Devolving health and social care in England: an opportunity to transform how we approach health and care?

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In recent years, the Department of Health and Social Care (DHSC) has increasingly encouraged the transfer of powers over health and social care in England away from central government and towards city regions. These bodies, DHSC argues, are uniquely placed to understand the challenges faced by their local populations, the capacities and expertise of their local NHS and to develop plans for the future. This should enable them to approach health at a local level, promoting increased delivery of care in the community, and a greater integration between health and care services.

Putting local places at the centre of “Build back better”

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, like taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

The NHS Long Term Plan has also outlined a new direction for the NHS based on the principle of collaboration rather than competition, and the introduction of new structures such as Integrated Care Systems, Integrated Care Providers and Primary Care Networks. These partnerships bring health and social care commissioners together to plan and deliver integrated and person-centred care.

In the context of “building back better”, awareness of how our external experiences and contexts impact our health and wellbeing (for example the impact of poverty, deprivation, housing, and unemployment) is increasingly important.

Beyond the immediate recovery from the pandemic, health devolution could be one way of opening up the possibility of integrating not just disparate services within the NHS – or even NHS and social care services in a locality – but bringing together in a combined strategy and structure all of the services, systems and partners in a community that have an impact upon the health of a local population, and the care services to better meet their health needs.

“It doesn’t have to be a battle”- partnerships and balance are the key to effective devolution

The move away from centralised processes and organisations towards more local ones can sometimes be portrayed as a rejection or an attempt to “break free” from central government. However, practitioners have been increasingly stressing that devolution does not mean complete independence, and that while improved local decision making will improve outcomes for local people, that does not mean that the need for some centralised decision making is completely removed.

On the contrary, some decisions should and will be taken at a national level, but the ability to distribute power, decision making and accountability to a local level will have significant positive impacts for improving “citizen voice”, transparency and co-production in decision making.

This is where the Health Devolution Commission argues that balance, communication, and partnership between the local and national infrastructure needs to be aligned so that devolution can be successful and sustainable. Integrated planning and management of long-term health care strategies is important, as is the ability to bring citizens and local decision makers into discussions about national health policy.

The Voluntary, Community and Social Enterprise (VCSE) sector, including patient voice and carers organisations, also plays an important role in linking together services and communities. As well as partnering to deliver services, these organisations also often offer vital bridges between statutory systems and those communities which can often be excluded from engagement with services or who can find it harder to access them. The commission also emphasised the importance of bringing these bodies into the conversation on devolution going forwards as they will be invaluable partners in the process.

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DevoManc providing the blueprint?

In 2016, as part of a pilot, control of the health and social care budget for Greater Manchester was transferred to a partnership team in the area comprising local authorities, clinical commissioning groups, NHS foundation trusts and NHS England.

The combined authority identified that the health of its population was one of the key obstacles to its economic growth. By relating the concept of regional economic prosperity with health, they began to see health in a completely different way – as part of a wider plan and an investment for growth, not a burden.

“It’s better to have decisions made locally, because local people understand what local problems are and what Greater Manchester needs. We need to work together.”

Lord Peter Smith, Chair of Greater Manchester Health and Care Board

The Greater Manchester Health and Social Care Partnership are working in partnership with other sectors including education and housing to support everything from good eating habits and exercise to education and everyone’s ability to earn a decent living. The partnership is taking action to give children the start they need, support independence in old age, tackle illness earlier on and even prevent it altogether by improving the lifestyles of local people.

Other areas of England are also currently undertaking their own health devolution journeys, including London, West Yorkshire and Harrogate, as well as some other combined authority areas. However, one of the big challenges is that currently, while we can learn from the experiences of those already on their devolution journey, there is no common, consistent or comprehensive understanding of what good heath devolution looks like, full evaluations of the benefits it brings or overarching strategies on how it should be developed.

This is something that will need to be addressed if health devolution is to be successfully rolled out across England.

