Healthy places: the link between your health and where you live

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  • Posted:Thursday 06 September 2018

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What’s the relationship between your health and where you live? How do we make places healthier? Helen McKenna talks with Kate Ardern, Director of Public Health at Wigan Council, André Pinto, Public Health Manager from Public Health England and Chris Naylor, Senior Fellow from The King's Fund.

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  • HM: Helen McKenna
  • KA: Kate Ardern
  • AP: André Pinto
  • CN: Chris Naylor

HM:     Hello, and welcome to the King’s Fund Podcast, where we talk about the big issues and ideas in health and care. I’m Helen McKenna and I’m a senior policy advisor here at the Fund, and I’m going to be your host for the next little while. And today we’re going to be talking about the role of place in health, about the relationship between where we live and our health, and why we should all be thinking about how to make places healthier. And I’m joined by three expert guests today that know all about this topic. So we’ve got Professor Kate Ardern, Andre Pinto, and Chris Naylor, and rather than me introduce you, I’m going to ask you each to introduce yourselves. And when you introduce yourselves, continuing the theme of healthy places, could you tell us where you live and what is the unhealthiest thing about it as a place? Let’s start with Kate.

KA:    Hello, I’m Kate Ardern. I’m the Director of Public Health for Wigan borough. That is the second biggest borough in Greater Manchester. I’m also working on Greater Manchester devolution, and I lead on the themes of drugs and alcohol and health protection reform as well. And part of my role in Wigan is looking after leisure services, and I’m also the Chief Emergency Planning Officer, so quite a wide brief.

HM:    Mm, massive.

KA:    I live in Liverpool, and you asked a question about what’s the most unhealthy part of the place, and I think I’m going to say this about both where I work and where I live, and that is the inequality between the richest and poorest in society in both boroughs.

HM:    Thank you, that’s really helpful. Andre, tell us a bit about who you are and where you live, and what’s unhealthy about it.

AP:    Sure. My name is Andre Pinto. I am a qualified planner, and I have been working on special planning and health issues for nearly ten years. I am originally from Portugal, so I have lived in Lisbon, and I have been living in London for the last 15 years. I think that one of the most unhealthy things that perhaps I notice in London is actually air pollution and the issues around air pollution, and how they affect you without you even realising that you’re being affected by it. And compared to Lisbon, for example, which is a city that is built on top of seven hills, it always surprises me how everyone is much more physically active in London, walking around, cycling, jogging than we are in Lisbon. So we have both good and not so great things that we need to improve on.

HM:    Thank you Andre. And Chris?

CN:    So my name’s Chris Naylor. I work here at the King’s Fund. I’m a senior fellow in health policy. I’m also a London resident. I live in Southwark in the south of London, and I guess I would echo the things that Andre and Kate have both said already in that health inequality is very much an issue in Southwark. We have great extremes of wealth and health, and also in terms of the public health issues that I think are at the top of public consciousness among people in Southwark, air quality is probably top of the list at the moment, partly because of the media attention that’s been given to it. There are some very big roads through the borough, and also some quieter leafier spaces as well, but it’s certainly something that I think people worry about.

HM:    Fantastic. So I’d like to start with some definitions just to make some of this stuff a bit clearer. What do we mean by healthy places, Chris?

CN:    Okay, well, I think there’s two parts to that. The first is that we are increasingly recognising that we need to be thinking not just about the people who are using health services in the here and now but also about the whole population, and that involves thinking about people who might be using health services in future and taking steps to avert that as much as possible. And then the second thing is that, as part of that, recognising that the places we live in, the communities we’re part of, the environments we’re surrounded by, the economies we participate in, all of these things have a really profound impact on our health and wellbeing. And so a place-based approach to health, very simply put, is one in which all of the different organisations and people who are responsible for all of those different aspects of our lives work together with local people to try and improve the health of the place.

HM:    And Kate, you’re actually doing some of this stuff yourself right now, so both in Wigan but also as part of the Greater Manchester devolution project. What are the things that you’re considering in terms of wider services?

KA:    Well, I always look at what makes a place healthy in terms of how humans interact with the place itself and with each other. A healthy place for me is where I feel safe, I feel welcome, I feel loved. And I think I start, when I think about services, I’m looking at the assets of the people of the place, its history, its culture, its passions, its enthusiasms. So as well as considering the factors like the built environment, which are incredibly important in terms of influencing behaviour, the history of a place – and I work in a very proud former mining community, but a community now that celebrates mining as part of its past history, they have moved forward into the future, which is coalmining was the past, datamining is the future. So I think it’s very important to think about, as well as the science bits of a healthy place, to think about the arts and humanities part of a healthy place, and part of my job is to engage as many citizens as possible in the process of determining both the needs and the assets of public health in a place. So the sense of place is made by the people who live in that place.

