The re-integration of health in urban development policymaking is still needed to shift from curative to preventative policies

Housing and urban environments are critical to public health. Poor conditions worsen inequalities, while healthier spaces prevent disease. The COVID-19 pandemic highlighted the need for transformative change in urban development policy, but progress has been stalled by political resistance and focus on housing quantity over quality. To support the shift from treatment to prevention, health must be re-integrated into urban planning and development policies.

Professor Nick Pearce is Director of the Institute for Policy Research (IPR) and Professor of Public Policy at the University of Bath. Dr Geoff Bates is a Lecturer in the IPR. Recently they were co-authors for two new papers – ‘Why didn’t the ‘critical juncture’ of the COVID-19 pandemic lead to the re-integration of public health into urban development policy in England?’ with Prof Sarah Ayres and Dr Andrew Barnfield, and ‘Are we any closer to tackling health inequalities in England?’ With Prof Sarah Ayres, Dr Jack Newman, Dr Anna Le Gouais and Dr Rachael McClatchey.

 

In the pantheons of Labour history, Nye Bevan is remembered as the architect of the NHS. It is sometimes forgotten that as Minister for Health in the post-war Attlee governments, Bevan was also responsible for housing. Conservative wags would joke that Labour only had ‘Half a Nye on Housing’ and that his overburdened policy portfolio meant that the Labour government failed to give housing the full attention it needed. But the coupling of housing and health in his Ministerial portfolio was a recognition, typical of policymaking for much of the 20th century, that poor public health and inequalities in health and life expectancy were a result of housing conditions. Bevan set out, not just to build council houses and offer them to the whole community, but to improve housing standards to improve the nation’s health.

A similar focus on housing and urban development is needed in health policy today. The Labour government has recently announced its plans to reduce NHS waiting times from 18 months to 18 weeks for 92% of patients. Understandably, given the significant deterioration in waiting times and the growth of waiting lists over the last decade, policy is focused on the acute sector.  But the government is also committed to preventing poor health, and to achieve its objective of shifting from treatment to prevention – an objective claimed by successive governments – requires a renewed focus on building healthier places to live. There is now a significant body of evidence which shows, not just that poor housing conditions impair physical and mental health, but that urban environments more broadly are critical determinants of health outcomes.

Poverty and deprivation are concentrated in cities and so action to tackle the social determinants of health is a necessary part of any health prevention strategy. Beyond this broad focus on the reduction of poverty and inequality, however, there are distinct challenges for improving public health in cities and urban environments. In his latest annual report the government’s Chief Medical Officer, Chris Whitty, sets out four of these:

• Healthy food deserts combine with junk food advertising to set children and adults up to live a shorter and unhealthier life through obesity and the diseases it causes, particularly in the more deprived areas of our cities.
• Air pollution is a particular risk in cities where the greatest levels of pollution are combined with the highest concentrations of people. It causes significant lung and cardiovascular disease.
• The health needs of young adults are concentrated in cities and are often overlooked. Mental health issues generally emerge by or in early adulthood, and current increases in mental health needs for already stretched mental health services therefore fall disproportionately in cities.
• The relatively poor, and falling, rates of routine immunisation and screening in our cities deprive their citizens of effective tools which could prevent major diseases. This needs action.

Now that the government is committed to building New Towns and large-scale housing developments there is an opportunity to tackle Whitty’s challenges, and to reduce the long-term burden on the NHS by building places that make people healthier and protect us against future outbreaks of disease. Yet our new research looking at whether health has been re-integrated into urban development policymaking following the Covid pandemic demonstrates that the opportunity to deliver healthy places to live in remains vulnerable to political and ideological countervailing forces.

For obvious reasons, the Covid pandemic sparked renewed debate about how health objectives should be secured in urban development decision-making. The pandemic demanded new approaches to urban design to minimise the spread of the Covid virus. But despite measures to encourage walking, cycling and outdoor recreation, and to secure social distancing, the pandemic did not prove a ‘critical juncture’ in which lasting change was achieved in urban policy, as arguably it was in respect in areas such as remote working and vaccine development. Our research with civil servants and policy specialists found that there was resistance to change, much of which was ideological: the previous Conservative government was largely hostile to increased regulation of either the urban environment or the commercial drivers of unhealthy consumption. Public health was also subordinated in policy discourses to the imperatives of economic growth and housing supply, instead of integrated into the planning and delivery of regeneration, new housing and urban development.

There are recent positive signs that health now has a higher profile than previously in urban development policy. Recent revisions to the National Planning Policy Framework require planning to

‘…enable and support healthy lives, through both promoting good health and preventing ill-health, especially where this would address identified local health and well-being needs and reduce health inequalities between the most and least deprived communities – for example through the provision of safe and accessible green infrastructure, sports facilities, local shops, access to healthier food, allotments and layouts that encourage walking and cycling.’

Think-tanks and campaigning bodies are also advocating for investing in health prevention and place-based programmes for building healthy communities, while officials also demonstrate a new appetite for incorporating health evidence into planning and appraisal tools. Moreover, increasing housing supply can itself improve health outcomes, by tackling overcrowding, improving housing conditions, and reducing poverty after housing costs.

Nonetheless, the opportunity for creating new towns and housing developments that prioritise public health and revolutionise urban design for the 21st century is at risk from pressures simply to prioritise quantity over quality for new housebuilding, and for the narrow commercial interests of housing developers to predominate in meeting housing supply targets. In heath, the acute sector is likely to continue to take priority over public health and health prevention, as historically it has always done – making it harder to shift from curative to preventative.

The Attlee governments built one million new homes, over 800,000 of which were council homes. In 1951, housing was taken out of the Ministry of Health and given to a new Housing and Local Government department. But the insistence on high standards of housing and the umbilical link between housing and health remained a feature of policy until the late 1970s. As Bevan once said, “We shall be judged for a year or two by the number of houses we build. We shall be judged in ten years’ time by the type of houses we build”. Policymakers venerating his legacy would do well to remember this.

This blog was first published by the University of Bath Institute for Policy Research

All articles posted on this blog give the views of the author(s), and not the position of the IPR, nor of the University of Bath.