources,promoteequitable,low-carbonlivingand‘goodcorporatecitizenship’,andjudgesuccessintermsofmediumandlong-termeffectsonsociety,economyandenvironment.BristolCityCouncil’sinnovativeapproachembeddingapublichealthexpertinthetransportdepartmentshowsthebenefitsofasharedresponsibilityforhealthinequalitiesandsmarterpartnershipworking.

Summary 9

2 Health inequalities: A timely agenda

Examiningabroaderrangeofindicatorsrevealsasimilarpattern,withinequalitiesevidentnotonlyinlengthoflifebutalsoquality of life. Mental health, self-reported health, morbidity and disability-free life expectancyalsodemonstratesocialgradients. Whilesocio-economicgroup(income)isusedtodefinehealthinequalities,thesegradients(differences) exist across a number of social and demographicfactorssuchassocialclass,occupationandparentaloccupation,levelofeducation,housingconditions,neighbourhoodquality,geographicregion,genderandethnicity. Healthinequalitiesareasymptomofotherformsofinequityandunfairnessinoursociety,andachievinghealthequityisthereforeamatterofsocialjustice.

While the health of the nation’s population has significantlyimprovedoverthelast150years,hugehealthinequalities–definedas‘systematicdifferencesin health status between different socio-economic groups’–remain.Lifeexpectancyandinfantmortalityindicatorsrevealthehealthgappersistsandhasevenin some cases increased,2 3althoughtherearesomewelcomerecentsignsofstabilisation.4

LifeexpectancyformalesinKensingtonandChelseawas84yearsin2005-07whileinGreenwichitwas75.Thereareevengreaterinequalitiesevidentat ward level with male life expectancy in Tottenham GreeninHaringeybeing17yearslessthanthe88yearsinQueen’sGateinKensingtonandChelsea(basedon2002-2006data).5

2.1 Introduction

2.2 The Marmot Review (2010) Fair Society, Healthy Lives6

InNovember2008,ProfessorSirMichaelMarmotwasaskedtoadvisetheSecretaryofStateforHealthonthefuturedevelopmentofahealthinequalitiesstrategyinEnglandpost-2010whichwaspublishedinFebruary 2010. It includes a comprehensive discussion oftheextentandnatureofhealthinequalities,andaspreviouslynoted,theintentionofthisSDCreportisnot to replicate this.

Social determinants of healthTheMarmotReviewfollowsthe2008publicationofClosing the Gap in a Generation, the report from the GlobalCommissiononSocialDeterminantsofHealth(CSDH),alsochairedbyProfessorSirMichaelMarmot.ItdrawsontheapproachoftheCSDHwhicharguesthat “health inequities are the result of a complex system operating at global, national, and local levels which shapes the way society, at national and local level, organises its affairs and embodies different forms of social position and hierarchy. The place people occupy on the social hierarchy affects their level of exposure to health-damaging factors, their

vulnerability to ill health, and the consequences of ill health.” 7 The Marmot Review sets out recommendations to reducehealthinequalitiesandachievetwosignificantpolicygoals,whichareto‘createanenablingsocietythat maximises individual and community potential’ and to ‘ensure social justice, health and sustainability are at the heart of all policies’.

PreventionWhilst the importance of ill health prevention is widely accepted in theory, in practice only four per centoftheNHSbudgetisdedicatedtothatend.8 TheMarmotReviewcertainlyarguesthatillhealthpreventionmustbestrengthenedandtailoredtoaddresshealthinequalities.Italsoplacesgreatemphasisontheimportanceofdevelopingeffectivedeliverymechanismstoaddresshealthinequalitiesacrossthewholesystem,beyondjusttheNHS.AmoredetailedoutlineofhowtheNHSandpartnerscantakeapreventativeapproachtohealthinequalitiesisincluded in Section 5.2.

3

Sustainable development and health inequalities


Sustainabledevelopmentprovidesalogicalstartingpointandanessentialanalyticalframeworkforfindingwaystoreducehealthinequalities.Therestofthis report explains what sustainable development is, whyitmattersforhealthinequalities,andhowitcanleadtopracticalimplicationsforpolicy-making.

Figure1 Five Guiding Principles of sustainable development.9

3.1 What is sustainable development?

Using sound science responsibly

Ensuring policy is developed and implemented on the basis of strong scientific evidence, whilst taking into account scientific uncertainty (through the precautionary principle) as well as public attitudes and values.

Promoting good governance

Actively promoting effective, participative systems of governance in all levels of society – engaging people’s creativity, energy and diversity.

Achieving a sustainable economy

Building a strong, stable and sustainable economy which provides prosperity and opportunities for all, and in which environmental and social costs fall on those who impose them (polluter pays), and efficient resource use is incentivised.

Ensuring a strong, healthy and just society

Meeting the diverse needs of all people in existing and future communities, promoting personal wellbeing, social cohesion and inclusion, and creating equal opportunity.

Living within environmental limits

Respecting the limits of the planet’s environment, resources and biodiversity – to improve our environment and ensure that the natural resources needed for life are unimpaired and remain so for future generations.

Sustainable development is understood in terms of fiveprinciplessetoutbygovernment.Theseofferasystemic approach that is consistent with the ‘social model’ of health (which considers how factors beyond the presence or absence of disease affect people’s health)andalsoextendsandstrengthensit. Bystressingtheneedtotakealong-termview,move away from the assumption of continued economicgrowth,andtofocusontheenvironmentaldeterminantsofhealthandhealthinequalities,

Thereisafocusoninequalitiesbetweendifferentsocio-economicgroups,onthegroundsthatsocio-economicstatusstronglyinfluencesandoftencompoundsinequalitiesrelatedtoethnicity,gender,ageanddisability.

sustainable development opens up opportunities to investin‘synergistic’measures,orco-benefits,thatreduceenvironmentaldamage,promotesocialjusticeandnarrowhealthinequalities.Itdrawsattentiontotheneedsandclaimsoffuturegenerations,andinter-generationalequity. Two‘bigpicture’dimensionsofsustainabledevelopment–climatechangeandasustainableeconomy–areexploredinmoredetailfromSection3.5 below.

Sustainable development and health inequalities 13

3.2 Healthier people, healthier environment

Unhealthylivingandillnesscreateaviciouscircle,whichreducesindividualandcollectivewellbeing,damagestheenvironmentandunderminesthelong-termviabilityofthehealthsystem.Thisisnotajudgmentonindividuals;unequaldistributionsof social, economic and environmental resources stronglyinfluenceandconstrainthechoicespeoplecanmakeabouthowtheylive. But unhealthy lifestyle choices can cause more damagetotheenvironmentthanhealthierones e.g.drivingnotwalking,andeatingcarbon-intensiveprocessedfoods.AreportfortheFoodStandardsAgencyshowedthatlowincomegroupseatlesshealthyfoodandengageinlessphysicalactivitythantheaveragepopulation.10Risingoverweightandobesity has serious implications not only for health

butalsoforgreenhousegasemissions;peoplewhoareoverweightand/orobeseconsumemorefood,and food production accounts for approximately 19 percentoftheUK’sconsumption-relatedgreenhousegasemissions.11, 12 Inaddition,illhealthusuallyrequireshealthcare,whichcancontributetotheNationalHealthService’sverysubstantialcarbonfootprint.In2007,NHSEnglandproduced21.2milliontonnesofcarbondioxide,aquarterofallEnglishpublicsectoremissions.13, 14 The majority of the carbon footprint is associatedwithprocurementofgoodsandservices,asFigure2illustrates.NHSEnglandalsoproduces600,000tonnesofwaste–morethanonepercentofalldomesticwasteproducedintheUK–andconsumes50 billion litres of water a year.15

Figure2 NHS England 2007 CO2 emissions – primary sector breakdown.16

Building energy use 24%

Procurement59%

Travel17%

Tacklingsocialandhealthinequalitiesisthereforeimportant not only because they are unethical, unjust and both socially and economically dysfunctional, but becausetheycontributetoenvironmentaldamage.So how would the overall level of ill-health in the

UKchangeifpeopleinlowersocio-economicgroupsenjoyed the same standards of health as those in highergroups?AndhowwouldthatimpactonthecarbonfootprintoftheNHS?Forspendingonobesityandoverweightrelatedill-healthinparticular,aNationalHeartForumstudyusingmodellingfromtheForesightProgramme,revealedNHScostsavingsof around 50 per cent that would result if those in lower social classes had the same BMI distribution as thoseinsocialclassone(seeboxonpage29formoredetail).PuttingthisinformationinthecontextofthecarbonfootprintoftheNHS,thesecostsavings mightalsorepresentareductionofover522,000tonnesofCO2. Ingeneral,iftherewerefarfewerpeopleleadingunhealthylivesandrequiringhealthcare,thiswouldconstrain or reduce the burden of demand on the health system, which in turn would reduce its carbon footprint.Itwouldalsoenablethelong-termfinancialviabilityoftheNHS,whichisparticularlyimportantintimesoflittleornoeconomicgrowth. Thepublicresourcessavedbypreventingavoidable diseases could be put to better use in helpingtoreduceinequalities,forexamplebyincreasingspendingonpublictransportsystems,education,‘green’skillsandjobs,affordable housingandsustainablelivingspaces.


Healthcare and prevention

Atthemoment,almostalloftheNHSbudgetinEnglandisspent–directlyorindirectly–onthetreatment and care of illness. Only four per cent of the£92.3billionitreceivedfromtaxpayersin2006–7was spent on prevention and public health,18 namely disease prevention, maternal and child health, family planningandschoolhealthservices.WhilethisishighincomparisonwiththeOECDpreventionexpenditureaverageof2.8percent,itisstillnotenoughtopreventillnessandreducehealthinequalities.

3.3 Prevention and co-benefits: Promoting health and sustainable development

Preventativestrategiesthatareconsistentwiththe principles of sustainable development offer co-benefits–theywillreducebothillnessandenvironmentaldamageacrosssocialandethnic

TheSDCbelievespreventingdisease,prolonginglifeandpromotinghealththroughtheorganisedeffortsofsocietyshouldbethefirstaimofhealthpolicy;thesecondbeingtoensurethepopulationcangethigh-quality,safetreatmentandcarewhentheyareunavoidably ill. Thisgoeshandinhandwitha‘socialdeterminant’approachtohealthandwiththefindingsofevidence-based reviews such as the Black Report,19 the Acheson Report20 and the Wanless Reports.21, 22

A new approach to prevention

Thedefinitionofpreventativepublichealthshouldbe revisited in order to encompass the root causes of healthinequalities.ButtheNHScannotimprovethehealthofthepopulationsingle-handedly.Instead,preventative public health needs to be a shared responsibility,witharangeofdifferentsectorsandservicesworkingtogether–education,employment,planning,housing,benefits,transport,sportandleisure, and environment. Vasculardiseaseisjustoneillnessforwhichresponsibility needs to spread beyond the formal healthsector.Vasculardiseaseaffects4.1millionpeople,kills170,000peopleeveryyearandisresponsibleforafifthofallhospitaladmissions. Itisthelargestsinglecauseoflongtermillhealthand disability and accounts for more than half the mortalitygapbetweenrichandpoor.23 The burden of disease falls disproportionately

onpeoplelivingindeprivedconditionsandonparticularethnicgroups,suchasSouthAsians(seeSection3.4,Areainequalities).Inadditiontothe2009introductionofvascularscreeningfortheover-40s,thehealthsystemcanandshouldworkhardertoinfluencetherootcauses,forexamplebyworkingwithpartnerstoalterthe‘obesogenicenvironment’(definedas“anabundanceofenergy-densefood,motorised transport and sedentary lifestyles”24) that has become the norm in some areas. Asoutlinedinmoredetailinrelationtofood,transport,greenspaceandthebuiltenvironment(seeSection4),suchanapproachwillachievetheco-benefitsofalongtermreductioninhealthinequalitiesandenvironmental,socialandeconomicgains.Growingandeatinglocalfood,swapping car journeys for public transport or ‘active travel’ on footorbybike,makingmoreofgreenspacesand

groups.Therearestrongsynergiesbetweenthesepolicyareas,suggestingitiscost-effectiveaswellassustainable to invest in measures that can achieve positive outcomes on both fronts.17


bringinghealthcareandpreventionliterallycloser tohomeallyieldco-benefitsthatreflectintrinsic (e.g.senseofcommunitybelonging)ratherthanextrinsic(e.g.materialistic)values25, 26 and redistribute income and level of carbon emissions acrosssocio-economicgroups. However,successrequiresstronglocalpartnerships, a broader sense of responsibility for

Prevention in action

Tomorrow’s People in-house employment service:Recognisingthelinksbetweenemploymentandhealth,RoyMacgregorandhispartnersattheJamesWiggGPPracticeinLondon’sKentishTownhavebeenmakingreferrals to an in-house employment service. Attheendofathreeyearpilotbetween2001–4,

healthandwellbeingandsystematicengagementbetweentheNHSandregionaldevelopmentagencies,localandregionalgovernmentandsocialcare.Anunderstandingandarticulationofhoweveryorganisationinvolvedcanaccesstheappropriatesynergisticco-benefits–whethertheirformalremitbefood,transport,planning,greenspaceetc.–islikelytofacilitate such relationships.

nearly 200 patients had seen its advisor. Ofthosewhocompletedtheprogramme,87percenthadreturnedtoemploymentorwerebackineducationandtraining.ThepracticeestimatesthatthepilothelpedsaveanaverageoffiveGPconsultationsperpatient,alreadysavingthesurgerythousandsofpounds.27


Health and area inequalities

Livinginadeprivedurbanareaincreasesaperson’sriskofpoorhealthevenaftertakingaccountofindividual characteristics.32, 33Thegapbetweenrichandpoorareasincreasedinthe1980sand1990s.34 There is a powerful relationship between local measuresofdeprivationandreducedlifeexpectancy:themoreaffluentyourneighbourhood,thelongeryouwilllive.In2001–2003intheNorthWest,menandwomenlivinginthenation’smostdeprivedfifthofareascouldexpectashorterlifeby6.8percentand5percentrespectively,comparedwiththeaverageforEnglandandWales.Bycontrast,menandwomenlivinginthemostaffluentfifthofareasnationallycouldexpecttolive3–4percentlongerthanthenationalaverage. Is it the area that has caused this lower life expectancy,asagainstthepovertyofpeopleliving

3.4 Area inequalities

In inner London, the relationship between the spatial distribution of social deprivation and mortalityisthesamenowasacenturyago.28

The local dimension of preventative public health isparticularlyimportant.Apersuasivebodyofresearch29, 30, 31 demonstrates that where a person lives affects how well that person lives now and in the future, and even their life expectancy. Whilst it encompassesthequalityofthebuiltenvironment,italsoextendsbeyondittothequalityoftheneighbourhood’ssocialinfrastructure.

Butitisalmostatruismtosuggestthatwhereyoulive determines whether or not you are exposed to air andindustrypollution,traffic,noiseandinfections.Itdeterminesyouraccesstogoodhousing,cheap,healthyfood,openspacesandqualityemployment,education,exerciseandhealthopportunities.Anditdetermines your beliefs, attitudes and expectations about yourself and those around you, which in turn affectsbehaviourandwellbeing,bothindividuallyand collectively. Anarea’sphysicalandsocialinfrastructuresareintimately connected (seeSection4).Butnotallareasareequal.Andareainequalitiesleadtohealthinequalities,promptingseriousgapsinbothlengthandqualityoflife.

inthepoorneighbourhoods?Whilstthisreporthighlightsthecomplexityoffactorsthatleadtohealthinequalities,ithasbeenfoundthatincountrieswherethegapbetweenrichandpoorareasisnarrower,thiseffect is less pronounced.35 PeoplelivingintheUK’smostdeprivedareasarebetweenthreeandtentimesmorelikelytosuffer from self-harm, violence, chronic obstructive pulmonary disease, alcohol-related conditions and birthstolonemothers,andtoclaimdisabilitylivingallowanceandincapacitybenefits.Residentsindeprivedareasaretwoorthreetimesmorelikelytofaceasthma,lungcancer,respiratoryconditionsandsmoking-relateddeaths,diabetesandheartdisease, alcohol-related deaths and poor mental health,epilepsy,self-ratedpoorhealthandfrequentemergencyhospitaladmissions.36

Vulnerable groups and area inequalities

Vulnerablegroupssuchaschildrenandyoungpeople,women,olderpeople,ethnicminoritygroupsanddisabled people can suffer particularly from area inequalities.Lowersocio-economicgroupsareconcentrated in deprived areas and tend to have higherlevelsofdisabilityduetopoorerhealth,more

accidents and more mental health problems,37 with psychiatric illness and psychoses closely mappingdeprivation.38, 39

Arecentstudyexploredtheimpactofthebuiltenvironmentandlocalneighbourhoodsonschoolagechildren.Theresearchshowedthatthequalityofthe


Rural area inequalities

Muchoftheresearchonhealthinequalitiesfocusesondeprived urban communities. But what about the 20 per cent of the population who live in the countryside?Whilstonaveragemostpeopletherelivelonger,havebetterphysicalandmentalhealthandenjoyhealthierlifestyles,theplightofthepoorestandmostdisadvantagedruralresidentscanremainhidden,maskedbytheprevailingaffluenceofmanyrural areas.

Cost,nationaltargetsandeconomiesofscaleareallweightedagainstruralservicesprovision.Whereservices do exist, distance, travel times and transport availabilitycancreatehealthinequalities,particularlyfor people without private transport. Older people can beparticularlydisadvantagedandtheproportionofolderpeopleinruralareasisincreasingfasterthaninurbanareas,particularlyinrespectofpeopleover85.Themedianageofruralresidentsisnearlysixyearsolder than their urban counterparts.42

physical environment affected children’s behaviour and attitudes to schools, and that schools were adversely affected by the poor physical condition of theirsurroundingneighbourhoods.40 Department of Health research also shows that someethnicminoritygroupsexperiencepoorerhealththanothers,undertakelessphysicalactivitythanthegeneralpopulationandalsoexperiencepooreraccesstofacilitiesandpoorerqualityofservices.41

This research found that coronary heart disease anddiabetesisfivetimeshigheramongstSouthAsiansandthreetimeshigheramongstpeoplefromAfricanandCaribbeanbackgroundsthanthegeneralpopulation.Only11percentofBangladeshiand14percentofPakistaniwomenwerereportedtohavedone the recommended amounts of physical activity, comparedwith25percentinthegeneralpopulation.