Final thoughts

Devolution of health to a more local level provides an opportunity to tackle the big public health challenges of our time at source, and to create a better, more joined up community health ecosystem. It also provides the chance to share and collaborate, learning from best practice and delivering improved health and social care services at a regional and national level.

It has been suggested that the coronavirus pandemic, while traumatic in more ways than one for the NHS and its staff, may provide the re-setting point needed to implement some of the changes proposed in relation to greater health devolution. Proponents of this view argue that improved funding to support effective and high quality care, improved integration between health and social care, and greater positioning of health and assessment of the impact of decisions on health across all policy areas, should be among the top priorities as the country looks to recover from the pandemic.

As the Health Devolution Commission underlines:

The pandemic has shown we cannot go back to the way things were. We need a ‘new normal’ and we believe that comprehensive health devolution is the only viable solution to the challenges the country now faces.”


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“The infrastructure of everyday life” – has the time come for the foundational economy?

The last few years has seen growing interest in what has been termed the ‘foundational economy’ and its potential value for achieving economic security and social sustainability. Accounting for around 44% of UK employment, it has been argued that supporting this section of the economy could ultimately improve productivity. And the current pandemic has placed even more emphasis on the importance of the foundational economy – the part of the economy that cannot be shut down.

What is the foundational economy?

The foundational economy provides universal basic services built from the activities which provide the essential goods and services for everyday life, regardless of the social status of consumers. Primarily delivered locally, these goods and services encompass infrastructures, utilities, food, retailing and distribution, education, health and welfare. Because of this, it is thought to have considerable potential to regenerate the areas where the local economy is relatively weak – perhaps the perfect solution for the levelling up agenda?

The initial manifesto for the foundational economy from researchers at the University of Manchester resulted from dissatisfaction with generic industrial and regional policy focused on promoting competition and markets; with success measured in terms of job creation and GDP growth. According to the manifesto, the foundational economy is “the mundane production of everyday necessities” which is taken for granted by all members of the population. As such, it is often also referred to as the ‘sheltered’ or ‘invisible’ economy.

Scale and value

In providing the infrastructure for everyday life, the foundational economy is also very large. It has been noted that in all European countries, it directly employs around 40% of the workforce. In the UK, around 44% of the workforce is employed in foundational activities. In Germany, it is 41% and Italy it is 37%. The value of foundational output and volume and diversity of foundational employment is therefore much larger than in high-tech and tradeable services, with which policymakers are determinedly focused on.

Other measures of value have also been highlighted, such as household expenditure. The initial manifesto notes the importance of weekly spend on the foundational economy with nearly 30% of all household expenditure going on foundational activities.

Despite providing vital services, and employing a significant portion of the UK population, the foundational economy is marked by low-tech, low-wage, part time and often precarious employment and is potentially at risk from automation, despite the significant ‘human’ element to many of the different job roles which make up this part of the economy. Within society a lot of foundational jobs are still considered by many (often who don’t work in the sector) to be “jobs you move on from” where in reality, for many people, particularly women and migrant workers, this isn’t the case.

But where would we be without these roles providing for all citizens’ basic needs? Job creation and GDP growth may suggest a successful economy but this, it is argued, does not show the wellbeing of all society or sustainability. In the face of current, and indeed future, crises, it seems perceptions may be starting to change as more and more people become concerned with health and wellbeing and the environment. Indeed, it has long been argued that necessity is only recognised in times of crises.

Has Covid-19 shone a vital light on the foundational economy?

While many sectors were shut down due to the coronavirus pandemic, the foundational economy remained open as it was considered systemically important for meeting basic needs. The pandemic has highlighted that this part of the economy is needed at all times, including at times of crisis.

Healthcare staff have become frontline heroes and food delivery drivers are recognised as key workers. But this enhanced status has also highlighted the poor pay and conditions of many key workers delivering these essential goods and services and the inherent inequality that exists in society.

Just like other crises, from natural disasters to large scale economic shocks, these bear most heavily on the poor and vulnerable. The pandemic has shown that these inequalities must be addressed so that basic everyday services are more equally available.