HM:    Fantastic. And who are all the different players involved when you’re doing this work?

KA:    Okay. I think it’s a wide range of partnerships, and if I think about our partners across both Wigan and Greater Manchester, we’re engaging very much with, for example, our sports clubs. So for example, I have Wigan Athletic and Wigan Warriors, two of our major professional teams, actually running our men’s weight management service, so really de-medicalising weight management but tapping into the passion within Wigan for sport, making health fun for people. But likewise, if I’m looking at broader more complex problems, and perhaps folks who interact with many different parts of the public sector, then within our multiagency safeguarding hub we’re involving the police, fire service, ambulance, housing, all the leisure services that I offer, plus faith networks as well. Within the borough we have two institutional anchor points: schools and GPs, so the places that people feel safe and feel permission to access, really important, and wrapping services around those two universal access points, so that’s a wide variety of both public services but also involving our businesses and those bigger voluntary sector agencies, like Age UK for example, with actually smaller groups as well that we work with, like Tenants Associations.

HM:    So it sounds like what you’re saying, Kate, is this work goes way beyond just the NHS and local authorities. I’m quite interested, Andre, in your background, because you’ve come from being a planner and now you work in Public Health England. I just want to know, what was it that you saw in your previous work as a planner that made you think, “I want to go and apply these skills to health”?

AP:    In my work as a planner, I worked for the private sector and then I worked for several different local authorities across England and the UK, and I had a desire to actually stop dedicating so much of my time actually writing policies, doing all of the consultation processes, community engagement and so on, so forth, which has a very long timeline, and actually use those skills and those expertise in order to influence what gets built on a day to day basis. And I thought that health was a very interesting issue because I think that a lot of planners understand health, understand what determines health, understand what needs to be done, but they don’t call it health, and they don’t call it health or wellbeing. They just call it infrastructure, transport, active travel, green spaces, green grid, blue spaces, how we integrate all of this, protection of the green belt, quality housing, pushing the standards forward, developing at a proper density. So those are all issues that planners debate on a day-to-day basis and have to actually use the concept of when they make every single decision that they have to do. They just don’t label it as health, but that is crucial for health and that is crucial for wellbeing.

HM:    Thank you. Chris, given your expertise in mental health, I think it would also be helpful if you could add some colour to this in terms of talking us through how a place-based approach to mental health could improve the quality of care and outcomes for patients in a way that the NHS alone dealing with this stuff might not be able to.

CN:    Okay. Well, I guess the first thing I’d say is that we have just over 50 Mental Health Trusts in England, all of which cover a very large population and often a very large geography as well. So what they often do with some of their services is to subdivide into local teams, and the question that I would ask is do those locality teams have the power to shape their own destiny? Do they have the latitude to engage creatively with local people and with local voluntary sector organisations? Because if they do, if they can work with local assets in that way then we have the ingredients for a place-based approach already, but if they don’t then there’s a potential problem there. So in practical terms, I think if we had a place-based approach to mental health, what we would see more of is we’d be seeing more partnership working between the NHS and voluntary sector organisations. We would see mental health experts working very, very closely with schools and with local businesses on the workplace wellbeing agenda, and I think we’d see a sense that all of those local partners are working collectively together with local people to try and improve the mental health and wellbeing of the population. And we do see that, we do see that in many parts of the country. There’s places like the Lambeth Living Well Collaborative, which is an example of where they’re taking that place-based partnership approach towards the population’s mental health and wellbeing. So we already have some good things to build on and it’s about taking those a step further.

HM:    And Kate, you’re part of the Greater Manchester devolution deal and I’m just interested in how important the powers that devolution has given you are to doing this place based working.

KA:    I think they’re very important, Helen. I think Greater Manchester’s unique in some ways because of course we’ve got health and social care devolution, which not every devolution programme has, and I think that has really engendered a very different conversation about health and social care, because we see across the Taking Charge document, which is the Greater Manchester health and social care devolution plan, that population health is the number one programme within that, alongside integrated care. And I think that’s produced some really interesting developments because in a lot of cases we’re seeing local care or integrated care organisations in boroughs now being commissioned jointly by councils and CCGs with council chief execs taking on the role of clinical commissioning group accountable officers, and that therefore brings together a more public service transformation approach to commissioning of wellbeing health and social care. It’s allowed a bit more freedom and flexibility to the way we look at things, and it also means that we’re connecting up with the broader devolution programme, particularly on economy and skills, very, very importantly recognising that an educated population is a productive population.