3.5 Big picture issue: Climate change

“Thepoliciesneededtomitigateclimatechangewillexerthealtheffectsbyactingonmanyof

thedeterminantsofhealthandhealthinequality.”43

Risks to human health and wellbeing

Climatechangeisoneparticularchallengethatthreatenstowidenhealthinequalitiesbetweenrichandpoorpopulations.Unsustainabledevelopmentthatdamagesthenaturalenvironmentwillcertainlyincreaseriskstohealthforallsocialgroups. But in important respects, they will also widen health

inequalities,bothgloballyandwithintheUK.44 Thereissubstantialevidencethatclimatechangeresultsfromcarbonandothergreenhousegasemissions,asillustratedinFigures3and4,and posespotentiallycatastrophicriskstohumanhealth.

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TheIntergovernmentalPanelonClimateChangeprojects that malnutrition, diarrhoeal disease, cardio respiratory disease, infectious diseases and extreme weather events will all increase due to climatechange.InEurope,themostprevalenthealtheffects will include excess heat-related mortality, changesininfectiousdiseasevectorsandincreasedseasonalproductionofallergenicpolleninhigh- and mid-latitudes.47 Climatechangewillalsoaffecthealthindirectly

throughitsimpactsonsocialandeconomicsystems.Resourceshortages,dislocation,migrationand conflictarelikelytosubstantiallyincreaselevelsofstress,anxietyanddepression,impairingmentalaswell as physical health. Climatechangemaybringsomehealthbenefits–forexamplebyreducingcold-relatedmortality in temperate areas48–butthesewillbeoutweighed by the detrimental impacts on the health of millions of people.49

Range of temperature predictions, based on a variety of models

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The poorest people are most at risk

Climatechange,leftunchecked,willalsoincreasehealthinequalitiesbetweenandwithincountries.Deprivation often increases vulnerability to climate changeandclimatechangeincreasesdeprivation.Peoplealreadyfacinghealth,incomeandhousinginequalitieswillbevulnerabletothephysicalandmentalhealthimpactsofclimatechange.50 In rich as well as in poor countries, factors that predispose individuals to suffer earlier or more severely includehavingalowincome,51 livingorworkinginageographicallocationthatisathighrisk,socialisolation,oldage,veryyoungageandchronicillness.52 Peopleonlowincomesaremorelikelytolivein‘urban heat islands’53 (whereby the density of urban buildingsraisesthelocaltemperaturehigherthanthesurroundingarea)andbecauseofthisareathigher riskofheatstroke.54Theyaremorelikelytoliveinhomes that are less well protected55 and in areas that are more exposed to weather extremes and flooding.56Theyaremorelikelytobeadverselyaffectedbyhomelessnessandmigrationstriggered byclimatechange.57

Crucially,theyarelesslikelytohaveaccesstoinsuranceagainstclimatechangeriskssuchasstormandflooddamage.58Althoughlow-incomecountries will suffer most acutely, in all countries therisksassociatedwithclimatechangewillfalldisproportionatelyon“theurbanpoor,theelderlyandchildren, traditional societies, subsistence farmers, and coastal populations.”59 Despitebeingtheleastlikelytocauseclimatechange,disadvantagedpopulationsarenotonlymorelikelytobeexposedtoitshealththreats,butaremorevulnerabletobecomingillandlessabletorespondeffectivelytoillhealth,asFigure5illustratesandother studies concur.60 AsMargaretChan,Director-GeneraloftheWorldHealthAuthority,powerfullyputsitinherintroductiontoTheLancet’s2009HealthandClimateChangeseries,61“Thecontagionofourmistakesshowsnomercyandmakesnoexceptionsonthebasisoffairplay. For example, countries that have contributed leasttogreenhousegasemissionswillbethefirstandhardesthitbyclimatechange.”

Despite being the least likely to cause climate change, disadvantaged populations are more likely to be exposed to its health threats.


Figure5 Global distribution of carbon emissions and mortality related to climate change (increase in diseases attributable to temperature rise in the past 30 years).62

Mortality related to climate change

Global distribution of carbon emissions

0–22–44–7070–120

Mortality per million population

0–11–55–1010–3535–37

Carbon emissions (billions of tons)


Policy interventions: Lower carbon, fairly

DespitethedisappointingoutcomeatCopenhagen,nationalandinternationalpolicymakersareincreasinglyfocusedontheneedtomitigate climatechange.Tocapglobaltemperatureincreasebetween2.0˚Cand2.4˚C(andglobalseariseduetothermalexpansionbelow1.4metres),theatmosphericCO2equivalentconcentrationmustbestabilisedat445-490partspermillion.Thiswillrequireglobalemissionscutsof50-85percentbetween 2000 and 2050.63TheUK’sCommitteeonClimateChangesetatargetof42percentby2020,againsta1990baseline.64 Reducingcarbonemissionswillmeanincreasingenergyefficiency,developingrenewableandlow-carbonsourcesofenergy,changingtolow-carbonmodesofproductionandtransport,andencouraginglow-carbon behaviour. Many of these measures will have positive effects onhealth,forexample,byencouraginghealthyeatingandactivetravel(seeSection4).Butifpeopleinhighersocio-economicgroupsdomoretochangetheirbehaviour(e.g.movingtolowcarbonlivingand alternative consumption patterns) than people inlowersocio-economicgroupsanddoitsooner(which tends to be the pattern for public health behaviourchange),healthandsocialinequalitieswillsimply widen.65Instead,low-carbonlivingmustbedevelopedandspreadinwaysthatareequitableandempoweringforallsocialgroups,especiallythosewhoarepooranddisadvantaged. Whilepovertyisstronglyassociatedwithill-health,people with lower incomes tend to have smaller carbon footprints than richer people, because of the stronglinksbetweenlevelsofaffluence,consumptionand carbon emissions.66, 67Sowhilstraisingpoorerpeople’sincomesmaygeneratemediumtermhealthequalities,withoutachangeincurrentconsumptionpatterns carbon emissions will also increase. However,acarbontaximposedequallyonricherandpoorerhouseholds“wouldbeveryregressiveandwould add to the unfair price burden these households arealreadyexperiencing.”68 This effect could be offset byintroducingacompensationpackageforlow-incomehouseholdsthroughthebenefitssystem.69 which could build on or adapt the policy measures that already exist

intheUK,suchasthefuelpovertyschemes(toimprovehouseholdenergyefficiency)orincomesupplementsvia the winter fuel payments. Intheory,somecarbonrationingandtradingschemesmayproducemoreequitableresults;70 the ‘contractionandconvergence’regulatoryframeworkhaspotentialhealthbenefits.Inthisapproach,everyindividualgetsanequalallocationofcarbon,withthetotal capped and reduced year on year to eventually meetanoveralltargetlimit.Oneexpertargues:“Thosewhodon’tusetheirallocation–mainlythepoor–willbeabletosellitatmarketratestothosewhowishtousemorethantheirallocation–mainlythe rich. This redistribution of wealth will reduce disparity, a crucial measure if we really wish to improve public health.”71Furtherworkisneededonthe appropriate measures to reduce carbon and health inequalitiesinanequitablemanner. Butmitigationalonewillnotbeenough.Theworldisalreadyfacingunavoidableclimatechangeandmusttakeactiontoadapttotheresultinghealthimpacts,forexamplethroughmonitoringofclimateriskstohealth,72 heat-health action plans,73 protection programmesforoccupationalheatexposure,74, 72floodmanagementpolicies,76moreefficientuseofwaterand other resources,77 relocation of some coastal populations,anddietarychanges. Bothmitigationandadaptationmeasureswillaffecthealthandhealthinequalities,byreducingthenegativehealthimpactsofclimatechangeandbyinfluencingotherhealthdeterminants.Forexample,buildingthecapacityofcommunitiestoadapttoclimatechangemayalsobuildstrongersocialconnectionsthatarelikelytohavepositiveeffectsonhealth.78TheLancethassetoutthequantitativepublichealthbenefitsofstrategiestoreducegreenhousegasemissionsfromhouseholdenergy,transport,foodandagriculture,andelectricitygeneration.79 Butaslow-incomegroupshavefewermaterialresources to enable them to adapt to climate changeandbenefitfromadaptationstrategies, thesewillwidenhealthinequalitiesunlesstheygohand-in-handwithstrategiestoreducesocialandeconomicinequalities.


3.6 Big picture issue: The economy

IntheUKthepercentageofpeoplereportingthemselves‘veryhappy’declinedfrom52percent

in1957to36percentin2007,eventhoughrealincomesmorethandoubledduringthattime.80

Achieving a sustainable economy

Therearenowpersuasiveargumentsthatasustainableeconomycannotbeachievedthroughcontinuingeconomicgrowthasweknowit,atleast indevelopedcountriessuchastheUK. Economicgrowthdrivesandisdrivenbytheincreasingconsumptionofgoodsandservices.81 Producingmostofthesegoodsandservicesrequiresnaturalresources,includingfossilfuelsandothernon-renewable materials, and causes the emission ofgreenhousegasesandotherpollutants. The‘dilemmaofgrowth’isthatitincreasinglydepletesthefiniteresourcesonwhichtheeconomydepends.Acommonresponseistoarguethateconomicgrowthcanbe‘decoupled’fromthedepletion of natural resources and the production of greenhousegasesthroughmoreefficientmethodsofproduction. But this is not the case. Thereissomeevidenceofrelativedecoupling,where the rate of depletion slows in relation to the rateofeconomicgrowth.Butastheeconomygrows,so does the overall use of resources and emissions. Asaresult,“fordecouplingtoofferawayoutofthedilemmaofgrowth,resourceefficienciesmustincrease at least as fast as economic output.”82 Butatagloballevel,allthekeyindicatorspointintheoppositedirection:carbonemissions,resourceextraction,wastegenerationandspecieslossareincreasing.Notonlyisthereafailuretoachievethenecessaryefficiencies,butincreasingconsumptionofresourcesremainsanecessarydriverofgrowth.

By 2050, with an estimated nine billion people across theworldallaspiringtoincomesthatmatchthetwopercentannualaveragegrowthintoday’sEuropeanUnion,carbonintensityperunitofeconomicoutputwouldhavetofallonaveragebymorethan11percentayeartostabilisetheclimate.Theglobalcarbonintensitywouldneedtobejustsixgramsperdollarofoutput, almost 130 times lower than it is now.83 In short, the idea that capitalism’s propensity forefficiencywillallowustostabilisetheclimateorprotectagainstresourcescarcityis“nothingshortofdelusional.”84Wecannotrelyontechnologyalonetodeliver the carbon reductions necessary to meet the targetsagreedatnationalandinternationallevels.However,justaseconomicgrowthisunsustainableinitscurrentformthealternativeof‘de-growth’isunstableatleastunderpresentconditions.Decliningconsumerdemandleadstorisingunemployment,fallingcompetitivenessandaspiralofrecession. This dilemma cannot be avoided and has to be takenseriously. Green Well Fair 85 sets out the case for a new social settlementthatmakesnoassumptionthatthemarketeconomywillgrow.Instead,suchasocietalsystemvaluesandnurturestwoothereconomies–theresourcesofpeopleandtheplanet.Thechallengeistofindadifferenteconomicsandadifferenteconomicstructure to ensure stability, maintain employment anddeliversustainability.Althoughthischallengeisgreat,thereisagrowingbodyofevidencetoshowthatmeetingitisbothessentialandpossible.86


Implications for health inequalities

However society decides to address this central challenge,theimplicationsforhealthinequalities are considerable. Theroleofinvestmentwillbecrucial,giventhe need to both enhance investment in public infrastructures,sustainabletechnologiesandecologicalprotectionwhilstprotectingand improvingpublicservicessuchashealthandeducation. For economic policy, that will almost certainlyrequireare-thinkingofthebalancesbetween consumption and investment, and between public and private investment.

If people who are poor are to have better education, health care and other public services to counteractthenegativeeffectsoftheireconomicdisadvantageontheirhealth,smarterwaysmustbefoundtoimprovethedesignanddeliveryoftheseservices. Mostfundamentally,overcomingthegrowthdilemma offers little opportunity for the current political approach, which tries to narrow social and healthinequalitiesbysimplyraisingpoorpeople’sincomes.Anewdefinitionofprosperityisrequired.

Redefining prosperity

AssetoutinProsperity Without Growth?, prosperity does not depend on constant increases in economic growth,but“hastodowithourabilitytoflourish:physically,psychologicallyandsocially”and“hangsonourabilitytoparticipatemeaningfullyinthelifeof society.”87Itreflectsourwellbeing,whichisbestunderstoodindynamicterms,connectinghowwefeel with what we do and what we are able to do, and with the material and non-material conditions of our lives.88,89

Prosperity has undeniable material dimensions butthereisstrongevidencethatbeyondacertainpoint, an increase in material consumption ceases tobematchedbyincreasingwellbeing.90,91,92,93,94 IntheUKthepercentageofpeoplereportingthemselves ‘very happy’ declined from 52 per centin1957to36percentin2007,eventhough realincomesmorethandoubledduringthattime.95

Ifgrowthisdrivenbyanddrivesincreasingmaterialconsumption,andifcontinuallyexpandingconsumptioncanunderminewellbeingandfuture

prosperity,itisimperativewefindroutestobetterphysicalandmentalhealthforallbyfocusingnotoneconomicgrowthbutonenablingpeopletoflourish.Theconditionsforhumanflourishingarecommonto most societies.96Thechallengeforsocietyisnotonly to create the conditions in which these basic entitlements are possible, but to distribute them evenlyacrosssocio-economicgroups. Policymakersfacemanyconsiderationswhentryingtoreducehealthinequalitiesinaneconomythatisconfrontingthechallengesetoutabove. Theseinclude:

Capabilitiesthatenablepeopletoflourishare•boundedbythefinitenatureofecologicalresourcesandanexpandingglobalpopulation97

Flourishingwithinsustainablelimitswillinvolve•replacingthecurrentcultureofconsumerism,which can help to reduce the social and economic variablesthatdeterminehealthinequalities

Prosperity does not depend on constant increases in economic growth, but has to do with our ability to flourish and participate meaningfully in the life of society.

Incomeinequalityaffectshealth–evenafter•adjustingforpeople’sindividualincomes–andunequalsocietiesarealmostalwaysunhealthysocieties.98Sostrategiestoreducehealthinequalitieswillneedtoaddressthegradientacrosssocialgroups.

Integratingsocialandenvironmentalpolicies–•both because social policies will have to address

anegativerangeofenvironmentalpressuresandimpacts(includingclimatechange),andbecausesocial policies can help to enable individuals and groupstomitigateandadapttoclimatechange.99

Planningforasustainable,low-carboneconomy•willinvolvetransformingsystemsandservices thatsafeguardandimprovehealthandwellbeingforallsocialgroups.100


Sustainable development policy implications

ThefiveGuidingPrinciplesofsustainable•development should be used as the central frameworkfordesigningandimplementingpoliciesforreducinghealthinequalities, acrossgovernment,nationallyandlocally.Particular attention must be paid to intergenerationalequity.

Priorityshouldbegiventoinvestingpublic•resources in such a way as to achieve synergisticoutcomesforbothhealthinequalitiesandotherenvironmentalsustainability issues especially carbon reduction (on physical activity, for instance, or local food production schemes). Methodsforappraisingtheimpactof•policymakingandprocurementacrossgovernmentshouldbereviewed,toensurethat success is measured in terms of health, environmental and economic outcomes. Appropriatemechanismsshouldbeputinplacetoensurethathealthinequalityandsustainabledevelopment are mandatory considerations at alllevelsofdecision-making.

Highprioritymustnowbegiventoreducing•emissionsofgreenhousegasesacrossthe entirehealthsector.AllNHSworkersshouldbeactingaschampionsforactiontoreducetheadverseeffectsofclimatechangeonhealth.However, even with extensive action to reduce futureemissionswewillstillexperiencearangeofclimateimpactsduetoexistingemissions.Actiontoadapttoclimatechangeisthereforeequallyimportanttohelpreducefuture healthinequalities.

Thepotentialimpactsofclimatechange •(andofmeasurestakentoaddressthoseimpacts)shouldbetakenfullyintoaccountwhenplanningactionforreducinghealthinequalities,withparticularattentionpaidtolow-incomegroups.

Planningneedstostartnowforasustainable,•low-carboneconomy,focusingoncreatingconditionsthatenablepeopletoflourishphysically,sociallyandpsychologically.

A sustainable approach to tackling health inequalities

4


4.1 Introduction

Thissectionappliestheframeworkofsustainabledevelopmenttofourdeterminantsofhealth–food,transport,greenspaceandthebuiltenvironment.Itdemonstrates how a sustainable approach to health inequalitieswouldworkinpractice.Thesefourareashave been chosen because they exemplify the themesoflowcarbonandasustainableeconomy;aswellasthecentralconceptthatmeasurestomitigateclimatechangealsohelpreducehealthinequalities.Theycanmakeabigimpactonthegrowingproblemsof obesity and mental health, both of which are moreprevalentamongpeopleonlowincomesashighlightedintheboxopposite. Theexamplesoffood,transport,greenspaceandthe built environment also serve to illustrate that, whiletheNHSneedstogivefarhigherpriorityto

preventingillhealth,itcannotdothejobalone. This is discussed in more detail in Section 5.2. Inacceptingthatsocial,environmentalandeconomicfactorsdeterminehealth,acompellingcaseismadefor all the different sectors and services in our society toshareresponsibility–andworktogether–toaddresstheunderlyingcausesofillnessandhealthinequalities.Recentpolicydevelopmentshavealsorecognisedthisneed,forexampletheemergingguidancefromtheNationalInstituteforClinicalExcellence(NICE)onspatialplanningforhealth,101 aswellasDCSF’sPlayStrategy.102 It is particularly important in the current economic climate not to retreat to the comfort of familiar professional boundariesbuttoacknowledgeandexerciseamuchbroaderresponsibilityforhealthandwellbeing.

Sustainable development is entirely consistent with the social determinants approach to improving health and provides an essential framework for finding ways to reduce inequalities. It opens up opportunities to invest in measures that have a number of co-benefits – reducing environmental damage, promoting social justice and improving health inequalities.