The pandemic has also shown that economies are about more than market economies. It has been argued that there needs to be a move towards meeting a population’s basic needs rather than on individual consumption.

Way forward

Advocates of the foundational economy argue that public policy should focus on securing the supply of basic goods and services for all citizens in a socially responsible way.

The 2020 manifesto for the foundational economy from The Foundational Economy Collective argues for the renewal of the foundational economy with a ten-point programme, including proposals related to:

  • better health and care
  • housing and energy
  • food supply
  • social licensing
  • tax reform
  • disintermediation of investment from pension funds and insurance companies
  • shorter supply chains in foundational commodities
  • citizen engagement
  • better technical and administrative capacity at all levels of government
  • international constructive responsibility

It has been widely agreed that a return to business-as-usual approach following the pandemic is not the way forward and that there needs to be a shift in economic policies in order to achieve a more socially and economically just society. Perhaps if such policy change is achieved, a more balanced economy that provides a good quality of life for all can eventually be realised.


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Healthy ageing: how health inequality can be tackled at the local level

Image: Peter Kindersley via Centre for Ageing Better

Older people make up a significant portion of our population, and projections show the proportion of people over the age of 60 within the global population is set to rise even further over the coming years. ONS data shows by 2066 there will be a further 8.6 million projected UK residents aged 65 years and over, taking the total number in this group to 20.4 million and making up 26% of the total population.

Supporting people to age well, and age healthily is something which both local and national policymakers will have to take account of in order to not only ensure good quality of life for their ageing populations but also ensure that services are not overwhelmed.

Studies show the higher levels of deprivation people face in their earlier years, the more likely they are to enter older age in poor health and die younger compared with people who experience lower levels of deprivation. This highlights the need to tackle inequality across the life course, with the preventative action having a positive knock on impact on health inequalities in later life.

Some of the main drivers of inequalities include: social exclusion and isolation; access to and awareness of health and other community services; financial difficulties including fuel poverty and housing issues; insecure or low paid employment, with reduced opportunity to save or enrol in a formal pension to prepare for retirement; a lack of transport and distance from services; low levels of physical activity; and mobility or existing poor health, often characterised by long term chronic health issues.

These inequalities often combine and overlap to create even more challenging situations as people move into older life. More recent research has shown that the Covid-19 pandemic has only exacerbated these inequalities further.

Tackling inequalities at the local level

Alongside the national discussions around ageing, local demographic change has received comparatively less attention, despite place-based policies and concepts like “ageing well in place” being used in public health conversations for a number of years.

Research from the Resolution Foundation explores the intersection between demography and place, and its implications for politics and policy while further research is looking increasingly at local level case studies to highlight pockets of best practice which could help to inform the national approach.

A review from Public Health England looked at the specific experiences of older people in coastal and rural areas and the specific challenges they face in comparison to people living urban areas, exploring local level interventions and interventions which adopt a place- based approach, responding to the specific needs of people living in the area.

Other research in this area stresses that councils have a clear leadership role in supporting an ageing society and that they are uniquely placed to create strategies which reflect the needs of their populations. Through local engagement of older people systematically and regularly, and through co-production and co-design in the production of local policies and services, councils are in a position to underpin a more positive outlook on ageing, ensuring that older people are regarded as full citizens, rather than objects of charity or pity.

Approaches to poverty reduction in Greater Manchester

In Greater Manchester, healthy ageing and age inequalities have been made mayoral priorities and the Greater Manchester Combined Authority set up the Greater Manchester Ageing Hub to respond to what policymakers there see as the opportunities and challenges of an ageing population.

In 2018 the city published an “Age Friendly Strategy” to promote increased social inclusion within the city by trying to tackle the barriers to inclusion created by poverty and inequality, including creating age friendly places which allow older people to participate within their local communities, and promoting healthy ageing through strategies like GM Active Ageing, a partnership with Sport England.