HM:    And I assume, Andre, you would say that it’s not essential to have devolved powers in order to be taking a place based approach to health.

AP:    So I would encourage everyone that is working in this field, looking at health and place and social care, to look at what can be done within the existing envelope and the existing powers that they have. I think that when we look across the country, I think that the picture is very mixed, so I think that some local authorities in the country are doing really well within the constraints that we have of national regulations, but obviously devolution does allow and does permit a local control of those sort of issues. And because that conversation is a local conversation, it’s much easier to actually pin down what the priorities are, what is really key for that area, where we can achieve the highest gain, and that I think is really crucial.

HM:    And Chris, I think you have something to say about that.

CN:    Yeah, to follow on from that, something we’ve seen in some of our research where we’ve been talking to people working in systems that have a devolution deal, it’s that actually sometimes the process of putting the deal together itself can be quite catalytic. It can help get things moving significantly, and there’s a sense that some of the systems that have been through that process, afterwards there’s a greater sense of self-confidence as a system and a higher level of ambition. So it certainly seems to be that devolution can be a catalyst but I don’t think it’s necessarily one of the essential ingredients. I think it’s perfectly possible to take a place-based approach in any part of the country.

HM:    So Chris, I know you’ve done some work recently on the role of cities in health. In terms of what you’ve seen in your research and what the essential ingredients are to making this stuff work – and I know this will be in the context of cities, but what are the key things you’d pull out?

CN:    I think it’s some of the things that we’ve already touched on about coming together as a system and having a unified vision. So lots of people at the moment are looking at the work that Amsterdam have done on obesity, and for my part, my take on what they’ve done there is that it’s not about the specific interventions that they’ve applied to try and reduce childhood obesity. It’s more about the fact that those interventions have been applied within a coherent framework that all of the city is united around and that’s held together by good project management at the centre. So that kind of overall framework I think is really important.

HM:    And Andre and Kate, any additional thoughts on what are the key things to making this work?

KA:    I think it’s about having excellent relationships between the various partners in the city, and I think one of the reasons Greater Manchester works is all ten boroughs have the same power, so they’re equal. And despite Manchester and Salford both being cities and the other boroughs being towns and of different sizes, everybody, every borough is equally important. So I think that for me is really important, to get the power balance right.

HM:    And Andre?

AP:    I think that with my planning hat on, I think it’s also crucial for us to actually understand key points within the planning system where you can really make a difference, and that is as early as possible within the design stage. The outcomes will only be felt 15 years down the line, 20 years down the line perhaps. Nevertheless, the decisions that you are making now at this point in time are crucial to influence the outcome. If, for example, we look at the big regeneration projects that we have had in the UK, so for example King’s Cross and the Olympic Park, they work from a health and wellbeing perspective, and some of the proposals from a placemaking perspective are really innovative in terms of community places, trying to make people as active as possible, open spaces, a sense of security and community, which is embedded within the placemaking, those decisions to build that were done probably five, six, seven years before the first brick was laid down. So I think that it is really important as well.

HM:    And Chris, I know you’ve been doing some work looking at NHS England’s Healthy New Towns programme. Is that programme doing some of this place-based stuff?

CN:    I think it is, yeah. I think there are so many opportunities for gaining synergies, added value when you’re working on multiple fronts at the same time, and that’s something that’s really come through in the Healthy New Towns programme. So we’ve been looking at the ten demonstrator sites across England, and these are places where they’re building a new community. So they’re new places, there’s a lot of building work being done. At the same time, they’re also developing new health services and trying to build a new community, and the added value that you get when you do all of those things at the same time. So if I give an example, in Bicester they’ve been developing a series of health routes, which are five kilometre routes for walkers and runners to use around the town. And at the same time as putting in place that kind of built infrastructure, they’ve also been doing work with the local community, so community development work, trying to get local champions in the population to promote the use of these health routes and come up with creative ways of using them. There is work going on, on the NHS side, that’s about redesigning the care for people with diabetes, and they’ve been trying to use these health routes as part of that new approach to diabetes, so people are trying to keep physically active as much as possible. And there’s work going on with GPs on things like social prescribing, so that people can be referred to exercise groups and walking groups and those sorts of things. And what I think is the beauty of a place-based approach is that if you’re able to make the connections between all of those different things that you can do in different parts of the system, then I think the whole really can be much greater than the sum of the parts.