Obesity and health inequalities

Obesityisofepidemicproportions–overhalf•ofalladultsinEnglandarenowconsideredoverweightorobese.104TheUKGovernment’sForesightProgrammehighlightedthefactthatin2009aloneexcessweightandobesitycosttheNHS£4.8billion.Ithaspredictedthatcosts could continue to escalate without radical changesacrosssocietyandindicatesthatby2050,60percentofadultmen,50percentof adult women and about 25 per cent of all childrenunder16maybeobese.105

Thepoorestinsocietyarebearingthebrunt•of this ill health. People from low income householdsaretheleastlikelytomeettherecommended levels of physical activity. Theyarealsothemostlikelytobesedentary–achievinglessthan30minutesofphysicalactivityperweek.Forexample,44percentofwomenand34percentofmeninthepooresthouseholdsinEnglandaresedentary,comparedtoonly33percentofwomenand28percentof men in the wealthiest households. These low physicalactivitylevelsareasignificantcauseofhealthinequalities,withinactivegroups

sufferingpoorerhealthandlivingshorter livesthanthegeneralpopulation.

ArecentstudyfromtheNationalHeart•Forum106showedthatifclassinequalitiesinobesity were eliminated, levels would drop dramatically,halvingtheNHS’s2009obesitybillof£4.8billionandreducingthe2025estimatefrom£8.9billionto£4.1billion,giventhepredictedriseinobesityespeciallyamongthemanualclasses.Forthistohappen,aradicalshiftneedstotakeplaceacrossawiderangeofsectors.In2006NICEpublishedaclinicalguidelineontheprevention,identification,assessmentandmanagement ofoverweightandobesityinadultsandchildren.Itadvisedlocalauthoritiestoworkwith local partners, such as industry and voluntaryorganisations,tocreateandmanagemore safe spaces for incidental and planned physicalactivity,suchasparks,andtoaddressas a priority any concerns about safety, crime and inclusion. In particular, they were advised to provide facilities and schemes such as cyclingandwalkingroutes,cycleparking, area maps and safe play areas.107

A sustainable approach to tackling health inequalities 29

Mental health and inequalities Mental Health, Resilience and Inequalities from the Mental Health Foundation108argues that mental health is the lynchpin between economic and social conditions. Poor mental healthexperiencedbyindividualsisasignificantcause of wider social and health problems, including:lowlevelsofeducationalachievementandworkproductivity;higherlevelsofphysicaldisease and mortality and violence, relationship breakdownandpoorcommunitycohesion.Incontrast,goodmentalhealthleadstobetterphysical health, healthier lifestyles, improved productivity and educational attainment and lower levels of crime and violence.

In Britain, one in four adults will have a mental •health problem in the course of a year.109 The economiccostsofthisareclear:mentalillhealthcostsEnglandover£77billioneveryyear.110 Foresightsetouthowsomementaldisorders couldgrowsubstantiallyinthefuture,although thewiderangeofinfluencingfactorsmakesprediction problematic.111

Within urban areas, rates of psychiatric illness •aregreatestinthemostdeprivedareas.Theratesfor psychoses map closely those for deprivation. Thesizeofacityalsomatters;schizophrenia rates in London are about twice those in Bristol orNottingham.112, 113

A 21st century challenge

Mentalhealthandlifestyle-relatedinequalitiessuchasobesityarewideningsignificantly.103


4.2.1 Food and sustainable development

4.2 Food systems

Asustainablefoodsystemwhichprovidessafe,healthyfoodwithpositivesocialbenefitsandlowenvironmentalimpactsisvitalforastrong,healthyandjustsociety.IntheUK,richerpeoplearemorelikelythanpoorerpeopletohavedietsthatgivethem better health.116,117 In its Food 2030strategy,118 theGovernmentsetoutitsvisionforasustainableandsecurefoodsystem.Itidentifiedasakeypriorityencouragingandenablingpeopletoeatahealthy,sustainable diet. Climatechangenotonlyhasanegativeimpactonhealth effects as discussed in Section 3, but will also increasinglyaffectfoodyield,nutritionalquality,foodsafety and affordability.119, 120, 121 While these will affect everybody, there will be disproportionate harm to

sociallydisadvantagedpopulations.122 Sustainable developmentandhealthequityarethereforefirmlyintertwinedandmutuallyreinforcing. ThelesshealthydietsofpoorersocialgroupsintheUKalsotendtobecharacterisedbyhigh-carbonpatternsofconsumption.Asustainablefoodsystemcanthereforebringmultiplebenefitstohealthandclimatechange. But clearly cost and physical accessibility must beaddressedfirst.Governmentfoodpoliciesandcorporatepracticesmustencourageandenablehealthy, affordable and sustainable food choices, boththroughpublicprocurementandfiscaland other policy mechanisms.

Reducing our food footprint

Foodaccountsfornearlyafifthofourtotalconsumption-relatedgreenhousegasemissionsintheUK.123,124Almosthalfoffood’sgreenhousegasemissionsareattributabletotheagriculturalstage,withlivestockandtheirassociatedinputscontributingthe most.125,126,127,128,129,130,131,132

Greenhousegasemissionspost-farmgatearefairlyevenlydistributedbetweenfoodmanufacturing,transport,retailing,cateringandfoodpreparation

andstorageinthehome.Inhighandmiddle-incomesocieties,thetypeandquantityoffoodthatreachesconsumersislargelydeterminedbysupermarkets and the food services sector.133 Within the sector, thereisahighcontentofenergy-dense,nutrient-poorfoodsthatarehighlyprocessed,packagedandhavealongshelf-life.134,135Thesesamewater-andenergy-intensivefoodshavehighenvironmentalproductioncosts.136

Peopleonlowincomeseattheleastamountoffruitandvegetables.114

Theperformanceof11-year-oldpupilseatingJamieOliver’sschoolmealsimprovedbyupto

eightpercentinscienceandasmuchassixpercentinEnglish,whileabsenteeismdueto

ill-health fell by 15 per cent. 115

Figure6 Projected global trends in meat and dairy consumption.137

AsFigure6aboveshows,globaldemandforfoodssuchasmeatanddairyisrising,withseriousramificationsforenvironmentalsustainability.138,139

Whilst there is certainly scope to reduce the greenhousegasintensityofagriculture,140,141 givenprojectedgrowthindemandformeatanddairyproducts,thesegainsarelikelytobecancelledoutbygrowthinlivestocknumbers. Weconsumeonaverageanestimated83kg ofmeatayearand243kgofmilkandrelated productsexcludingbutter.Thisismorethanthreetimestheaveragelevelofmeatconsumptioninthedevelopingworldandfivetimesitspercapitaconsumptionofmilk.

Tocutgreenhousegasesandlivewithinourenvironmentallimitsweneedtochangeour diet;142,143 in particular we need to consume fewer livestockproducts.Reducingmeatanddairyconsumption,eliminatingfoodwasteandcuttingfattyandsugaryfoodswouldmakethebiggestcontributiontowardsimprovinghealthandreducingthe environmental impacts of the food system.144

Cuttingconsumptionofsaturatedfat–particularlyfrommeatanddairyproducts–iswellestablishedhealth advice to reduce diet-related preventable disease.145,146However,theexactlevelsneedtotakeaccountoffactorssuchasironconsumption,buildingon evidence from the current consultation from the ScientificAdvisoryCommitteeonNutrition.147

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4.2.2 Food, health and inequalities

Anestimated963millionpeopleworldwidedonothaveenoughfood.148 Yet, at the same time, a‘nutritiontransition’tohighlyrefinedfoodsandanimalsourcefoodshighinsaturatedfatsisoccurringaroundtheworld.Thisiscontributingtoobesity andassociateddiseases,particularlyamongmanysociallydisadvantagedgroups,inallbutthepoorestcountries.149,150,151,152,153

influentialindividualsandgroups–includingeducation and health professionals, retailers andthemedia–promotingphysicalactivityandhealthyeatinginitiativesforbothchildrenand their parents.155 The project’s results in participatingtownswerestaggering.Theproportionofoverweightboysalmosthalvedfrom19percentandtherateamonggirlsdroppedfrom10 per cent to seven per cent.156

Obesityisanareaofwideninghealthinequality,andaFrenchprojectoffersinsightsintolocal,joined-upactiontotackleit.

EPODE(‘Ensembleprévenonsl’obésitédesenfants’,or‘Together,let’spreventobesityin children’) is a community-based, family-oriented nutrition and lifestyle education programme.Itaimstopreventchildobesityatcommunitylevelbybringingtogether

Food systems have the potential to provide direct healthbenefitsthroughthenutritionalqualityofthe foods they supply. Food systems can also deliver communityandhealthbenefitsthroughemployment,incomeandensuringtheviabilityofruralcommunities.However,livingwithinenvironmentallimits is also pivotal to health,154 in particular with regardtoclimatechange.

Affordable, sustainable food

In most countries, low income households spend a higherproportionoftheirincomeonfoodthanthemoreaffluent.Suchhouseholdsarethehardesthitbyfoodpricefluctuations–fivepercentofpeopleonlowincomesreportskippingmealsforawholeday.157Atightbudgetisalsoabarriertomakingdietarychangesorexperimentingwithunfamiliarorperishable fresh foods.158

Itishighlylikelythatrisesinfoodandfuelpriceswillexacerbatediet-relatedhealthinequalities.Thosepeople on low incomes will only be able to purchase thecheapestsourcesofcalories–oftenenergy-dense,highly-processedproductsthatincreasetheriskofobesityanddiabetes.Globallymanymillionswillbeunable to afford even that.159

Internationally,studieshaveshownthatamonglowincomegroupspriceisthegreatestmotivatingfactoroffoodchoice.IntheUSA,pricereductionshave seen positive increases in the sales of low-fat foodsandfruitandvegetables.160 The era of cheap foodiscomingtoanend,butpricesignalsandhealthmessagesarenotalwayscongruent.161Consumerexpectations are still of low prices, which fail to internalise the full environmental costs.162 Whileconsideringwaystoimprovetheaffordability of healthy and sustainable food, we therefore need to determine the real cost of a healthy andsustainablediet,andmakesurethatsocialprotectionschemesandnationalwageagreementsreflectthis.163,164,165

Good food on the doorstep

Priceisclearlyonebarrier,buttacklinghealthinequalitiesalsomeansensuringthatthatallgroupsinsocietyhaveadequatephysicalaccesstonutritiousfood, and that it is socially and culturally relevant to them.UKresearchindicatesthattheshopsmostusedbylow-incomegroupsarelesslikelytostockhealthyoptions. When they do, they are often more expensive than in other outlets.166 ProjectsintheUKaimingtoimproveaccessto nutritious and sustainable food include communitygrowingschemes,gardeners’clubsandallotments, but there has been no comprehensive

evaluation of their effectiveness. Public sector food procurement, however, provides a proven andsignificantopportunitytoinfluenceaccesstoqualityandsustainability.Therearesuccessfulexamples across the public sector,167 168 but there is farfromcomprehensiveengagement.TheHealthierFoodMark,aschemetoencourageandrecognisepublicsectorbestpracticeindeliveringhealthyandsustainablefood,isbeingdevelopedbyDefra,theDepartmentofHealthandFSA.Thisisapromisinginitiative,althoughthelevelofambitionitwillsetremains to be seen.169

ArecentevaluationofJamieOliver’sFeed Me BettercampaigninGreenwichSchoolsin2004showed“substantial”positiveeffectsonKeyStage2scoresinbothEnglishandSciences.Theperformanceof11yearoldpupilseatingOliver’smealsimprovedbyuptoeightpercentinscience

andasmuchassixpercentinEnglish,whileabsenteeism due to ill health fell by 15 per cent.170Consideringtheimportanceofeducationas a determinant of health, this is could be a powerfulmechanismwhentargetedatareasofsocialdisadvantage.

Qualitativeandquantitativeresearchmethodshavebeendevelopedtohelpbetterdefine,describe and spatially map the patterns of food accessindeprivedcommunitiesacrosstheUK.MeasuringaccesstohealthyfoodinSandwell,171 an area of deprivation in the West Midlands, is one exampleofcommunityledfoodmappingresearch.LiketherestoftheUK,Sandwellhasexperiencedamajorshiftinfoodretailingwiththegrowthoflargesuperstoreslocatedinsuburbanareas.Peoplewithoutaccesstocarsmustchoosebetweenusinglimitedpublictransporttogettosuperstoresorbuyingfromincreasinglyinadequatelocalshops. The research172foundthattherewerelargenetworksofstreetsandneighbourhoodsin

Sandwellwherenoshopssellingfreshfruit and/orvegetablesexistorwheretheydidexist theywereexpensive.Reasonablypriced,good qualityfood,includingfreshfruitandvegetables, isavailableinsmall,concentratedshoppingareas, to which the majority of the population would have totravelbycarorpublictransport.Also,small retailersstruggletosurviveinthetown,especiallyiftheytrytooffer“healthy”foodandperishablegoods,againstcompetitionfromlargerstores.Theresultsoftheresearcharecontributingtolocalbaseline indicators of conditions and needs, and to thedevelopmentofstrategiestoaddressinadequateaccess to healthy foods, and the development of local food policy.



Food policy implications

Prioritymustbegiventoreducinggreenhouse•gasemissionsfromthefoodandagriculturesector, with an emphasis on the need for a reduction in the consumption of animal source foods.

Newfiscalpoliciesarerequiredtoimprove•affordability of healthy and sustainable food choices.Thecostofensuringanutritiousandsustainabledietshouldbereflectedinsettingminimumwageandbenefitlevels.

Policy should be informed by successful •publicsectorfoodprocurementprogrammes,in particular those which exceed statutory nutritionstandards(e.g.Jamie’sSchoolDinners) as mechanisms to ‘choice edit’ out less healthy/sustainablefoodsandencourage

access to more nutritious and sustainable foodsthroughschools,hospitals,social care and prisons.

Indices should be developed to show •geographicvariationsinpriceandavailabilityof healthy food and health outcomes, and these data sources used to develop remedial strategiesincludingencouragingcommunity-led responses as with the Sandwell Food AccessProject.

Workneedstobecarriedouttounderstand•fully the social, environmental and economic benefitsofexistingsustainablefoodprojects(suchasmarketgardens,allotments,gardeners’clubs,communitygrowingschemesetc)toguidepolicydevelopmentinfuture.

4.3.1 Transport and sustainable development

4.3Transport

Childreninthemostdeprived10percentofwardsinEnglandarefourtimesaslikelytobe hit by a car as children in the least deprived 10 per cent of wards.173

Modern society’s dependence on motorised transport isdetrimentaltotheenvironment,wellbeingandhealthequity.Thetransportsectoroffersaclearillustration of how the principles of sustainable development can be used to reduce health inequalitiesanddeliverenvironmental,socialandhealthbenefits.

The distances people travel and the ownership and use of private motor vehicles have increased dramaticallyovertime,asFigure7shows.Yetthenumber of destinations reached, and the time spent travelling,hasremainedrelativelyconstant.175 Provided people are able to meet their basic needs, there is little evidence that further increases in mobilityresultingreaterwellbeing.176,177,178


AstudybytheLondonSchoolofHygieneandTropicalMedicineshowedthat20mphspeedzonesinLondonhadreducedroadinjuriesbymorethan40percentbetween1986to2006.174

Figure7 Distance travelled by mode.

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There is a need both to reduce the unsustainable growthintrafficvolumesthatadverselyaffectthequalityoflifeofthoselivingclosetobusyroads–particularlyintownsandcities–aswellastacklingthemajorpublichealthburdensarisingfromover-dependenceonmotorisedtransportincludingroadinjuries, air pollution, noise and physical inactivity.

Transportisamajorcontributortoclimatechange,whichrepresentsoneofthegreatestthreatstofuturehumanwellbeing.179,180,181,182,183 Its adverse effectsarelikelytoaffectpoorerpopulationsdisproportionately, because they have fewer resources to help them adapt, as already discussed in Section 3.5 above. Thisraisesbiggerissuesofinter-andintra-generationalequity.Aninnovativehealthimpactassessment of road transport in Sweden184 made a firstattempttobringtogetherthedifferenthazardsassociated with road transport. It analysed fatalities and injuries, disease cases due to exposure to road transportandthelikelyfuturehealtheffectsof

4.3.2 Transport, health and inequalities

greenhousegasemissionsfrommotorvehiclesinSweden. It found the total health impact in Sweden, as measured in disability-adjusted life years, could be fourtimesgreaterthantheinjuryimpact. It also found that the health impacts suffered in developingcountriesasaconsequenceofemissionsofgreenhousegasesfromtheSwedishroadtransportsystemmaybethreetimesgreaterthanthemortalityfromroadtrafficaccidentsinSwedenitself(basedonestimateddiseaseburdenrelatedtoglobalclimatechange).Thestudyemphasisestheneedforanewapproachtocost-benefitanalysisoftransport,andotherinvestmentsthattakeintoaccountallhealthcostsandtheimplicationsforhealthequity.

Poorer people suffer most from traffic

The connections between transport and health are multiple, complex,185 and socio-economically mixed. Poorer families tend to have lower mobility. Householdsinthelowestincomequintiletravel 4,124milescomparedwith11,588milesforthehighestincomequintilehouseholds.186 Yetpoorerfamiliestendtofacegreaterexposureto adverse environmental conditions, such as local trafficandoutdoorairpollution.Theyarealsomoresusceptible to the adverse health effects from transportbecausetheybeargreaterburdensofpre-existingillnessorotherformsofvulnerability.Thatsuchdifferentialsexistis,inpart,aconsequenceofaffluentgroupshavinggreateropportunitytomoveaway from unhealthy environments.

Theimpactoftransportonhealthinequalitiesinclude:

Road deaths and injuriesAlmost3,000peopleayeararekilledand28,000seriouslyinjuredinroadtrafficincidentsinEngland.Verywidesocio-economicdifferentialshavebeenrepeatedly reported in children187 and adults.188,189,190

Childreninthemostdeprived10percentofwardsEnglandarefourtimesaslikelytobehitbyacar as children in the least deprived 10 per cent of wards.191Roaddeaths,especiallyamongpedestriansandcyclists,areparticularlyhighamongchildrenofparentsclassifiedasneverhavingworkedoraslongtermunemployed(NationalStatisticsSocio-economicClassification(NS-SEC)group8),asshowninthefigurebelow.192

Amajorshiftintransportpolicythataddressesenvironmentalissuesandsupportsequitableandsustainable communities will also have a positive impactonhealthandhealthinequalities.Inparticular,thereisanurgentneedtoreducetransport-relatedgreenhousegasemissionsbyreducingtheuseofmotorisedtransport,switchingawayfromfossilfuels,andpromotinglow-CO2emittingmeansoftransport.