Image: Peter Kindersley via Centre for Ageing Better

Creating a consensus on healthy ageing

The Centre for Ageing Better and Public Health England established 5 principles for healthy ageing which they are urging government and other policy actors to adopt to support future healthy ageing the five principles are:

  1. Prevention
  2. Opportunities
  3. Good homes and neighbourhoods
  4. Narrowing inequalities
  5. Tackling ageism

These principles can be used as building blocks to help organisations create strategies and policies which accurately reflect the core needs of people as they age. One thing which continues to be a challenge, however, is integrating intersectionality into both research and strategies or frameworks on ageing.

Not treating “older people” as one homogenous group, but taking account of the individual experiences of specific groups and how this may impact on their experience of inequalities: this is something researchers are making efforts to resolve in their work, and while there are limited studies which look specifically at BAME or LGBT groups, in the future taking account of intersectionality in ageing and inequalities will become more commonplace.

The future of ageing

We are living longer than ever before. Taking steps to reduce inequalities and support healthy ageing will ensure that those extra years are fulfilling, both for the individual and for society.

Helping people to continue to contribute to society, to really live into old age, embrace and enjoy it and not just exist in old age should be a priority for everyone, Reducing inequalities to support people to age well will be a major contributor to ensuring this happens.


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A home for life? Developing lifetime neighbourhoods to support ageing well in place

“Same storm, different boats”: addressing covid-19 inequalities and the ‘long term challenge’

Inclusive streets: from low expectations to big dreams

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From rainbows to Banksy – have lockdowns created a new appreciation for the value of the arts?

Cultural and creative sectors are among the worst affected by the coronavirus pandemic. Recent analysis suggests that jobs at risk in the sector range from 0.8 to 5.5% of employment across OECD regions. In the UK, the arts, entertainment and recreation sector saw the second largest economic decline of all sectors of the economy during the pandemic.

While the negative impact of crises is justifiably focused on, there are often positive opportunities to arise from such shocks such as widespread collaboration and innovative behaviours to find solutions. Indeed, the current pandemic is no different. Amidst the myriad of reports of the dire economic impact emerges a much more colourful picture of a resurgence in arts and creativity across not only the country but the world.

Rising creativity

From the abundance of rainbows displayed in windows across the UK to singers and musicians entertaining their neighbours from their balconies in Italy and elsewhere, the global pandemic has led to many turning to the arts and creative activities in a bid to help each other’s wellbeing and to thank those on the frontline for their heroic efforts to protect us all.

Many young people found new ways to express themselves through creativity during lockdown, whether drawing or making things, creating music or videos to share on social media. Examples of what young people in England have been creating are presented in Arts Council England’s project The Way I See It .

All sorts of artists from across the globe have been sharing their coronavirus-inspired artwork via social media.

The infamous street artist Banksy has also been joining in, creating a variety of new work from rats encouraging people to wear face masks on the London Underground to a piece paying tribute to NHS workers in Southampton General Hospital.

And the industry itself has had to get creative finding new ways to reach people. Many cultural and creative organisations have moved to delivering digital content to keep audiences engaged, which has opened the door for many future innovations. Organisations and individuals have also been doing a variety of work to reach those most in need such as projects creating new programmes or adapting existing work to reach people who are shielding or vulnerable in their homes, overwhelmingly addressing loneliness and isolation. One participant described their experience:

“I found the process of drawing and painting both cathartic and healing at the most difficult time of my life.”

Economic and social value

While there has generally been a need to make the case for the value of arts and creative activity, whether in education or business, perhaps the impact of lockdowns has afforded the opportunity for everyone to recognise their value both at times of crisis and as part of recovery.

The sector is already an economic driver and source of innovation. In 2019, the economic output of arts and culture was equivalent to 0.5% of the whole UK economy. And despite the immediate economic impact of the pandemic, there is hope that the sector will recover quickly, albeit with significant government support. Recent research from the Centre for Economic and Business Research (CEBR) predicts that the sector’s Gross Value Added (GVA) will return to its pre-lockdown level of £13.5bn by 2022 with the help of the Culture Recovery Fund, a full year earlier than was anticipated without government intervention. The research also shows the sector is set to be worth £15.2 billion to the economy by 2025.   