HM:    Beyond the Healthy New Towns initiative, I have a question about how seriously the NHS takes this approach. I think when I look at sustainability and transformation partnerships and the plans that were originally published, there was a lot on integrating, joining up health and social care services and a lot on reducing delayed transfers of care, for example. And then there were a few examples bringing in education, focusing on early years services but not a lot on the wider determinants of health? So Andre and Kate, what’s your take on how serious the NHS is about looking at the wider determinants of health and trying to stop this stuff from getting further downstream?

AP:    I think that, for example, the Healthy New Towns and the fact that NHS has decided to create this programme looking at place-based approaches and how places can be utilised in order to reduce the costs to the NHS of care but also promote prevention and from people getting ill in the first place, I think that that is a clear sign that the NHS is starting to actually recognise as an organisation the importance of this agenda. I think that there is a greater sense that the NHS really does need to look at prevention and needs to look at wider determinants of health in a slightly different way than perhaps we have in the past, in order to really solve some of the problems that we are debating with at the moment. So we all know that the rates of obesity are going through the roof and they will cripple totally the NHS if we do not do something quite drastic to actually minimise their impact. Air pollution, which I mentioned before as well, you know, it’s another major issue that will have extreme significant impacts and the financial burden for the NHS will be huge if something is not done, and I think that there is starting to be a recognition of that.

CN:    I think that’s true and I think it’s really encouraging that NHS England is starting to think about the importance of place through things like the Healthy New Towns programme. I think for people working in the system though, there can still be a very real tension between looking out and looking up. Name me a hospital chief executive who has been sacked for not engaging sufficiently well with local voluntary sector organisations, whereas we can name people who have lost their jobs for not meeting national must-do targets. So, you know, there’s still that tension in the system, I think. I don’t know if that’s how you experience it, Kate.

KA:    I think it’s very interesting. I welcome the New Towns move by NHS England. I think that’s very helpful, but it is a drop in the ocean. I think the NHS needs to get real about engaging with Derek Wanless’ recommendations, which are just as pertinent today as they were when he made them in the early 2000s. He said that the NHS was only sustainable in the long-term future as a publicly funded system if it took seriously prevention.

HM:    Kate, I have a specific question for you, which is just about if you were the Prime Minister and you wanted to improve health outcomes as opposed to health services, would you have put the money into the NHS, as the Prime Minister recently did in her announcement?

KA:    No, I would have put it into local government and into transforming the NHS into a population health system. So unfortunately, I think what we tend to do is to put money into doing the same old thing in the same old way, and we get the same old result. In other words, you know, we’re putting lots of money into acute and managing people in acute situations when actually investing upstream – and we’ve seen this locally by shifting investment to prevention in the borough – and I should point out that Wigan as a borough had the third biggest cut to its revenue grant of any borough in the UK, so if we can do it, you can do it. We have one of the few, if not the only, balanced adult social care budgets in the country because we shifted to a prevention model. So, I would want to put money into actually investing in things which are going to take demand out of the system. I’d like to see that invested in housing, in the determinants of health and through local government. And yes, of course the NHS clearly needs some investment, no one’s denying that, but it needs to be in the primary care end and in mental health, where again you’ve got much more opportunity for prevention and early intervention.

HM:    Really interesting, thank you. So final question, and this one is for each of you to answer in a sentence, if you were to start from scratch and you were asked to create the perfect healthy place, so this is a utopian vision of a healthy place, what would be the first thing you would look at?

CN:    So, it has to be about the people of that place and the communities that exist there and putting the power to improve health in the hands of those communities.

HM:    Thank you Chris.

KA:    I’d be looking at whether there is hope, whether there is confidence or whether there’s despair. So, looking at how does the place feel? Do people have civic pride?

AP:    I think that probably I would start looking at barriers and opportunities for placemaking and how you can improve what is there and what is needed to meet the needs of the community.

HM:    Thank you very much. So, thanks to all our contributors today. That’s Chris Naylor, Kate Ardern and Andre Pinto. It’s been a really interesting conversation around place and health, and how we get that right. That’s it from us. Thank you for listening. Please subscribe, rate and review us on iTunes, and if you have feedback or ideas for topics you’d like to hear covered in future episodes, then please get in touch either on Twitter @thekingsfund, or my account @helenamacarena, or you can leave feedback on our website. I hope you can join us next time. Thank you.


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