Figure8 Relationship between road injury-related deaths and socio-economic group based on theNationalStatisticsSocio-economicClassification(NS-SEC).(7).

Physical inactivity and associated ill healthOver-dependence on motorised transport is contributingtolowerlevelsofphysicalactivity,194 lackoffitness,obesity,chronicdiseasesuchascardiovasculardisease,stroke,diabetesandsomecancers,195196andpoorermentalwellbeing. People from the poorest households are least likelytomeettherecommendedlevelsofphysicalactivity, mainly because of differences in recreational and sports activity. The differentials in activity are paralleled by differentials in obesity.197,198,199,200 There are many complex reasons behind the observed

variations, but environmental factors and transport systems may play a role.201,202,203,204,205,206,207,208,209

Figure9showshowoverafairlyshortspaceoftime–fifteenyears–theratioofcarusehasincreasedcomparedwithcyclingandwalking.Carownershipisdirectlyrelatedtotheamountthatchildrenwalk–thosewithtwo-pluscarswalkverymuchlessthanthosewithoneornocars.Consideringthatcarownership increases with income level, this element mayhavesomepositiveimpactonhealthinequalitiesdespitethegeneralpatternofthosefrompoorerhouseholdsbeinglessphysicallyactive.

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Figure9 Annual distances walked by children from families with and without cars.

Since1950,therehasbeenafive-foldreductionincyclingacrossGreatBritain,primarilyduetoconcernsaboutsafety.SurveyresultsfromtheCTC(nationalcyclists’organisation)Safety in Numberscampaignfoundthat85percentofwomenand61percentofmenagreedwiththestatementthat“theideaofcyclingonbusyroadsfrightensme.”

Air pollutionEvidencefortheadverseeffectsofoutdoorairpollution is very clear,211 especially for cardio-respiratory mortality and morbidity.212,213,214,215,216 Roadtransportisamajorcontributortofineparticlepollution,nitrogendioxide,carbonmonoxide,volatileorganiccompoundsand,indirectly,ozone.217 Those livingclosetobusyroadshavea50percentincreasedriskofrespiratoryillness.218,219

The standardised mortality ratio for respiratory illness, (the ratio of observed deaths to expected deaths)tendstobehighestinareasofgreatestnitrogendioxidelevels.220 Poorer communities tend tosuffergreaterburdensofairpollution-related deathandsickness,bothbecausetheytendtoexperiencehigherconcentrationsofpollution,221 andbecauseoftheirhigherprevalenceofcardio-respiratory and other disease. Thereisacloselinkbetweenareasofhighmultipledeprivationandpollution–thepoorertheareathehigherthenitrogendioxidelevels.222 There are also important urban-rural differentials, as illustrated forsoutheastEnglandinFigure10.Thoseinurbansettingstendtohavelessaccessto(andneedfor)privatemotorvehicles–yettheyexperiencethegreaterburdenoftraffic-relatedpollution.

If, by 2015, the number of cycle trips returned to 1995 levels, the savings in health, pollution and congestion would be around £500 million.


Figure10 Ward-level maps for south east England showing quintiles 223Lightestshading=lowest

Darkestshading=highest

Carstairsindexofsocioeconomicdeprivation Percentageofhouseholdswithaccesstoacar

AnnualmeanNO2 concentrations (in ppb)

Standardizedmortalityratioforrespiratorydisease, 0–74yearsofage,1986–1995

NoiseNoiseisaproblemforoneinthreehouseholdsintheUKandhasamajorimpactonthewellbeingofoneina hundred people. Opinion poll research conducted in 2003foundthatproblemsareworseinareasofhighdensityhousing,rentedaccommodation(bothsocialand private sectors), areas of deprivation and areas

whicharehighlyurbanised.224, 225Trafficisbyfarthemaincauseofnoisepollution.Over40percentof thepopulationarebotheredbyroadtrafficnoisealthoughmanyarealsoaffectedbyaircraftandindustrial sources.226 Asignificantbodyofresearchhasfocusedonnoise

Where are people dying?

Where are the cars?

Where is the pollution?

Where is the poverty?


impact on children’s behaviour, educational outcomes aswellasgenerallevelsofstress.Transport-relatednoisehasbeenlinkedtosleepdisturbanceandincreasedcardiovascularrisk,227, 228, 229, 230 and may haveanegativeeffectonlearning231, 232, 233 and mental health.234, 235Noisefromaircraftandairportssignificantlyelevatesstressamongchildrenfarbelowthosenecessarytoproducehearingdamage.236

Social cohesion and community severanceTransport systems and increased mobility also have adverse effects on social interactions and on the cohesiveness of communities, which in turn have negativeimpactsonhealth.Ithasbeensuggestedthat people who are socially disconnected are betweentwoandfivetimesmorelikelytodiethanmatched individuals who have close ties with family, friends, and the community.237 Residents of busy streets have less than one quarterthenumberoflocalfriendsthanthoseliving

onsimilarstreetswithlittletraffic.238 It has been suggestedthatthedamagethattrafficdoestosocialsystems in urban areas is the most serious of all the problems it causes, yet there has been little or no attempttoquantifythis.239 Increased mobility has led to reduced neighbourhoodinteractionandfamiliesbecomingdispersed. It has also led to local shops and services losingouttoretailchainsandout-of-townretailparks,withknock-oneffectsonthequalityandaffordabilityof sustainable and healthy food, as discussed in section4.2.Noisy,congestedorfasttrafficroutescanalsoimpaircommunitycohesion,withconsequencesforhealthandwellbeing.240, 241, 242, 243, 244, 245

Making the Connections: Final Report on Transport and Social Exclusion(2003)highlightedhowthosehouseholds without access to a car and with poor public transport alternatives suffered reduced life chances.

Transport and active travel

Thegreatesthealthbenefitsarelikelytoarisefromthepromotionof‘activetravel’suchascyclingandwalkingasrecommendedtotheGovernmentbySustrans.246 Initsreportonhealthinequalities,theGovernment’sHealthCommitteehasrecommendedaPlanningPolicyStatementonhealththatwouldcreateabuiltenvironmenttoencouragewalkingandcycling.Itwouldalsomakeprimarycaretrustsstatutoryconsulteesforlocalplanningprocedures.247

TheSustainableDevelopmentCommissionsupportspolicyinterventionsinthefollowingareas:

Urban designWellplannedandmanagedlocalenvironmentsarelikelytoincreasephysicalactivity,248, 249, 250 withconsequentbenefitstophysicalandmentalwellbeing.251Therearearangeofmeasuresthatcanbeusedfromprovisionofhighquality,safeand

attractiveroutesforcyclingandwalkingthroughtorestrictingvehicleaccessandparking.InCopenhagensuchchangeshaveresultedin55percentofallresidentsnowcyclecommuting.252

AreviewbytheNationalInstituteforClinicalEvidence(NICE)foundthattrafficcalminginterventionsmaybeusefulinenablingchildren tobenefitfromphysicalactivitythroughplayoutdoorsintheshortandlongterm.Italsoconcludedthatclosingorrestrictingroadscanleadtolongtermincreasesinwalkingandcyclingandadecreaseinroadtrafficaccidents.Additionally,provisionofcyclinginfrastructurecanalsoleadtoalongtermincreaseincyclingand a reduction in cycle casualties.253


Walkable neighbourhoods ‘Walkable’neighbourhoodsareassociatedwith higherlevelsofphysicalactivityandlowerlevels ofobesity.Althoughwalkabilityisconceptualisedinvariousways,atypical‘walkable’neighbourhood willhavehighresidentialdensity,avarietyoflanduse,goodconnectivityandaccessibilitytoavariety of destinations such as retail facilities. It has beenshownthatresidentsinhighwalkableneighbourhoodsreportedapproximatelytwotimesmorewalkingtripseachweekthanresidentsoflowwalkableneighbourhoods.254, 255

Peoplearealsomorelikelytobephysicallyactiveiftheyliveinneighbourhoodswithmanydestinations, as well as street intersections between residential and commercial districts.256 Neighbourhoodsthatareperceivedtohavehighlevels of functionality are associated with more walking,forexamplewalkingtowork,walking forrecreationortaskedrelatedwalking.257 Public transportBetter public transport has been shown to result insignificantchangesintravelpatterns.AhealthimpactassessmentinEdinburghcomparedhowthree transport scenarios would impact differentially ondeprivedandaffluentpopulations,intermsofaccidents,pollution,physicalactivity,accesstogoodsandservicesandcommunitynetwork.Thestudyfoundthatdisadvantagedgroupsbeartheheaviestburdenofnegativeimpactsandhavemosttogainfromthepositiveimpacts,andsuggestedthatgreaterspendonpublictransportandsupportingsustainablemodesoftransportwasbeneficialtohealth,andofferedscopetoreduceinequalities.258

Road measuresEvidencesuggeststhattrafficcalming,forexample20mphzones,isassociatedwithabsolutereductionsininjuryratesand,ifappropriatelytargeted,canhelpachieverelativereductionininequalitiesinroad-injuries and deaths.259 The introduction of 20mph speed limits in London has been shown to havereducedroadinjuriesbymorethan40percentbetween1986to2006.Anditwaschildrenthatbenefitedthemost–deathorseriousinjurywas cutinhalfforthisgroup.Thestudyalsohighlightedhow injuries to pedestrians were reduced by just under a third and causalities to cyclists were down by16.9percent.260

Area-wide20mphspeedlimitsforresidentialareas,as demonstrated in Portsmouth, below, have the potential for a much wider impact, by virtue of the facttheycoveramuchgreatergeographicalarea.Schemes such as these can also have a positive impact on social cohesion as they draw on community engagementtosetthemupandensurecompliance. Ingeneral,reductionsintrafficspeedshavenumeroussustainability,healthandequalitybenefits.They can lead to reductions in both carbon dioxide emissions and other air pollutants. They also create a safer environment with fewer deaths and injuries and canpromotemorewalkingandcycling. Asaferenvironmentalsohelpstopromotechildren’sindependenttravel,providingphysicalandmentalhealthbenefits.Finallylowerspeedshelpreducetrafficnoise. StudieshavesuggestedthattheLondonCongestionChargingSchemehasreducedlevelsofairpollution-related loss of life and road injuries,261, 262, 263 butthehealtheffectsthroughwalkingandcyclinghavenotyetbeenquantified.

While a number of London councils have introduced20mphspeedlimitzonesinpartsoftheirboroughs,Portsmouthwasthefirstcityin Britain to have a 20mph limit on almost all residentialroads.Thenewspeedlimitdesigned to protect pedestrians and cyclists in residential roadsbecamecitywidein2008.Initialfindingsindicatethatalreadythelimitontrafficspeedsishavingapositiveimpactonsafetywithcasualtiesfallingby15percentandtotalaccidentsby13 per cent.264

Homes Zones also improve residents’ health byslowingdownaswellorreducingtraffic.Inparticular the health of children is improved due to the reduction in accidents and the opportunity for more outdoor play and increased physical activities.265


CyclingCyclingofferstheopportunitytoincorporatephysicalactivity into daily life at a low cost. It also offers the opportunity to reduce carbon dioxide emissions and replacemoremotorisedjourneysthanwalkingalone.Research calculates that each additional cyclist boosts theeconomybyaround£600ayear,andthatif,by2015, the number of cycle trips returned to 1995 levels,thesavingsinhealth,pollutionandcongestionwould be around £500 million.266 TheUKisoneofonlyfourcountriesinWesternEuropewhereaninjuredpedestrianorcyclisthasto show that a driver who hit them is liable for their injuries before they can claim compensation.267 If pedestrians and cyclists injured on the road were presumedentitledtocivilcompensation(assumingtheiractionswerenotnegligentorillegal)itcouldhelp promote improved driver behaviour and a shift to these more sustainable modes of transport.

Smarter choicesMeasuressuchasdevelopingaschool‘walkingbus’,have reduced levels of car travel to school by up to 20 per cent.268Work-basedtravelplanshavealsoproveneffective,ashavecarclubswhichcantacklesocialexclusionbyprovidinglowcostaccesstoacar.

Withmorethan18000trafficmovementseachdayAddenbrooke’sHospitalisthelargestsinglegeneratoroftrafficinCambridgeshire.Tocopeithasdevelopedanaccessstrategytohelpreducecarparkingdemandandtrafficcongestion.Atpeaktimesmorethan60busesnowstopatAddenbrooke’sperhour.Bicycleusehasbeenpromotedthroughinterestfreeloans,300 bicycleparkingspacesandarepairservice.Thetrust also operates pool cars and a car share scheme. Bus use has now almost doubled at 23percentandcyclingisat25percent.269

Transport policy implications

In line with • Take action on active travel,270 ambitioustargetsshouldbesetforagrowth inwalkingandcycling–andshouldbemet. The use of 20mph speed limits should be •greatlyincreased,preferablythroughtheuse of area-wide 20mph limits, in line with theproposedrevisedguidancerecentlypublished by the Department for Transport.271 Such limits should cover all streets which are primarily residential in nature as well as town or city streets where pedestrian and cyclist movementsarehigh,suchasaroundschools,shops,markets,playgroundsandotherareas.

Ambitioustargetsshouldbesetforyear-on-•yearimprovementsincontrolofroad-trafficpollutionthroughmeasurestoreducetheneed for travel and to promote a shift to less pollutingmodesoftransport.

Aprogrammeofinitiativesshouldbe•developedthroughplacesofemploymentandeducation,includingChildren’sCentres,to promote healthy behaviour in transport. Everyschoolandmajoremployershouldhave in place a travel plan which is properly implemented,monitoredandregularlyreviewed. This could include measures suchas‘greentravel-to-work’schemes,cyclisttrainingandsupportschemes;and‘walkingbuses’forprimaryschoolchildren.Provision also needs to be included for unemployed people.


Livingwithinenvironmentallimitsisoneoftheprinciples of sustainable development 275 and promotingmoreequitableaccesstogreenspacesisapreventativeandsynergisticapproachwitheconomic,environmental,socialandhealthbenefits.Theconceptofbiophilia–loveoflivingsystems–proposesan instinctive bond between humans and nature. Mostpeopleknowfromfirsthandexperiencehowreconnectingwiththeworldoutdoorsisoneoflife’ssmall but important pleasures. In Health, Place and Nature,276 the Sustainable DevelopmentCommissionhighlightsthelinksbetweenhealthandgreenandopenspaces. This builds on previous evidence bases by, for example the Royal Society for the Protection of Birds(2004,2007),277 278theRoyalCommissiononEnvironmentalPollution(2007)279andNewton(2007).280 Other literature reviews281 282 have continuedtosupportthedirectandindirectlinksbetweengreenspaceandhealth.

4.4.1 Green space and sustainable development

4.4 Green Space

Only50percentofchildreninEnglandratetheirlocalgreenspaceasfairlygood,andonly29per cent of children today enjoy most of their adventures in the natural outdoors, compared with70percentofadultsaschildren.272

Income-relatedhealthinequalitiesarelowerinpopulationslivinginthegreenestareas.273

Naturalresourcesarevitaltoourexistenceandtotheflourishingofcommunities.Greenspaces,oropen,undevelopedlandwithnaturalvegetation,274 have been shown to have physical and mental health benefits.Mostfundamentally,theymayhelpto reducelong-termstress,amajordeterminantof healthinequalities.

4.4.2 Green space, health and inequalities

Numerousstudiespointtothemanybenefitsofgreenspaceforbothphysicalandmentalhealthandwellbeing.283 284 285 286 287 This has been expressed in terms of a decrease in health complaints,288 blood pressure, cholesterol, stress levels,289 290 restoration,291

292perceivedgeneralhealth293 and ability to face problems.294

Anumberofstudieshavefocusedontheeffectofexposuretonatureinorganisationalsettingssuch as hospitals and prisons, with positive effects beingobservedinrecoverytimeandpainkillerrequirements,295 stress levels of patients,296negativereactions,297 and a lower need for healthcare for prisonerswithaccesstoagarden.298


Green space and mental health

The increased level of physical activity associated withgreenspacealsohasmentalhealthbenefits.306

307 There is a well established relationship between physical activity and mental health,308 309 310 311 312 butstudiesalsosuggestthat‘greenexercise’can havemorepositivementalhealthbenefitsthan otherkindsofexercise.313 314 For example, the psychologicalbenefitsofjogginginanurbanparkoutweighthoseofstreetjogging.315‘Greengyms’have been shown to result in positive physical and mental health outcomes.316 AstudybyMindfoundthatself-esteemlevelsincreasedanddepressionlevelsdecreasedfollowing

agreenwalk.317Ithasproposedthatdesignfor mentalwellbeing,includingnaturalspaces,should berecognisedasgoodpracticeforarchitectureandtownandcountryplanning.318 Thereisgrowingevidencethatmanydiseases,such as coronary heart disease,319 depression,320 diabetes321 andcognitivedeclinearerelatedtoinflammatoryprocessesinthebody.Chronicstressisknowntoincreasetheseinflammatoryprocessesandis more prevalent in deprived communities. The increased physical activity322 323 and social cohesion,324 325associatedwithaccesstogreenspaceareknowntoincreaseresiliencetostress.