As well as contributing to the economic recovery, the sector can also play a crucial role in the social recovery as indicated by the many examples highlighted above.

As non-educators, many home-schooling parents have moved towards cultural and creative enrichment for their children. It has been well-documented that arts and creative activities can help improve mental health and wellbeing and at a time when there are grave concerns about young people’s mental health, surely this can only be a good thing.

As previous pandemics and disasters have consistently shown, a major focus of recovery needs to be on mental health; something that the arts and creative industries can clearly help with.

Final thoughts

At time when we might all feel like social distancing from ourselves, the arts and creative activities can provide an escape for everyone. The value of arts and culture, both economically and socially, cannot be underestimated. Perhaps the most positive outcome of the current pandemic for these sectors, will be the newfound appreciation of them from all walks of life which will hopefully translate into decision-makers thinking twice before laying the brunt of budget cuts at their door.


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Cross-border handshakes: what’s next for digital contact tracing?

As we enter a new year, and a new phase of the Covid-19 pandemic, we are reminded of the need to follow public health advice to stop the spread of the virus. The emergence of new variants of Covid-19, which appear to be more transmissible, has resulted in tougher restrictions across the world. Although the emergence of new variants of Covid-19 can seem frightening, we are not powerless in preventing the spread of the virus; face coverings, social distancing, regular handwashing and self-isolating remain effective.

Additionally, the development and subsequent roll-out of numerous vaccines should provide us all with hope that there is light at the end of the tunnel. However, although vaccines appear to protect people from becoming seriously ill with the virus, there is still uncertainty regarding the impact vaccines will have on viral transmission of Covid-19.

Therefore, the need for those with symptoms to self-isolate, get tested and undergo contact tracing when a positive case is detected is likely to remain. This will become even more important in the months ahead, as we see the gradual re-opening of hospitality, leisure and tourism sectors.

Effectiveness of contact tracing

Contact tracing is a tried-and-tested public health intervention intended to identify individuals who may have been in contact with an infected person and advise them to take action that will disrupt chains of transmission. Prior to Covid-19, contact tracing was often used to prevent the spread of sexually transmitted infections, and has been heralded as vital to the eradication of smallpox in the UK.

According to modelling, published by the Lancet Infectious Diseases, a combination of self-isolation, effective contact tracing and social distancing measures, may be the most effective and efficient way to control the spread of Covid-19.

However, for contact tracing to be at its most effective, the modelling estimates that for every 1,000 new symptomatic cases, 15,000 to 41,000 contacts would have to be asked to self-isolate. Clearly, the logistical burden of operating a manual contract tracing system is high. As a result, governments have chosen to augment existing systems through the deployment of digital contract tracing apps, which are predominantly built using software developed by Apple and Google.

Digital contact tracing

As we go about our day-to-day lives, especially as restrictions are eased, it may not be possible to name everyone you have encountered over the previous 14 days if you later contract Covid-19. Digital contact tracing provides a solution to this issue by harnessing the Bluetooth technology within our phones to help identify and remember potential close contacts. Research by the University of Glasgow has found that contact tracing apps can contribute substantially to reducing infection rates when accompanied by a sufficient testing capability.

Most countries have opted to utilise a system developed by Apple and Google, known as Exposure Notifications, as the basis for digital contact tracing. Public health authorities have the option to either provide Apple and Google with the criteria which defines when an alert should be generated or develop their own app, such as the Scottish Government’s Protect Scotland.

Exposure notification system

In order to protect privacy, the exposure notification system can only be activated by a user after they have agreed to the terms; the system cannot be unilaterally activated by public health authorities or Apple and Google. 