The importance of outdoor play

Outdoor play is a vital part of childhood, and as such isanimportantaspectofthegovernment’saimtomakeEnglandthebestplaceintheworldtogrowup,asstatedintheDepartmentforChildren,SchoolsandFamilies’(DCSF)Children’sPlan.326Lackofoutdoorplay327hasbeenidentifiedasacausativefactorinincreasedmentalhealthproblemsamongstchildrenandyoungpeople328andinthecurrenthighlevelsofchild obesity.329Studiesexaminingchildren’scontactwith natural environments have shown that, as with adults, it can reduce stress.330Accesstogreenspacesimproves concentration in children with attention deficitdisorderandself-disciplineamonginnercitygirls.331 332 It has also been shown to enhance the

emotional development of schoolchildren.333 Thereisagreatdealofevidenceonthehealthandwellbeingvalueofchildrenplayinginanaturalsetting;thiswasparticularlynotedinareviewofnaturalplaycommissionedbytheChildren’sPlayCouncil,Play Naturally,334 and in Natural Thinking by William Bird for the RSPB.335Benefitsincludeimprovementsinmotorfitness,co-ordination,balance,agility,336 337 selfconfidenceand socialskills.338 In Every Child’s Future Matters,339 the Sustainable DevelopmentCommissionhasarguedthatitmaynotbepossibletodeliverthegoalsofgovernment’sEvery Child Matters white paper unless the environment

Green space and obesity

Localaccesstosafenaturalgreenspaceisassociatedwithhighlevelsofphysicalactivity299 300 301 and lower levels of obesity within communities.302 Some studies havesuggestedthatthehigherthequalityandaccessibilityofthegreenspace,themorelikelyit istoencouragehighlevelsofwalkingandotherphysical activity.303 304

RecentresearchintheUSAhasstudiedtheeffect ofneighbourhoodgreennessontwo-yearchanges inthebodymassindexofchildrenandyoung people,findingthatgreennessisinverselyassociatedwith BMI. This study supports the exploration of thepromotionandpreservationofgreenspace withinneighbourhoodsasameansofaddressingchildhood obesity.305

becomesoneofitsleadingconsiderations.Thisreportidentifiesgreenspaceasoneoffivepriorityareasbecauseofthenegativeeffectsonphysicalandemotional health associated with reduced time spent in the natural environment, and the positive effects of increasedtimespentingreenspaces. Risingtothechallengeofcreatingsafe,welcoming,interestingandfreeplacestoplayin

everyresidentialcommunity,theDCSF’sPlayStrategycommits to develop such play areas, improve safer accesstothemandencouragelocalpartnerstodevelop child-friendly communities and public spaces beyondsegregatedplayareasalone.Thestrategyalsoemphasisestheneedtofacilitatebetterworkingrelationships between local play, transport and planningpartners.


Green space and social cohesion

Naturalspacesofferopportunitiesforrelaxation340 and havebeenshowntofacilitatehigherlevelsofsocialcontactandsocialintegration,341 342 particularly in underprivilegedneighbourhoods.343 344 Studies have shown that access to a natural environment provides ameetingplaceforallagesandhasapositiveeffectonsocialinteractionandcohesionfordifferentagegroups.345 The presence of nearby natural spaces has also been related to reductions in crime346 as well as to

increasedneighbourliness.347Communitygardensandgreenactivitieslinkedtoclubsorgroupshavebeenshowntoprovideopportunitiesforsocialising,helpingtostrengthenneighbourhoodties.348 349AsdiscussedinSection4.3.2,alackofsocialtiescanhavedetrimentalimpactsonhealth.Buildingcommunitiesthroughparticipationinlocalnatureactivitieshasalso been shown to increase a sense of community strengthandpride.350 351

Green space and air quality

Greenspaceandvegetationhaveaprovenpositiveeffectonairquality.Forexample,thereisevidencethaturbantreesremovelargeamountsofair pollutionandconsequentlyimproveurbanairquality.352ColumbiaUniversityresearchers353 foundthatasthmaratesamongchildrenagedfourandfivefellbyaquarterforeveryadditional343treespersquarekilometre.TheUKhasoneofthehighestprevalences of childhood asthma internationally, with

about 15 per cent of children affected 354 and a higherprevalenceinlowersocio-economicgroups in urban areas. Urbanareaswillbeparticularlyvulnerabletorisingtemperatures due to the urban heat island effect,355 which in turn will have a detrimental impact on health andhealthinequalities.Onestudy356 found that anadditionaltengreenspacescanmitigateurbanheatislandsbyupto4°C,offeringhelpwithclimatechangeadaptation.


Green space and health inequality

Arecentstudy357intheLancetsuggestedthatincome-relatedinequalityinhealthwouldbelesspronouncedinpopulationswithgreaterexposuretogreenspace.ByclassifyingthepopulationofEnglandon the basis of income deprivation and exposure to greenspace,theresearcherswereabletoshowthathealthinequalitiesrelatedtoincomedeprivationwerelowerinpopulationslivinginthegreenestareas.The effect held for all-cause mortality and mortality from circulatory diseases, but no effect was found forcausesofdeathunlikelytobeaffectedbygreenspace,suchaslungcancerandintentionalself-harm. Dutchresearchfoundnotonlythatthepercentageofgreenspaceinaperson’sresidentialareawaspositivelyassociatedwiththeirperceivedgeneralhealth,butthatthisrelationshipwasstrongestforlowersocioeconomicgroups.358AnAmericananalysis of how residents in low-income, minority communitiesusepublic,urban,neighbourhoodparksandhowparkscontributetophysicalactivityfoundthatpublicparksarecriticalresourcesforthem.359 EvaluationofthenationalGreenGymschemeconcluded that the overall physical health status

ofparticipantsimprovedsignificantly,witha strongereffectforpeoplewiththepoorestphysicaland mental health.360 Inadditiontothisevidencedirectlyrelatingtohealthinequalities,itwouldseemthatgreenspaceisparticularlyinfluentialonconditionswhicharesignificantcontributorstohealthinequalities,suchasobesity, circulatory disease, mental health, chronic stress and asthma.361

TheGreenGymsprogrammerunbyBTCV helpspeopletotakeexerciseoutdoorswhileparticipatinginactivitiesthatimprovetheenvironment.Nineoutoftenparticipants with poor mental or physical health show an improvement within seven months. One participantsaid:“Iusedtogetdepressed about the future but now that is not the case. Ihavebeenonmedicationfor18yearsbut sincedoingthisIhavehalvedtheamountI take.Mylifeisalotbetter”.362

Green space policy implications

TheNHS,socialcare,localandregional•authorities, schools, private sector etc should recognisetheextensivebenefitsofcontactwiththenaturalenvironmentandtakeanactiveroleinpromotingthisintheirlocalcommunity as well as on their own estate.

There should be increased investment in the •creationofqualitygreenspaces,especiallyindeprivedareas,includingtreeplantingprogrammesforresidentialstreets.

AnincreaseinGPreferralstoinitiatives •likeGreenGyms,BlueGymsandHealth Walksshouldbeactivelyencouraged;NICEshouldberequiredtoevaluatetheeffectiveness of these interventions.

Fuel poverty

MostoftheUK’shousingstockconsistsofolderproperties, many of which are occupied by low income households.Existinghomesareresponsiblefor27percentoftheUK’stotalCO

2emissions,andaround80

per cent of the homes we will inhabit in 2050 already existtoday.Theneedforurgentactiontoupgradeexistinghousingstockisnowwidelyrecognised.367

Butwhilstthegovernmenthasanumberofprogrammesinplacetotacklepoorhousingstock,itrequiresmoreinvestmentinamoreintegratedway.368 Forexample,theinvestmentinenergyefficiencymeasurescanhelpwithneighbourhoodrenewalbycreatingmorelocaljobsandimproving the local economies.369AreabasedapproachessuchastheCommunityEnergySavingsProgrammecurrentlybeingtrialledthroughouttheUKcouldhelpto deliver this. Poorhousingstockishardertoheatandcoldweatherisbelievedtobethemainfactorunderlying


Over3millionhouseholdsintheUKwereinfuelpovertyin2006–latestestimatespredictthatthe problem had worsened in recent years.363

Between 1995 and 2000, Britain lost approximatelyone-fifthofitslocalservices,includingcornershops,postofficesandbanksand it is predicted that we will lose a further third over the next decade.364

4.5.1 The built environment and sustainable development

4.5 The Built Environment

Asthisreporthighlightsabove,thereisacloselinkbetween the built environment, health outcomes andinequalitiesinhealth.Forexample,airpollution,trafficaccidents,noise,obesityandmentalhealth

are all aspects of the built environment particularly affectingdisadvantagedcommunities.Lackofplayandgreenspaceimpactsonchildren’shealthandwellbeing.365Tacklingheavytrafficandpromotingsocialcontactandcohesionarealsosignificantwhenlookingathowthebuiltenvironmentcanhelpimprovehealthinequalities(seeSections4.3ontransportand4.4ongreenspaces). In Health, Place and Nature,366 the Sustainable DevelopmentCommissionhighlightshowthe location of shops and services, and the travel connectionstothem,caninfluencelevelsofphysicalactivityandsocialcontact.Theenvironmentalqualityandperceivedsafetyofanareaalsoinfluencethis–thehighertheperceivedlevelofcrimeandthemorelitterandgraffitianareahas,thelowerthelevelofphysical activity.

4.5.2 The built environment, health and inequalities

the extra deaths between December and March compared with the death rate for the rest of the year.Children,olderpeopleandpeoplewithlongtermillnessarethemostvulnerablegroupsin cold weather.370 371 Formanyvulnerablepeopleheatingissimplytoocostly,andfuelpovertycanforcethestarkchoiceof‘eatorheat’.Fuelpovertyisdefinedas‘wheninordertoheatitshometoanadequatestandardofwarmtha household needs to spend more than 10 per cent of its income on total fuel use.’372In2006,approximately3.5millionhouseholdsintheUKwereinfuelpoverty,includingalmostaquarterofhouseholdsinWalesandathirdofhouseholdsinNorthernIrelandandScotland.More recent estimates predict that the problem had increasedby2008.373Risingfuelpricesexacerbateproblemsforpeoplelivinginpoorlyinsulatedandenergy-inefficienthomes,causingmoreserious fuel poverty and related poor health.


Thegovernmentrunsanumberofprogrammestocombat fuel poverty, such as the Warm Front Scheme and the Decent Homes Standard, to which all council-ownedandmanagedpropertiesshouldconformby2010.FortypercentoftheCarbonEmissionsReductionTargetProgrammeisalsoprioritisedtowardslowincomegroups374 375andtheCommunityEnergySavingsProgrammefocusesentirelyonpeopleindeprivedneighbourhoods.

Access to facilities for everyone

Easyorpooraccesstoeverydayamenitiessuchasshops,workplaces,healthcare,greenspace,andpublic transport can reduce or exacerbate health inequalities,particularlyinruralareas.Accessiblelocal facilities, such as schools, libraries, shops and cafésprovideopportunitiesforsocialinteractionandhelp create a sense of community,377promotinggoodmentalhealthandwellbeing.Bycontrast,landuseplanningthatisolatesemploymentlocations,shopsand services and locates them far from residential areaswithoutadequatepublictransportcanresultin,andreinforce,socialexclusionandhealthinequalities.Elderly,disabledandlowincomegroupsinparticularcanfindthemselvesisolatedand/orpayingoutahigherproportionoftheirincomeontransport,reinforcinghealthinequalities.378 Inadequatetransportcanleadtounemploymentandpooreducation,bothriskfactorsforillhealth.379 Poortransportisthekeyfactorinoneinfouryoungpeoplenotapplyingforaparticularjob;sixpercent of16–24yearoldsturningdownfurthereducationandtrainingopportunitiesand1.4millionpeoplemissing,refusingorchoosingnottoseekmedicalhelp.380 Buteveniflocalpublictransportisgood,youstillneedadestinationworthtravellingto,andlocalamenitiesaredisappearing.Between1995and2000,Britainlostapproximatelyone-fifthoflocalservicessuchascornershops,postofficesandbanks,anda

further third are expected to disappear over the next decade.381 Reduced access to healthy, reasonably priced food and daily opportunities for social contact islikelytoexacerbatediet-relatedandmentalhealthinequalitiesandcanleadtogreatercardependencyin more isolated communities. This will increase carbonemissionsandfurtherdisadvantagingthemostvulnerableinsociety,whoarelesslikelytohaveaccess to a car.382 383 The location and accessibility of some local services may help or hinder the rise of obesity in terms of encouragingordiscouragingphysicalactivity384 and providingahealthydiet.Onestudyhasfoundthatgoodaccesstoleisurecentresreducedtheriskofbeingobeseby17percent.385ArecentstudyinnorthwestEnglandlookedattheassociationbetweenperceptionsofthelocalneighbourhoodandphysicalactivity. It found that the perception of access to leisure facilities was associated with physical activity, butperceptionsofaccesstoshoppingfacilitiesandpublic transport were not.386 Evidenceconsistentlyshowsthatpeoplewhohaveeasy access to facilities for physical activity - cycle paths,localparksandothergreenspaces,beaches,orrecreationcentres-aremorelikelytobeactivethanthose who do not.387Inadequatefacilities,orbarriersto access such as steep hills or busy roads, have a negativeimpactonphysicalactivity.388USstudies

AreportfoundthatSheffield’sDecentHomesProgrammehadamajorimpactonthehealthandqualityoflifeofresidents–reducingheartandrespiratorydisease,reducingthenumberofaccidentsinthehomeandgivinggreatersecurityandmentalwellbeing.376

A Greenspace Scotland report found that nearly half the Scots interviewed were afraid to use their local green space for exercise or children’s play.

The built environment and crime

Mentalhealthinequalitiesinparticularcanbeinfluencedbybeingsafeandfeelingsafe.There isastrongifcomplexcorrelationbetweencrime,poverty and ill health, with the poorest communities sufferinghighhealthinequalitiesalsosuffering highcrimerates.390 Despite a drop in the proportion ofhouseholdsconsideringlocalcrimetobea seriousproblemfrom22percentin1994-5to12percentin2005-06,tenantsinsocialrentedaccommodationweretwiceaslikelytoconsider it a serious problem.391 Thelocalbuiltenvironment’sdesigncaninfluencelevelsofcrimeandfeelingsofsafety,392 and people aremorelikelytomakethemostoflocaloutdoorspace if they consider it safe.393AGreenspaceScotlandreportfoundthatnearlyhalfofthe1,017Scotsinterviewedwereafraidtousetheirlocalgreenspacefor exercise or children’s play.394 AstudyinnorthwestEnglandfoundthatpeoplewhofeltsafeintheirneighbourhoodsweremorelikelytobephysicallyactive,althoughnoassociationsbetweenactuallevelsofcrime(e.g.vandalism,assaults,muggings)andphysicalactivitywerefound.395Thisstudyconcludedthatfeelingsafe, ratherthanactuallybeingsafe,wasmostlikelytoincrease levels of physical activity.

Thislinkbetweenincreasedexerciseandfeelingsafewasalsofoundintwostudieslookingatperceivedsafety and physical activity from the same data sets acrosseightEuropeancities(notincludingtheUK).396

397 In addition, these studies found that the more graffitiandlitterpresentinanarea,thelesssafepeoplefelt,andthathighlevelsoflitterdiscouragedexercise.Residentsinareaswithhighlevelsofgraffiti,litteranddogmesswere50percentlesslikelytobephysicallyactiveand50percentmorelikelytobeoverweight/obese. Evidencefromthe2003HealthSurveyforEnglandalso shows that perception of social nuisance (such as graffiti,litteretc.)inthelocalneighbourhoodincreasestheriskofobesityandpoorself-ratedhealth,whereaspositive perceptions of the social environment were associatedwithhigherlevelsofphysicalactivity,andlower levels of obesity and poor self-rated health.398 Litterandgraffitimayblightthelocalenvironment,butgreenerycanenhanceit.AndevidencefromtheUnitedStatessuggeststhattreesandgrasscanreducelevelsofcrimeinpoorinner-cityareas,althoughthetypeandlevelofvegetationisimportant,sinceotherstudieshaveshowndensevegetationtobeconduciveto criminal activity.399 Other interventions such as streetlightingcanalsohelpreducecrime,400 and designthatincreasesfootfallandsocialcohesion may also help reduce social nuisance.401 402


haveshownthatpopulationsingeographicareaswithlowereconomicstatushadreducedaccesstofacilities;this in turn was associated with decreased physical activity and increased levels of obesity.389 Levelsofphysicalactivityamongstdisabledpeopleare limited or promoted by built environment factors, particularlybuildingdesign.Barriersincludelackof

curb cuts, inaccessible access routes, doorways too narrowforwheelchairaccess,receptiondesksthataretoohighforgoodcommunication,andlackoflifts,slipperyfloorsandtheabsenceofhandrailsonstairs.Facilitatorsincludeaccessibleparkingspaces,push-buttonoperateddoors,multilevelfrontdesks,wheelchair and ramp access.


TheUniversityofHuddersfieldandWestYorkshirePolice conducted an evaluation of Secured by Design(SBD)housingwithinWestYorkshire.Theyfoundthattwooftherefurbishedhousingestatesrecorded67percentand54percentreductionsincrimeratesandasignificantimprovementinperception of safety post-SBD improvements.403 SimilarresultswerefoundfortheNorthviewestateinSwanley,Kent,whichfocusedonexternallandscapingandresidentialsecurity

featuresaspartofaregenerationprogramme.Landscapingwasusedtodefinepublicandprivatespace, natural surveillance across the estate was maximised,secureareaswereprovidedforbikesand rubbish, and other areas such as children’s playgroundsweregivencleardelineation.Figuresrevealan80percentreductionincrimesincludingtheftandcriminaldamagesincetheworks were completed.404

The built environment policy implications

Theplanningsystemshouldrequireall•significantdevelopments(orchangestoexistingdevelopments)tobeabletodemonstrateameaningfulpositiveimpact on health.

Successfulareapilotstargetingspecific•problemssuchascrime,graffiti,schoolmeals,pre-schoolprogrammes(e.g.SureStart)andplay areas, which can transform conditions, particularlyforchildrenandyoungpeople(seetheforthcomingevaluationoftheDepartmentforChildren,SchoolsandFamilies’PlayStrategy)shouldbesustainedandexpanded.

Informalaswellasformalneighbourhood•supervision will help people in poor areas feel safe, increase children’s ability to play freely outside and reduce stress. Local authorities shouldinstigateregularstreetandparkpolicingalongsidelocalneighbourhoodmanagement.

Thereneedstobearecognitionthat •improvingderelictplacesreducescrimeand makesthemmoreattractive,encouraging increased footfall, social contact, and a sense of security that helps prevent disorder and enhancespeople’swellbeing.Neighbourhoodrenewalprogrammesmustcontinueonanongoingbasis.Regenerationprogrammes shouldbeintegratedwithworktoupgrade theenergyefficiencyofexistinghomes.

Homeupgradinginpoorerareasbrings •manybenefits,includinggreaterenergy andwaterefficiency,tacklingfuelpoverty,helpingattractmoremixedcommunitiesandmitigatingtheimpactofclimatechange.Governmentmustdevelopacomprehensiveprogrammetoimplementenergyefficiencymeasures,targetingdeprivedareasthroughprogrammessuchastheCommunityEnergySavingsProgrammeandafollowupprogrammetoDecentHomes.Fundingmechanismsmustbein place to enable households across all tenures toupgradetheirhomes.