Once activated, the system utilises Bluetooth technology to swap anonymised IDs with other users’ devices when they come into close contact. This has been described as an anonymous handshake. Public health authorities set what is considered as a close contact (usually contact at less than a 2-metre distance for over 15 minutes), and the app calculates proximity measurements over a 24-hour period.

Anonymised IDs are not associated with a user’s identity, change every 10-20 minutes and collected anonymised IDs are securely stored locally on user devices for a 14-day period (incubation period of Covid-19) before being deleted.

If a user tests positive for Covid-19, the public health authority will provide them with a code that confirms their positive diagnosis. This will then provide users with an option to upload collected anonymous IDs to a secure public health authority server. At least once a day, the user’s phone will check-in with this server to check if any of the anonymised IDs collected in the previous 14-days match up with a positive case. If there is a match, and the proximity criteria has been met, a user may receive a notification informing them of the need to self-isolate.

Analysis conducted by the National Institute for Health Research highlights that the use of contact tracing apps, in combination with manual contact tracing, could lead to a reduction in the number of secondary Covid-19 infections. Additionally, the analysis revealed that contact tracing apps identified more possible close contacts and reduced the amount of time it took to complete contact tracing. The analysis concluded that the benefits of digital contact tracing include the ability to trace contacts who may not be known to the infected individual and the overall reliability and security of digitally stored data, rather than an individual’s memory or diary.

Therefore, it could be said that digital contract tracing apps will be most effective when restrictions ease and we are more likely to be in settings where we may be in close contact with people we may not know, for example, when we’re on holiday or in a restaurant.

Cross-border handshakes

Covid-19 naturally does not respect any form of border, and as restrictions on domestic and international travel are relaxed, opportunities will arise for Coivd-19 to spread. In order to facilitate the reopening of the tourism sector, there have been calls for countries which have utilised the Exposure Notification system to enable these systems to interact.

Examples of interoperability already exist internally within the UK, as an agreement exists between Scotland, England and Wales, Northern Ireland, (plus Jersey, Guernsey and Gibraltar), that enables users to continue to receive exposure notifications when they visit an area they do not live in, without the need to download the local public health authority app.

EU Exposure Notification system interoperability, European Commission, 2020

Additionally, the European Union has also developed interoperability of the Exposure Notification system between member states, with a commitment to link 18 national contact tracing apps, establishing the world’s largest bloc of digital contact tracing. The EU views the deployment of linked apps as vital to re-establishing safe free movement of people between member states, for work as well as tourism.

Over the next few months, it is likely that links will be created across jurisdictions. For example, the Scottish Government has committed to investigating how interoperability can be achieved between the Scottish and EU systems. The interoperability of Northern Ireland and Ireland’s contact tracing app highlights that on a technical level there appears to be no barrier for this form of cross-jurisdiction interaction.  

Therefore, as restrictions ease, the interoperability of digital contact tracing apps may become a vital way in which to ensure safe travel, as we learn to live with the ongoing threat of Covid-19.

Final thoughts

Covid-19 has proven itself to be a persistent threat to our everyday lives. However, the deployment of effective vaccines provides us with hope that the threat will be minimized soon. Until then, the need to utilise contact tracing is likely to remain.

As the roll-out of mass-vaccination programmes accelerates, and restrictions are relaxed, we are likely to be in more situations where we will be in contact with more people, not all of whom we may necessarily know. This will be especially true as domestic and international tourism begins to re-open. In these scenarios, the Exposure Notification system, and interoperability between public health authority apps, will become increasingly vital to the operation of an effective contact tracing system.

In short, digital contact tracing may prove to be key to the safe re-opening of the tourism sector and enable users to easily and securely be contact traced across borders.


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Further reading: articles on COVID-19 and digital from The Knowledge Exchange blog

Why are we still talking about healthy places?

In recent years, there has been a wide ranging debate across the housing, planning, health and infrastructure sectors about the development of healthy places in both regeneration and newly approved projects.