A sustainable health system

5


Despiteemphasisingotherorganisations’roleinreducinghealthinequalities,theNHSwillstillhaveavitalroletoplayinrealisingthehealthsystemofthe future. But the balance of the services it delivers and the ways in which it delivers them will have to change.Already,partsoftheNHSarestartingtotakea more sustainable approach to health and health inequalities,witheffortstomovetomorecommunity-

5.1 A more sustainable NHS

based services, to lower its carbon footprint and to prevent problems rather than treat symptoms. Acloserlookatexamplesofthesedevelopmentsoffers powerful lessons to the public sector in howanorganisationcancreateanew,moresustainable vision of its remit and develop services and operations to match.

How services are delivered

Primary care Primarycarewillhaveavitalroletoplayincreatingasustainable health system. International evidence405 suggeststhatafirstcontactprimarycareservice–asintheUK–hasmultiplebenefits. Universalaccesstoprimarycareisassociatedwithreducedinequalitiesinhealthoutcomesandthequantityandqualityofprimary care is associated with lower and better useofhospitals.Healthcaresystemswithagreaterorientation towards primary care are also associated with lower overall system costs. WhilstdifferingsignificantlyfromtheUK’sfreepublichealthservicemodel,insightsfromAmericacanbeuseful.Astudyexaminingtherelationshipbetweenprimarycare,incomeinequalityandmortalityintheUS406 found that the impact of a greaterprimarycarephysiciansupplyisgreaterinareasofhighincomeinequality.Thegreaterthesupply of primary care physicians, the lower the totalmortality,heartdiseasemortality,andstrokemortalityatUScountylevel.In35analysesdealingwith differences between seven types of area and fiveratesofmortality(total,heart,cancer,strokeandinfant),28foundthegreatertheprimarycarephysician supply, the lower the mortality. Toensureahealthy,strongandjustsociety,theremustbeequalprovisionofandaccesstohealthservicesacrosstheUK.Butcurrentlythereare20percentmoreGPsper100,000peopleinthemostaffluentfifthofprimarycaretrusts,incomparisontothepoorestfifth.407 There is also evidence of an ‘inverse care law’408operating,withshorterconsultationswithworkingclasspatients409 410 andhigherlistsizesinpoorerneighbourhoods. AnIPPRreportentitledPublic Services At The Crossroads411 explores British attitudes to public servicesandshowsthatthemoreaffluentandbetter

educatedapersonis,thegreaterthehealthbenefitstheygainfromtheNHS.Primarycarepolicyneedstobe developed to ensure that lower socio-economic groups–andparticularlysociallyexcludedgroups (forexamplethehomeless)–gainequalbenefits frompublicservicesashighersocio-economicgroups. Commissioningisanaspectofprimarycaretrust activity with the potential to improve health bycreatingpositiveimpactsonthedeterminantsofhealth,asillustratedbyNHSManchesterintheexampleofgoodpracticeonpage55.

Community-based servicesWhen it comes to a sustainable health system, there isastrongcaseforincreasingcommunity-basedtreatmentservices.‘Careclosertohome’implieslessdistancetotravelandfewerbarrierstoequalaccess,andisarobustmodelforensuringlongtermviabilityofthehealthsystem.Muchhigh-carbonhospitalcarecanbeundertakenincommunitysettings,reducingtheNHS’scarbonfootprint. Healthvisitorscantakeastrongroleinleadinganddeliveringinitiativessuchasthe‘HealthyChildProgramme’(forwhichthereisagoodevidencebase412)usingafamily-focusedpublichealthapproach,ordeliveringintensiveprogrammes for the most vulnerable children and families. AnothergoodexampleistheFamilyNursePartnerships, which have been shown to achieve significantandconsistentshortandlongtermimprovementsinthehealthandwellbeingofthemostdisadvantagedchildrenandtheirfamilies. The development of school health services is pivotaltothehealthandwellbeingoftheschoolcommunity,andcouldhelptospreadknowledgeabout public, as well as personal, health issues.

Work-basednursingservicescouldplayamoresignificantroleincommunicatingchildhealthmessagesandsupportingemployeesasparents,withaparticularfocusonlowincomesettingssuchaspostoffices,factories,andcallcentres. But community based services, particularly health visiting,couldalsoextendtoincludea‘shift’basedoption.Normalisingcommunityprovisionto7am-10pmcouldworkwellforhealthvisitorswhohavehadtogiveupworkbecauseoftheirownchildcareneeds,andforworkingparentswholoseincomewhen they access day-time public services. Aswellashealthprofessional-ledcommunityservices, social capital-based health promotion and intervention initiatives such as ‘community mothers’,413 414formallyidentified‘healthtrainers’andtheexpertpatientprogrammecouldbeexpanded,improvinghealthandcreatingemploymentopportunities.LocalauthoritiesandtheNHScanalsosupportandsponsor‘SureStart’programmes(thelongtermbenefitsofUS‘HeadStart’programmehavebeen reported415).

Self careEnablingpeoplewithexistinglongtermconditionstotakecareofthemselvesisanewandmoresustainable approach to health service delivery. It puts individualsinchargeoftheirownhealthcareandreduceshealthinequalities.Personalhealthserviceshavearelativelygreaterimpactonseverity(includingdisability and death) than on incidence of health problems, and severity is even more instrumental in healthinequalitiesthanincidence. Thereisaverystrongevidencebaseforthebenefitsofselfcare,suggestingahugereductioninvisitstoGPsandinuseofmedicines,416 417 418 419 420 421

422 423 424andupto12:1savings-costratio.425 426 Studies suggestthatself-monitoringresultsinhighlevelsofsatisfaction, and medicines utilisation can improve by 30 per cent.427 It also represents a low-carbon care pathway.

Good Corporate Citizenship ThewaytheNHSoperates,aswellastheservicesitdelivers,canhaveapowerfulimpactonreducinghealthinequalitiesanddeliveringsustainabledevelopment (see Section 3.2 Healthier people, healthier environment). BuildingonthestrongcasesetoutbytheKingsFundinClaiming the Health Dividend,428 the Choosing Healthpublichealthwhitepaper(2004)setouttheNHS’sroleasa‘goodcorporatecitizen’.ThistermdescribeshowNHSorganisationscanembracesustainabledevelopmentandtacklehealthinequalitiesbymakingsurethattheyarehavingapositive impact on the determinants of health throughtheirday-to-daybusiness,assetoutin Figure11below. Therehasbeenagrowingrecognitionoftheimportance of sustainable development within the NHS.Over50percentofallNHStrustsandprimarycaretrustshaveregisteredwiththeNHSGoodCorporateCitizenshipAssessmentModel(www.corporatecitizen.nhs.uk).TheNHSalsoestablishedaSustainableDevelopmentUnitandpublishedanNHSCarbonReductionStrategyinJanuary2009.429 Such an assessment model need not apply solelytotheNHS,butcouldbeappliedtoallpublicsectororganisations.Andindeedtoallprivateandvoluntarysectororganisations,too.Everyorganisationcreatesahostofdirectandindirectimpacts–social,environmentalandeconomic–throughitsoperations,overandaboveitscoreproductorservicedelivery.Aspartofsharingresponsibilityforhealthinequalities,everyorganisationinvolvedwillneedtobehaveasa‘goodcorporatecitizen’,ensuringthatitsownoperational choices support, rather than undermine, the transition to a more sustainable future for all. Employmentandskills,communityengagement,transport,procurement,newbuildingsandfacilitiesmanagementareissuesmostorganisationsface.ThefollowinggoodpracticeexamplesfromtheNHSshowhowthoseissuescanbemanagedformaximumco-benefitsbyanyorganisation.

A sustainable health system 53


Figure11 The virtuous circle of good corporate citizenship.430

ACTIVATE programme: DevelopedbytheUniversityHospitalBirminghamin2002,thisprogrammefocusesonentryleveljobsandtrainingfortheunemployedintargeteddisadvantagedareas.ItworkswithpartnerNHStruststoprovidethreeweeksdirecttrainingfollowedbythreeweeksplacement.Initsfirstfiveyears,ACTIVATEtrainedmorethan600people,with65percentofparticipantsgainingajobormovingonto further education.431

Rushey Green Time Bank:RusheyGreenGPPracticeinCatford,southLondon,isalsoafullyoperationaltimebank–wherebymembersexchangeskillsusingtimeratherthanmoneyascurrency–with55individualmembersandfivelocalorganisations.MembershavevisitedtheGPlessasaresultofparticipation.432OneofitsGPs,DrRichardByngsays:

Good corporate citizenship

Local economic, social and environmental conditions

Health of local population

Demand forservices

Capacitytoproduce qualityservices

Health of local population

Demand forservices

Health services resources

“Thisalternativemethodoftreatmenthasledtoalotofpatientsbeingtakenoffantidepressants.Tooofteninthepast,doctorswouldgivepeopledrugsornothingatall.Nowwehavethisnewmethod,andtheresultsIhaveseenhavebeenremarkable.”

Cornwall NHS Food Programme: Thisprogrammenotonly provides patients with healthy, nutritious meals, but has cut carbon emissions from road transport by two-thirds.Over80percentofthetrust’sfoodbudgetisnowspentwithlocalcompanies,withmorethan40percentofthatgoingonCornishproduce.433

Green GP surgery:ThePlowrightSurgeryinSwaffhamwasbuiltusingatimberframeandlow-energy,benignmaterialswherepossible.Ithaslargeoverhangingeavestopreventoverheatingin

NHS organisations can embrace sustainable development and tackle health inequalities by making sure they are having a positive impact on the determinants of health.

summer,andoffersfullaccessibilityforpeopleusingwheelchairs.Itusesjust54kWhofelectricityand90kWhofgaspersquaremetreperyear,or15.2GJ/100m3;athirdofDepartmentofHealthnew buildtargets.

Carbon Trust NHS Carbon Management Programme434,435 Thisprogrammewaslaunchedin2006,andisnowinthefourthyearofoperation.Fromthe42trustsithasworkedwith,over800,000tonnesofannualCO

2savingshavebeenidentified.

NHSandSocialServicesshouldexplicitly•accountforimprovingthepublic’shealth andhealthequity.Thiswouldinvolvemechanismssuchas:

A sustainable health system 55

Implemented measures have already led to annual savingsofover£20million.

Commissioning: NHSManchesterincludesclausesongoodcorporatecitizenshipinallitscontractspecifications.Thiscommunicatesastrongmessagethatgoodcorporatecitizenshipisattheheartofprovidingqualityhealthcare,althoughfurtherpolicyinterventions could ensure a more comprehensive engagementwiththisagenda.

Policy implications

ThepercentageofNHSmoniesforallprimary•careservicesshouldbeincreasedsignificantlyandurgently,withtheemphasisonequalityof provision and care provided within the community.Thepercentageofexpenditureonprevention and public health services should be increased steadily year on year over the next 10 years, in line with the recommendation made intheSDC’sBreakthroughsreport.436

The Secretary of State for Health should report •annuallytoParliamentonprogressinreducinghealthinequalitiesandimprovinghealthcare,andensuringthelong-termviabilityofthehealthsysteminthefaceofclimatechangeandpressureonenergyresources,withevidenceofinvolvingLocalStrategicPartnerships.

-PCTsandSocialCareDepartments(AdultandChildren)tobejudgedaccordingtooutcomeofComprehensiveAreaAssessments

-AllCommissionersandPurchaserstobeheldtoaccountfortheircontributiontoreducingemissionsofgreenhousegases

-NHSorganisationstoreportprogressonGoodCorporateCitizenshipcategoriesintheirannualqualityaccounts,andsocialcareorganisationstoreportsimilarprogress.


Asustainablehealthsystembasedonpreventionwouldsupportalongtermreductioninhealthinequalities,buildingonandstrengtheningthesocialmodelofhealthanddeliveringenvironmentalbenefits.Aspectsofsuchanapproachinclude:promotingwellbeingforall;focusingonpreventingillness;valuingthehumanresourcesinvolvedinhealthandcare;promotinglow-carbonliving;andjudgingsuccessintermsofmediumandlong-termeffects on society, the environment and the economy. In order to achieve this, the concept of preventative and public health must be expanded beyond the currentnarrowdefinitionofillhealthpreventionbytheNHS.TheNHScannotsingle-handedlyimprovethe health of the population, certainly not if it means tacklingthecomplexcausesofillhealth(seeSection3.3Preventionandco-benefits:Promotinghealthandsustainable development). Astheresearchevidencethroughoutthisreportoverwhelminglydemonstrates,forapreventativeapproachtohealthinequalitiestotakeroot,ownership for health issues must be spread beyond health professionals and indeed, at times, even

5.2 Conclusions: A new, partnership approach to prevention

beyondthepublicsectore.g.privatesectorworkplacetransport schemes and health advice. Butourevidenceabouttheco-benefitsavailablefromadoptingasustainable,preventativeapproachtoreducinghealthinequalitiessuggeststhat,ratherthanan additional burden, such an approach is a successful wayofmakingbudgetsworkharderandachievingwide-rangingimprovementsinhealth,environmentaland economic terms. SystematicmethodsofengagementneedtobedevelopedbetweentheNHSandregionaldevelopmentagencies,localandregionalgovernmentandsocialcare,witharangeofdifferentsectorsandservicesworkingtogether–education,employment,planning,housing,benefits,transport,sport and leisure, and environment. SpatialPlanningforHealthGuidancebeingdevelopedbyNICE437 and aimed at local authorities andPCTsexemplifiestheapproachneeded,recognisingtheimpactspatialplanningcouldhavebyaddressingthewiderdeterminantsofhealth.Encouragingly,suchsmartpartnershipworkinghasalreadybeguntohappenincitiessuchasBristol.

FundedbyNHSBristolandmonitoredbythecity’slocalstrategicpartnership,anewposthasbeencreatedplacingthefirstpublichealthexpertinthecountry in a council transport department in Bristol CityCouncil’sCityDevelopmentdirectorate. This part time post is to help planners and transportengineersunderstandhowtheyinfluencepublichealthchallengessuchasobesity,mental health and cardiovascular disease, and

how they can create environments which encouragepeopletowalkorcycleinsteadofdrivingcars. The post also contributes health evidence to transport consultations and bids and helps facilitateprogrammesforBristol’sDepartment of Public Health to reduce injuries and fatalities on the roads.438

Endnotes The Marmot Review (2010) 1 Fair Society, Healthy Lives London: The Marmot Review.

Shaw,M.,Smith,G.D.&Dorling,D.(2005).HealthinequalitiesandNew2

Labour:howthepromisescomparewithrealprogress.British Medical Journal330:1016-1021.

Department of Health (2009). 3 Tackling Health Inequalities: 10 Years On – A review of developments in tackling health inequalities in England over the last 10 years.

Sassi, F. (2009). 4 Health inequalities: a persistent problem.In:J.Hills,T.SeftonandK.Steward(Eds.),Towardsamoreequalsociety?Poverty,inequalityandpolicysince1997.Bristol:ThePolicyPress.

GreaterLondonAuthority(2009)TheLondonHealthInequalities5

Strategy(Draftforpublicconsultation)

The Marmot Review (2010) 6 Fair Society, Healthy Lives London: The Marmot Review.

CommissionfortheSocialDeterminantsofHealth(2008).7 Closing the Gap in a Generation: health equity through action on the social determinants of health.FinalReportoftheCommissiononSocialDeterminantsofHealth.Geneva:WorldHealthOrganization.

HealthEngland(2004).8 Public Health and Prevention Expenditure in England.ReportNo.4.

HMGovernment(2005).9 Securing the Future: delivering the UK sustainable development strategy.London:TheStationaryOffice.

FoodStandardsAgency(2007).10 Low income diet and nutrition survey. London:TheStationaryOffice.http://tiny.cc/cfE9U

Edwards,P.&Roberts,I.(2009).Populationadiposityandclimate11

change.International Journal of Epidemiology:April1-4.

Garnett,T.(2008).12 Food, greenhouse gas emissions and our changing climate.Surrey:FoodClimateResearchNetwork.

SustainableDevelopmentCommission,NHSSustainableDevelopment13

Unit&StockholmEnvironmentInstitute(2008).NHS England Carbon Emissions Carbon Footprinting Report.http://tiny.cc/NGfPP

NHSSustainableDevelopmentUnit,ARUP&StockholmEnvironment14

Institute (2010) NHS Carbon Footprint: GHG emissions 1990-2020 baseline emissions update.http://tiny.cc/s1EHP

NHSSustainableDevelopmentUnit(2009)15 . NHS Board Level Sustainable Development Management Plan Guidance. http://tiny.cc/IAlgD

SustainableDevelopmentCommission,NHSSustainableDevelopment16

Unit&StockholmEnvironmentInstitute(2008).NHS England Carbon Emissions Carbon Footprinting Report.http://tiny.cc/NGfPP

Coote,A.(2008).Preventionisbetterthancure.17 Asian Hospital and Healthcare Management:15.http://tiny.cc/RWBtp

HealthEngland(2009).PublicHealthandPreventionExpenditure 18

inEngland.ReportNo.4.http://tiny.cc/eFlA9

DepartmentofHealthandSocialSecurity(1980).19 The Black Report - Inequalities in health.ReportofaResearchWorkingGroup. London:DHSS.

DepartmentofHealth(1998).20 The Acheson report: Independent inquiry into inequalities in health report.London:TheStationaryOffice.

Wanless, D. (2002). 21 Securing our future health: taking a long-term view.Finalreport.London:HMTreasury.

Wanless,D.(2004).22 Securing good health for the whole population. Finalreport.London:HMTreasury.

Department of Health (n.d.). 23 Vascular Disease.http://tiny.cc/1BiYX

Butland,B.,Jebb,S.,Kopelman,P.,McPherson,K.,Thomas,S.,Mardell,24

J.,etal.(2007).Foresight. Tackling Obesities: Future Choices – Project Report.2ndEdition.London:GovernmentOfficeforScience.

Kasser,T.(2002).25 The High Price of Materialism.Cambridge, Mass:MITPress.

Kasser,T.(2007).Avisionofprosperity:thinkpiecefortheSustainable26

Development’sRedefiningProsperityproject,London,SustainableDevelopmentCommission.InJackson,T.(2009).Prosperity without Growth,London:SustainableDevelopmentCommission;Chapter9,p88.

Kmietowicz,Z.(2006).WhereGPsgo,politicianswillfollow.27 British Medical Journal:332:258.

Dorling,D.,Mitchell,R.,Shaw,M.,Orford,S.,&DaveySmith,G.(2000).28

TheGhostofChristmasPast:HealtheffectsofpovertyinLondonin1896and1991.British Medical Journal,321:1547-1551.

Lupton,R.&Power,A.(2005).29 Disadvantaged by where you live? NewLabourandneighbourhoodrenewal.InHills,JohnandStewart,Kitty,(eds.)Amoreequalsociety?Newlabour,poverty,inequalityandexclusion.Bristol:PolicyPress:199-142.

Power,A.(2007).30 City survivors: bringing up children in disadvantaged neighbourhoods.Bristol:PolicyPress.

Power,A.&Mumford,K.(2003).31 Boom or abandonment: resolving housing conflicts in cities.Coventry,UK:CharteredInstituteofHousing.

RoyalCommissiononEnvironmentalPollution.(2007a).32 Study on Urban Environments Wellbeing and Health.London:The StationaryOffice.

RoyalCommissiononEnvironmentalPollution(2007b).33 The Urban Environment.London:TheStationaryOffice.

Shaw,M.,Smith,G.D.&Dorling,D.(2005).HealthinequalitiesandNew34

Labour:howthepromisescomparewithrealprogressBritish Medical Journal,330:1016-1021.

Pickett,K.E.,&Pearl,M.(2001).Multilevelanalysesofneighbourhood35

socioeconomiccontextandhealthoutcomes:acriticalreview.Journal of Epidemiology and Community Health,55:111-122.

Wood,J.,Hennell,T.,Jones,A.,Hooper,J.,Tocque,K.,&Bellis,M.A.36

(2006).Where wealth means health: illustrating inequality in the North West.Liverpool:LiverpoolJohnMooresUniversity.

Hills,J.(2007).37 Ends and Means: The Future Roles of Social Housing in England.London:CASE/LSE.

RoyalCommissiononEnvironmentalPollution(2007a).38 Study on Urban Environments Wellbeing and Health.London:TheStationaryOffice.

Endnotes 57



PerpetuityGroup(2009).40 One More Broken Window: The Impact of the Physical Environment on Schools.Leicester:NASUWTTeachingUnion.

Department of Health (2009). 41 Be active Be healthy: A plan for getting the nation moving.London:DepartmentofHealth.

SocialExclusionTaskForce(2009).42 Working together for older people in rural areas.http://tiny.cc/PPlLB

CommissiononSocialDeterminantsofHealth.43 Closing the gap in a generation; Health equity through action on the social determinates of health.FinalReportoftheCommissiononSocialDeterminantsofHealth.Geneva:WorldHealthOrganization.http://tiny.cc/xctPx

CharteredInstituteofEnvironmentalHealth(2008).44 Climate Change, Public Health and Health Inequalities, p3.

Stern,N.(2006).45 The Economics of Climate Change; The Stern review. London:HMTreasury;chapter7,p175.

TyndallCentre,EffectiveandEquitableResponsestoClimateChange,46

presentation.http://tiny.cc/CHKTC(Slide6)

IntergovernmentalPanelonClimateChange(2007).47 Climate change 2007: Synthesis report of 4th assessment.Geneva:IntergovernmentalPanelonClimateChange,p33.

Stern,N.(2006).48 The Economics of Climate Change; The Stern review. London:HMTreasury;chapter5,p.7.

IntergovernmentalPanelonClimateChange(2007).49 Climate change 2007: Synthesis report of 4th assessment.Geneva:IntergovernmentalPanelonClimateChangep48.

CAGConsulting(2009).50 Differential Social impacts of Climate Change in the UK:SNIFFER.

Stern,N.(2006).51 The Economics of Climate Change; The Stern review. London:HMTreasury;chapter5,p.10.

IntergovernmentalPanelonClimateChange(2007).52 Climate change 2007: Synthesis report of 4th assessment.Geneva:IntergovernmentalPanelonClimateChangep53.

Stern,N.(2006).53 The Economics of Climate Change; The Stern review. London:HMTreasury.

Ibid.54

Ibid.;chapter5,p10.55

EnvironmentAgency(2006).56 Addressing environmental inequalities: flood risk,Bristol:EnvironmentAgency.

Stern,N.(2006).57 The Economics of Climate Change; The Stern review. London:HMTreasury;partIIp16,92.

Pitt,M.(2008).58 The effect of the summer 2007 floods on individuals and communities. The Pitt Review: Lessons learned from the 2007 floods.TheCabinetOffice;chapter2.

IntergovernmentalPanelonClimateChange(2007).59 Impacts, Adaptation and Vulnerability.ContributionofWorkingGroupIItotheFourthAssessmentReportoftheIntergovernmentalPanelonClimateChange,M.L.Parry,O.F.Canziani,J.P.Palutikof,P.J.vanderLindenandC.E.Hanson,Eds.,CambridgeUniversityPress;393.

McMichael,A.,Campbell-Lendrum,D.,Kovats,R.,etal.(2004). 60

Climatechange.InEzzati,M.,Lopez,A.,Rodgers,A.,Murray,C., eds.Comparativequantificationofhealthrisks:globalandregionalburdenofdiseaseduetoselectedmajorriskfactors.Geneva:WorldHealthOrganization.

Chan,M.(2009).Cuttingcarbonimprovinghealth.61 Lancet374,9705.In:theHealthandClimatechangeseries.http://tiny.cc/GMadc

PatzJ,GibbsH,FoleyJ,RogersJ,SmithK.(2007).Climatechangeand62

globalhealth:quantifyingagrowingethicalcrisis.EcoHealth;4:397-405.

IntergovernmentalPanelonClimateChange(2007).63 Climate change 2007: Synthesis report of 4th assessment.Geneva:IntergovernmentalPanelonClimateChange;p67.

CommitteeonClimateChange(n.d.).64 Carbon Budgets. http://tiny.cc/kyHTk.

EnvironmentAgency(2006).65 Addressing Environmental Inequalities:Flood Risk.http://tiny.cc/tnINF

Jackson,T.(2009).66 Prosperity without Growth,London:SustainableDevelopmentCommission;chapter5.

Brand,C.&Boardman,B.(2008).67 Taming of the few – the unequal distribution of greenhouse gas emissions from personal travel in the UK,EnergyPolicy,36:224-238.

Ekins,P.&Dresner,S.(2004).68 Green taxes and charges. Reducing their impact on low-income households.http://tiny.cc/eg624

Ibid.69

Stott, R. (2005).70 Implications for health.In:Livinginalow carbonworld:Thepolicyimplicationsofrationing.PolicyStudiesInstitute, London.

Ibid.71

Haines,A.,Kovats,R.S.,Campbell-Lendrum,D.&Corvalan,C.(2006).72

Climatechangeandhumanhealth:impacts,vulnerability,andmitigation.The Lancet367(9528):2101-2109.

IntergovernmentalPanelonClimateChange(2007).73 Climate change 2007: Synthesis report of 4th assessment.Geneva:IntergovernmentalPanelonClimateChange.

Kjellstrom,T.,Holmer,I.&Lemke,B.(2009a).Workplaceheatstress,74

healthandproductivity–anincreasingchallengeforlowandmiddleincomecountriesduringclimatechange.Global Health Action (www.globalhealthaction.net).DOI10.3402/gha.v210.2047.

Kjellstrom,T.,Gabrysch,S.,Lemke,B.&Dear,K.(2009b).The“Hothaps”75

programforassessmentofclimatechangeimpactsonoccupationalhealthandproductivity:Aninvitationtocarryoutfieldstudies.Global Health Action(www.globalhealthaction.net).DOI10.3402/gha.v210.2082.

Stern,N.(2006).76 The Economics of Climate Change;TheSternreview.London:HMTreasury;chapter5,p.7.

IntergovernmentalPanelonClimateChange(2007).77 Climate change 2007: Synthesis report of 4th assessment.Geneva:IntergovernmentalPanelonClimateChange.

Johnson,V.,Simms,A.,Walker,P.,Ryan-Collins,J.(2009).78 Bridging the gap between climate change, resource scarcity and social justice: the future role of civil society association, report by new economics foundation for the Carnegie Trust; chapter 3.

HealthandClimatechangeseries(2009).79 The Lancet. http://tiny.cc/AbGvJ

Veenhoven,R.(2002).80 Freedom and happiness: a comparative study in 46 nations in the early 1990’s, World Happiness Database.http://tiny.cc/9WqKC

Jackson,T.(2009).81 Prosperity without Growth?London:SustainableDevelopmentCommission;chapter5.

Ibid.82

Ibid.83

Ibid.84

Coote,A,&Franklin,J.(2009).neweconomicsfoundation. 85

http://tiny.cc/CjU4t

Jackson,T.(2009).86 Prosperity without Growth?London:SustainableDevelopmentCommission;chapter5.

Ibid.;chapter9,p86.87

DepartmentforEnvironment,FoodandRuralAffairs(2007).88

Sustainable Development Indicators In Your Pocket 2007. London:HMSO;111.

Thompson,S&Marks,N.(2008).89 Measuring Wellbeing in Policy: Issues and Applications, report to the Foresight Project on Mental Capital and Wellbeing. new economics foundation.

Marks,N.etal.(2007).90 Exploring the relationship between sustainable development and wellbeing and its policy implications: Project 3B - SD12007.neweconomicsfoundation/DepartmentforEnvironment,FoodandRuralAffairs.

Burroughs,J.E.&Rindfleisch,A.(2002).Materialismandwellbeing:91

Aconflictingvaluesperspective.Journal of Consumer Research 29(3):348-370.

Kasser,T.&Ryan,R.M.(1993).ThedarksideoftheAmericanDream:92

CorrelatesofFinancialSuccessasaCentralLifeAspiration.Journal of Personality and Social Psychology65(2):410-422.

Hamilton,C.(2002).93 Overconsumption in Australia: The rise of the middle-class battler.DiscussionPaperNumber49.The AustraliaInstitute.

Hamilton,C.&Mail,E.(2003).94 Downshifting in Australia: a sea- change in the pursuit of happiness,DiscussionPaperNumber50, TheAustraliaInstitute.

Veenhoven,R.(2002).95 Freedom and happiness: a comparative study in 46 nations in the early 1990’s, World Happiness Database 2002. http://tiny.cc/ajoA5

Jackson,T.(2009).96 Prosperity without Growth?London:SustainableDevelopmentCommission

Ibid97

WilkinsonR.&Pickett,K.(2009).98 The Spirit Level: Why More Equal Societies Almost Always Do Better:p87.London:PenguinBooksLtd.

citing,interalia,SVSubramanianandIKawachi.Incomeinequality andhealth:whathavewelearnedsofar?EpidemiologicReview2004,26:78-91

Gough,I.,Meadowcroft,J.,Dryzek,J.,Gerhards,J.,Lengfeld,H.,99

Markandya,A.&Ortiz,R(2008).Symposium:Climatechangeandsocial policy. Journal of European Social Policy,18(4):325-344.

Coote,A.&Franklin,J.(2009).GreenWellFair:Threeeconomiesfor100

social justice. new economics foundation.

NationalInstituteforHealthandClinicalExcellence(2010).101 Spatial planning for health.http://tiny.cc/z24cO

DepartmentforChildren,SchoolsandFamilies(2008).102 The Play Strategy.http://tiny.cc/JFQkE

Sassi,F.(2009).Healthinequalities:apersistentproblem.In:J.Hills,103

T.Sefton&K.Steward(Eds.),Towards a more equal society? Poverty, inequality and policy since 1997.Bristol:ThePolicyPress.

TheNHSInformationCentre(2007).HealthSurveyforEngland2007.104



NationalHeartForum(2010).106 Social Class and Obesity – Effects on disease and health service treatment costs. To be available at www.heartforum.org.uk

NationalInstituteforClinicalExcellence.(2006).107 Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children.

Mental Health Foundation (2009). 108 Mental health, resilience and inequalities.http://tiny.cc/xLQvl

TheOfficeforNationalStatistics(2001).109 Psychiatric Morbidity report.

The future vision coalition (2009).110 A future vision for mental health. http://tiny.cc/jSfWK

Foresight(2008).111 Mental Health: Future challenges Government. OfficeforScience.http://tiny.cc/JVpIa

RoyalCommissiononEnvironmentalPollution.(2007a).112 Study on Urban Environments Wellbeing and Health.London:TheStationaryOffice


DepartmentforEnvironment,FoodandRuralAffairs.(2000). 114

NationalFoodSurvey2000.http://tiny.cc/nSjlV

Belot,M.,James,J.(2009).115 Healthy School Meals and Educational Outcomes.Oxford:InstituteforSocialandEconomicResearch.

Dowler,E.(2008).Foodandhealthinequalities:thechallengefor116

sustainingjustconsumption.Local Environment 13(8):759-772.

FoodStandardsAgency(2007).117 Low income diet and nutrition survey. London:TheStationaryOffice.

DepartmentforEnvironment,FoodandRuralAffairs(2010).118 Food 2030.London:Defra.

Ibid.119

Endnotes 59


IntergovernmentalPanelonClimateChange(2007).120 Climate change 2007: The Physical Science Basis.NewYork:CambridgeUniversityPress.

UnitedNationsDevelopmentProgramme(2007).121 Human Development Report: Fighting climate change: human solidarity in a divided world.NewYork:UnitedNationsDevelopmentProgramme.

Friel,S.,Marmot,M.,McMichael,A.J.,Kjellstrom,T.&Vågerö,D.122

(2008).Globalhealthequityandclimatestabilisation-needforacommonagenda.TheLancet,372(9650):1677-1683.

GarnettT.(2008).123 Food, greenhouse gas emissions and our changing climate.Surrey:FoodClimateResearchNetwork.

DepartmentforEnvironment,FoodandRuralAffairs(2009).124

Information bulletin: Anaerobic digestion: new Task Group to deliver shared goals.London:Defra.


FoodandAgriculturalOrganisation(2006).126 Livestock’s Long Shadow—Environmental Issues and Options.Rome:FoodandAgricultureOrganisation.

Casey,J.W.&Holden,N.M.(2005).Therelationshipbetween127

greenhousegasemissionsandtheintensityofmilkproductioninIreland. Journal of Environmental Quality,34:429–436.

Casey,.J.W.&Holden,N.M.(2006).Quantificationofgreenhouse128

gasemissionsfromsuckler-beefproductioninIreland. Agricultural Systems,90:79-98.

Cederberg,C.&Mattson,B.(2000).Lifecycleassessmentofmilk129

production—acomparisonofconventionalandorganicfarming.Journal of Cleaner Production,8:49-60.

Cederberg,C.&Stadig,M.(2003).Systemexpansionandallocation130

inlifecycleassessmentofmilkandbeefproduction.International Journal of Life Cycle Assessment, 8(6):350-356.

Lovett,D.K.,Shalloo,L.,Dillon,P.&O’Mara,F.P.(2006).Asystems131

approachtoquantifygreenhousegasfluxesfrompastoraldairyproductionasaffectedbymanagementregime.Agricultural Systems, 88(2-3):156-179.

Basset-Mens,C.,vanderWerf,H.M.G(2005).Scenario-based132

environmentalassessmentoffarmingsystems:thecaseofpigproduction in France. Agriculture, Ecosystems and Environment, 105:127-144.

Dixon,J.,Omwega,A.,Friel,S.,etal.(2007).TheHealthEquity133

DimensionsofUrbanFoodSystems. Journal of Urban Health, 84(1S):118-129.

Hawkes,C.(2006).Unevendietarydevelopment:linkingthepolicies134

andprocessesofglobalizationwiththenutritiontransition,obesityand diet-related chronic diseases. Globalisation and Health 2(4).doi:10.1186/1744-8603-2-4.

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NutritionTransition.In:Labonte,R.,Schrecker,T.,Packer,C.,Runnels,V,eds.Globalization and Health: Pathways, Evidence and Policy.NewYork:Routledge.

Pretty,J.,Ball,A.,Lang,T.&Morison,J.(2005).Farmcostsandfood136

miles:AnassessmentofthefullcostoftheUKweeklyfoodbasket.Food Policy,30(1):1-20.

FoodandAgriculturalOrganisation(2003).137 World agriculture: towards 2015/2030. An FAO perspective.Rome:FoodandAgriculturalOrganisation/Earthscan.

McMichael,A.J.,Powles,J.W.,Butler,C.D.&Uauy,R.(2007).Food,138

livestockproduction,energy,climatechangeandhealth.The Lancet, 370,55–65.

Delgado,C.L.(2003).RisingConsumptionofMeatandMilkin139

DevelopingCountriesHasCreatedaNewFoodRevolution.Journal of Nutrition, 133(11):3907S-3910.


CommitteeonClimateChange(2008).141 Building a low-carbon economy – the UK’s contribution to tackling climate change: The First Report of the Committee on Climate Change.London:UKGovernment.

Gerbens-Leenes,P.W.&Nonhebel,S.(2002).Consumptionpatterns142

andtheireffectsonlandrequiredforfood.Ecological Economics, 42S,185-199.

Gold,M.(2004).143 The Global Benefits of Eating Less Meat.Petersfield,UK:CompassioninWorldFarmingTrust.

SustainableDevelopmentCommission(2009).144 Setting the Table: Advice to Government on priority elements of sustainable diets.

Gold,M.(2004).145 The Global Benefits of Eating Less Meat.Petersfield,UK:CompassioninWorldFarmingTrust.

WorldHealthOrganisation(2002).146 Food and The Food and Agriculture Organisation of the United Nations Diet, nutrition and the prevention of chronic diseases. Draft report of the joint WHO/FAOexpertconsultation,

ScientificAdvisoryCommitteeonNutrition(2009).DraftIronand147

HealthreportScientificConsultation.http://tiny.cc/cP7Eh

FoodandAgriculturalOrganisation(2008).148 The State of Food Insecurity in the World 2008.Rome:FoodandAgricultureOrganisation.

Doak,C.M.,Adair,L.S.,Bentley,M.,Monteiro,C.&Popkin,B.M.(2004).149

The dual burden household and the nutrition transition paradox. International journal of obesity and related metabolic disorders, 29(1):129-136.

Drewnowski,A.&Specter,S.(2004).Povertyandobesity:therole150

ofenergydensityandenergycosts.American Journal of Clinical Nutrition, 79(1):6-16.

Friel,S.,Chopra,M.&Satcher,D.(2007).Unequalweight:equity151

orientedpolicyresponsestotheglobalobesityepidemic.British Mentoring Journal, 335(7632):1241-1243.

Hawkes,C.(2006).Unevendietarydevelopment:linkingthepolicies152

andprocessesofglobalizationwiththenutritiontransition,obesityanddiet-relatedchronicdiseases.GlobalisationandHealth.

Popkin,B.M.(2006).Globalnutritiondynamics:theworldisshifting153

rapidlytowardadietlinkedwithnoncommunicablediseases.American Journal of Clinical Nutrition, 84(2):289-298.

McMichael,A.J.,Powles,J.W.,Butler,C.D.&Uauy,R.(2007).Food,154

livestockproduction,energy,climatechangeandhealth.The Lancet, 370,55–65.

DepartmentofHealth(2008).155 Healthy Weight, Healthy Lives: A cross-government strategy for England 2008. London.



FoodStandardsAgency(2007).157 Low Income and Diet Survey.London:FoodSafetyAuthority.

Dowler,E.&Dobson,B.(1997).NutritionandpovertyinEurope:an158

overview. Proceedings of the Nutrition Society,56:51-62.

Friel,S.,Marmot,M.,McMichael,A.J.,Kjellstrom,T.&Vågerö,D.159

(2008).Globalhealthequityandclimatestabilisation-needforacommonagenda.The Lancet,372(9650):1677-1683.

InstituteofAgricultureandTradePolicy(2006).160 Food without Thought: How U.S. Farm Policy Contributes to Obesity.Minneapolis,Minnesota:InstituteofAgricultureandTradePolicy.

HealthCommittee(2004).Obesity:161 Third Report of Session 2003-03. London:TheStationaryOffice.

Barling,D.,Lang,T.&Sharpe,R.(2008).Therootoftheproblem.162 RSA Jour nal,Spring,29.http://tiny.cc/UFnVw

Morris,J.,Donkin,A.,Wonderling,D.,Wilkinson,P.&Dowler,E.(2000).163

AMinimumIncomeforHealthyLiving.Journal of Epidemiology and Community Health,54,885-889.

Saunders,P.(1998).164 Global pressures, national responses: The Australian welfare state in context.SocialPolicyResearchCentre,Sydney.

Friel,S.,Walsh,O.&McCarthy,D.(2006).Theironyofarich 165

country:IssuesofaccessandavailabilityofhealthyfoodintheRepublic of Ireland. Journal of Epidemiology and Community Health,60,1013-1019.

Ibid.166

FoodforLife.www.foodforlife.org.uk167

GoodFoodonthePublicPlate.Sustainweb.http://tiny.cc/F8rD3168

DepartmentofHealth(n.d.).HealthierFoodMark-Promoting169

healthier,moresustainablefood.http://tiny.cc/Lz2Qp

Belot,M.&James,J.(2009).170 Healthy School Meals and Educational Outcomes.Oxford:InstituteforSocialandEconomicResearch.

Dowler,E.,Rex,D.,Blair,A.,Donkin,A.&Grundy,C.(2001). 171

Measuring Access to Healthy Food in Sandwell.Sandwell: SandwellHealthAuthority.

ICLEILocalGovernmentsforSustainability(n.d.).http://tiny.cc/bzRRV.172

Department for Transport (2009). 173 A Safer Way – Making Britain’s Roads the Safest in the World.http://tiny.cc/roZEW

Grundy,C.etal.(2009).Effectof20mphtrafficspeedzonesonroad174

injuriesinLondon,1986-2006:controlledinterruptedtimeseriesanalysis. British Medical Journal,339:b4469.

Metz,D.(2008).175 The Limits to Travel.Earthscan.

Adams,J.(2001).176 The Social Consequences of Hypermobility.RSAlecture.http://tiny.cc/GuE8s.

Layard,R.(2006).177 Happiness: Lessons from a New Science. London:Penguin.

Sloman,L.(2006).178 Car Sick – Solutions for our car addicted culture. Devon,England:GreenBooksLtd.

Haines,A.,Kovats,R.S.,Campbell-Lendrum,D.&Corvalan,C.(2006).179

Climatechangeandhumanhealth:impacts,vulnerability,andmitigation.Lancet,367(9528):2101-9.

Patz,J.A.,Campbell-Lendrum,D.,Holloway,T.&Foley,J.A.(2005).180

Impactofregionalclimatechangeonhumanhealth.Nature. 438(7066):310-7.

IntergovernmentalPanelonClimateChangeSecretariat, 181

WorldMeteorologicalOrganization,UnitedNationsEnvironmentProgramme(2007).Climate Change 2007: impacts, adaptation and vulnerability.ContributionofWorkingGroupIItotheIntergovernmentalPanelonClimateChangeFourthAssessmentReport.Summaryforpolicymakers.Cambridge,UKandNewYork, NY,USA:CambridgeUniversityPress.

SternN.(2006).182 The Economics of Climate Change; The Stern review. London:HMTreasury.

Woodcock,J.,Banister,D.,Edwards,P.,Prentice,A.&Roberts,I.(2007).183

EnergyandTransport.Lancet370:1078-88.

Kjellstrom,T.,Ferguson,R.&Taylor,A.(2009).184 The total public health impact of road transport in Sweden.Technicalreport.Borlange:SwedishNationalRoadAuthority.http://tiny.cc/Via2A.

Woodcock,J.,Banister,D.,Edwards,P.,Prentice,A.,Roberts,I.(2007).185

EnergyandTransport.Lancet,370:1078-88.

DepartmentforTransport(2007).2006Nationaltravelsurvey.186

Transport Statistics.

Graham,D.J.&Stephens,D.A.(2008).Decomposingtheimpact187

ofdeprivationonchildpedestriancasualtiesinEngland.Accident Analysis and Prevention, 40(4):1351-64.

Graham,D.,Glaister,S.&Anderson,R.(2005).Theeffectsofarea188

deprivation on the incidence of child and adult pedestrian casualties in England.Accident Analysis and Prevention, 37(1):125-35.

Jones,A.P.,Haynes,R.,Kennedy,V.,Harvey,I.M.,Jewell,T.&Lea,D.189

(2008).GeographicalvariationsinmortalityandmorbidityfromroadtrafficaccidentsinEnglandandWales.Health Place, 14(3):519-35.

DepartmentforTransport.(2008).190 Road Casualties Great Britain 2007. http://tiny.cc/mGRlw.

Department for Transport. (2009). 191 A Safer Way – Making Britain’s Roads the Safest in the World.http://tiny.cc/KXv5O

OfficeforNationalStatistics(2002).192 National Statistics Socio-economic Classification: User Manual.London:OfficeforNationalStatistics.

Edwards,P.,Roberts,I.,Green,J.&Lutchmun,S.(2006).Deathsfrom193

injuryinchildrenandemploymentstatusinfamily:analysisoftrendsinclassspecificdeathrates.British Medical Journal, 333(7559):119.

Frank,L.D.,Saelens,B.E.,Powell,K.E.&Chapman,J.E.(2007).194

Steppingtowardscausation:dobuiltenvironmentsorneighborhoodandtravelpreferencesexplainphysicalactivity,driving,andobesity?Social Science and Medicine, 65(9):1898-914.

Endnotes 61



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Endnotes 63


Steinbach,R.,Wilkinson,P.,Edwards,P.,Grundy,C.TheCongestion263

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Department for Transport (2009) 264 Interim Evaluation of the Implementation of 20 mph Speed Limits in Portsmouth http://tiny.cc/oqaLf

Biddulph, M. (2001). 265 Home Zones: A Planning and Design Handbook. Bristol:PolicyPress.

CyclingEngland.(2008).266 Planning for Cycling.http://tiny.cc/XuiHU

EuropeanParliament.(2007).267 Compensation of victims of cross-border road traffic accidents in the EU: Assessment of selected options. http://tiny.cc/mXWpn

Sloman,L.(2006).CarSick–268 Solutions for our car addicted culture. Devon,England:GreenBooksLtd.

SustainableDevelopmentCommission(2004).269 Progress in Practice: Addenbrooke’s Hospital Travel Plan.http://tiny.cc/o1qxo

Sustrans(2009). 270 Take Action on Active Travel.http://tiny.cc/BF6wg

Department for Transport (2009). 271 Call for comments on revision of DfT’s speed limit cicular.

PlayEngland(2008)PlaydaySurvey272


environmentonhealthinequalities:anobservationalpopulationstudy. The Lancet,372:1655-1660.

CentersforDiseaseControlandPrevention(2008).274 Healthy Places Terminology.http://tiny.cc/8qhj5


SustainableDevelopmentCommission(2008).276 Health Place and Nature: How outdoor environments influence health and wellbeing: a knowledge base.

Bird,W.(2004).277 Natural Fit: Can green space and biodiversity increase levels of physical activity?http://tiny.cc/GBYCr

Bird,W.(2007).278 Natural thinking.RSPB.http://tiny.cc/8X27v


Newton,J.(2007).280 Wellbeing and the natural environment: A brief overview of the evidence.http://tiny.cc/9HMnh

Croucher,K.,Myers,L.&Bretherton,J.(2007).281 The links between greenspace and health: a critical literature review,UniversityofYork.

GreenspaceScotland(2008).Greenspaceandqualityoflife:acritical282

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Pretty,R.(2007).283 The Earth Only Endures.London:Earthscan.

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Naturalenvironments–healthyrelationships?Anexploratoryanalysisoftherelationshipbetweengreenspaceandhealth.Environment and planning A 35,1717-1731.

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attention in the inner city. Environment and Behaviour, 33:5-33.

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Bird,W.(2004).299 Natural Fit: Can green space and biodiversity increase levels of physical activity? http://tiny.cc/GBYCr

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HealthCounciloftheNetherlandsandDutchAdvisoryCouncilfor301

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Ellaway,A.,Macintyre,S.,Xavier,B.(2005).Graffiti,greeneryand302

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Giles-Corti,B.,etal.(2005).Increasingwalking:howimportantis304

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(2007).GreenexerciseintheUKCountryside:EffectsonHealthandPhysiologicalWellbeing,andImplicationsforPolicyandPlanning.Journal of Environmental Planning and Management, 50(2), 211-231.

Mind(2007).307 Ecotherapy: The green agenda for mental health. http://tiny.cc/KryDO

TheMentalHealthFoundation(1997).308 Knowing Our Own Minds: A survey of how people in emotional distress take control of their lives. London:TheMentalHealthFoundation.

The Mental Health Foundation (2000). 309 Strategies for Living: A Report Of User-Led Research Into People’s Strategies For Living With Mental Distress.London:TheMentalHealthFoundation.

Abbottetal.(2004).Walkinganddementiainphysicallycapable310

elderly men. Journal of the American Medical Association, 292: 1447-1453.

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TheMentalHealthFoundation(1997).312 Knowing Our Own Minds: A survey of how people in emotional distress take control of their lives. London:TheMentalHealthFoundation.

Pretty,J.,Peacock,J.,Sellens,M.&Griffin,M.(2005).Thementaland313

physicalhealthoutcomesofgreenexercise.International Journal of Environmental Health Research, 15(5):319-337.

Ibid.314

Bodin,M.&Hartig,T.(2003).Doestheoutdoorenvironmentmatter315

forpsychologicalrestorationgainedthroughrunning?Psychology of Sport and Exercise, 4:141-153.

BTCV(2008).316 BTCV Green Gym national evaluation report: Summary of findings 2008.http://tiny.cc/X89Vh

Mind.(2007).317 Ecotherapy: the green agenda for mental health. http://tiny.cc/KryDO

Ibid. 318

Gimeno,D.,Brunner,E.J.,Lowe,G.D.,Rumley,A.,Marmot,M.G.&319

Ferrie,J.E.(2007).AdultSocioeconomicposition,C-reactiveproteinandinterlukin6intheWhitehallIIprospectivestudy.European Journal of Epidemiology, 22:675-683.

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Freeman,D.J.,Norrie,J.,Caslake,M.J.,Gaw,A.,Ford,I.,Lowe,G.D.,321

O’Reilly,D.S.,Packard,C.J.&Sattar,N.(2002).WestofScotlandCoronaryPreventionStudy.C-reactiveproteinisanindependentpredictorofriskforthedevelopmentofdiabetesintheWestofScotlandCoronaryPreventionStudy. Diabetes, 51(5):1596-600.

Ellaway,A.,Macintyre,S.,Xavier,B.(2005).Graffiti,greeneryand322




Kuo,F.E.,Sullivan,W.C.,Coley,R.L.&Brunson,L.(1998).Fertileground324

forcommunity:Inner-cityneighbourhoodcommonspaces. American Journal of Community Psychology, 26:825-851.

Lewis,C.A.(1996).325 Green Nature/Human Nature: The Meaning of Plants in our Lives.Chicago:UniversityofIllinoisPress.

DepartmentforChildren,SchoolsandFamilies(2007).326 The Children’s Plan: Building brighter futures.Norwich,UK:TheStationaryOffice.

PlayEngland(2007).327 Play day 2007: Our Streets Too! Street Play Opinion Poll Summary.ICM.

Mental Health Foundation (1999). 328 Brighter Futures: Promoting Children and Young Peoples Mental Health.

AuditCommission,TheHealthcareCommission&TheNational329

AuditOffice(2006).Tackling Child Obesity – First Steps.London:TheStationaryOffice.

Wells,N.,&Evans,G.(2003).NearbyNature;Abufferoflifestress330

amongRuralChildren.Environment and Behaviour, 35(3), 311-330.

Faber,T.A.,Kuo,F.,&Sullivan,W.(2001).CopingwithADD:The331

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Faber,T.A.,Kuo,F.,&Sullivan,W.(2002).Viewsofnatureandself-332

discipline:evidencefrominner-citychildren.Journal of Environmental Psychology, 22:49-64.

Kellert,S.(2002).Experiencingnature:affective,cognitive,and333

evaluative development in children. In Children and Nature: Psychological, socio-cultural and Evolutionary Investigations. Boston, UnitedStates:MITPress.

Lester,S.&Maudsley,M.(2006).334 Play Naturally: A Review of Children’s Natural Play.CommissionedbytheChildren’sPlayCouncil.London:NationalChildren’sBureau.


Fjortoft,I.(2004).LandscapeasPlayscape:theeffectsofnatural336

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Ibid.337

Maan,N.(2005).338 The delivery of environmental play projects by the Better Play Funded Organisations.Barnardos,Briefing4,2005.http://tiny.cc/jQQoq

SustainableDevelopmentCommission(2007).339 Every Child’s Future Matters.http://tiny.cc/i6Fxz

Endnotes 65



Coley,R.L.,Kuo,F.E.&Sullivan,W.C.(1997).Wheredoescommunity341

grow?ThesocialcontextcreatedbynatureinUrbanPublicHousing.Environment and Behavior, 29(4):468-494.

Sullivan,W.C.,Kuo,F.E.&Depooter,S.F.(2004).TheFruitofUrban342

Nature:VitalNeighborhoodSpace.Environment and Behaviour, 36(5):678-700.


(2007).GreenexerciseintheUKCountryside:EffectsonHealthandPhysiologicalWellbeing,andImplicationsforPolicyandPlanning.Journal of Environmental Planning and Management, 50(2):211-231.

Sullivan,W.C.,Kuo,F.E.&Depooter,S.F.(2004).TheFruitofUrban344

Nature:VitalNeighborhoodSpace.Environment and Behaviour, 36(5):678-700.


Kuo,F.E.&Sullivan,W.C.(2001).EnvironmentandCrimeintheInner346

City:DoesVegetationReduceCrime?Environment and Behaviour; 33(3):343-367.

Kuo,F.E.,Sullivan,W.C.,Coley,R.L.&Brunsn,L.(1998).Fertileground347

forcommunity:Inner-cityneighbourhoodcommonspaces.American Journal of Community Psychology, 26:825-851.

Lewis,C.A.(1996).348 Green Nature/Human Nature: The Meaning of Plants in our Lives.Chicago:UniversityofIllinoisPress.

Maller,C.,Townsend,M.,Pryor,A.,Brown,P.&StLegerL.(2006).349

Healthynaturepeople:‘contactwithnature’asanupstreamhealth promotion intervention for populations. Health Promotion International, 21:45-54.

Austin,M.(2002).Partnershipopportunitiesinneighbourhood350

treeplantinginitiatives:buildingfromlocalknowledge.Journal of Arboriculture, 28:178-186.

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GreenInfrastructure.Built Environment, 33:1115-133.


environmentonhealthinequalities:anobservationalpopulationstudy. The Lancet, 372:1655-1660.

MaasJetal.(2006).Greenspace,urbanity,andhealth:howstrong358

is the relation? Journal of Epidemiology and Community Health, 60, 587-592.



BTCV(2008).360 BTCV Green Gym national evaluation report: Summary of findings 2008.http://tiny.cc/X89Vh

Mental Health Foundation (2009). 361 Mental health, resilience and inequalities.http://tiny.cc/Bxp5x

SustainableDevelopmentCommission(2007).362 Healthy Futures #6: The natural environment, health and wellbeing.

SustainableDevelopmentCommission(2009).363 Breakthroughs for the 21st century.


DepartmentforChildren,SchoolsandFamilies&DepartmentofHealth365

(2009). Healthy Lives: Brighter Futures: The Strategy for Children and Young People’s Health.London:COI.http://tiny.cc/Knv0l


HMTreasury(2006).367 Stern Review on the Economics of Climate Change.London:HMTreasury.

SustainableDevelopmentCommission.(2006).368 “Stock take”: delivering improvements in existing housing - UK.London:SustainableDevelopmentCommission.

GermanEnergyAgency(DeutscheEnergie-Agentur)(n.d.). 369

www.dena.de



Boardman, B. (1991), 372 Fuel poverty: from cold homes to affordable warmth. Belhaven Press, London.

SustainableDevelopmentCommission(2009).373 Breakthroughs for the 21st century,page7.



Gilbertson,J.,Green,G.,&Ormandy,D.(2006).376 Decent Homes Better Health - Sheffield Decent Homes Health Impact Assessment.Sheffield:SheffieldHallamUniversity.


TheInstituteofPublicHealthinIreland(2006).378 Health Impacts of the Built Environment: A review.

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Poortinga,W.(2006).Perceptionsoftheenvironment,physical385

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Gordon-Larsen,P.,Nelson,M.,Page,P.,&Popkin,B.(2006).Inequality389

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