In 2016, Town and Country Planning Journal published an article on building health and wellbeing into the built environment (Town and Country Planning, Vol 85 No 11 Nov 2016, Knowledge Exchange customers can login to view the article here) In 2017 and 2018 the talk was all about healthy towns initiatives, and a Design Council report in 2018 looked at the relationship between healthy placemaking and the impact on our communities. In 2019 the Town & Country Planning Association (TCPA) called on members to “reunite” health and planning

It is clear that everyone involved in placemaking agrees building places that promote health and wellbeing for all is of vital importance to our communities, The Covid-19 pandemic brought this into sharp focus, and the idea remains at the forefront of design policy, particularly in urban city contexts. But, over four years after the initial conversations and thought pieces, why are we still talking about it, and what actions still need to be taken to integrate the idea of a healthy place into planning to the extent that it just becomes the norm in the planning and design of our places?

Preventing avoidable disease

The phrase ‘healthy placemaking’ has been defined by Design Council as: “Tackling preventable disease by shaping the built environment so that healthy activities and experiences are integral to people’s everyday lives”.

Public Health England defined healthy placemaking as: “Placemaking that takes into consideration neighbourhood design (such as increasing walking and cycling), improved quality of housing, access to healthier food, conservation of, and access to natural and sustainable environments, and improved transport and connectivity”

Research has shown preventable diseases linked to lifestyle and environment are among the most significant threats to public health. Lifestyle-related conditions like heart disease and cancer, as well as being health problems in their own right, can also contribute to the development of other chronic conditions, exacerbate symptoms and create complications with care which are costly to the NHS.

Creating healthy spaces is not just about encouraging people to live more active lifestyles by facilitating active travel and improving the environment around buildings, although this is a significant part of it. “Healthy places” include approaches to improve air quality, reduce loneliness, allow people to age well in place, promote mental as well as physical wellbeing, reduce deprivation and inequality through projects like housing, infrastructure development, and high street regeneration.

Healthy places also have a preventative role to play in public health management, not just a health improvement role; such interventions are essential to help avert the onset of disease, improve people’s quality of life and reduce health inequalities. And evidence shows the return on investment from public health interventions is high and creates value of different kinds – economic, social and personal.

In short people who live in healthy places, tend to live healthier lives, place less strain on services and “contribute” more to society, both economically through work or spending and socially through community engagement.

Victoria Park, Belfast. Image: Fiona Ann Paterson

Enabling planning practitioners to think about creating healthy places

Research published in 2020 by the Royal Town Planning Institute (RTPI) explored local, national and international planning practices that enable the creation and delivery of healthy places. While a lot of research draws attention to the barriers to building healthy places – including a lack of funding, different requirements from developers and conflicting policy priorities – the RTPI report instead sought to identify important challenges faced by planners who try to integrate healthy placemaking principles in their decisions and then offer potential solutions to these in practice. Key themes emerging from the report include a need to improve collaboration, knowledge sharing and the skills of planners.

The report provides case studies looking at: the place standard tool; the livewell development accreditation; connecting communities in Tower Hamlets; health planning in South Worcestershire; and train station district rejuvenation in Grasse, France. It also identifies seven steps to plan for healthier environments

Across the sector there have been calls for planners to be allowed to be innovative, creative and take a “visionary” approach to planning to help make places healthier in order to address the convergence of challenges around public health, the climate emergency, and economic recovery from Covid-19.

How has the coronavirus pandemic changed how we think about healthy spaces?

The lockdowns  imposed as a result of the coronavirus pandemic have thrown the importance of quality space into sharp focus. Places that facilitate health and wellbeing among the people who live there, and places where the indoor living quality is as important as the outdoor space have become incredibly important.

The pandemic has highlighted what it really means to have a healthy space. It has also demonstrated how wider socioeconomic deprivation and inequality – linked to living conditions as well as other factors – is having an impact on infection and hospital admission rates, with those groups who live in more deprived areas being found to be at a higher risk of becoming seriously ill or being admitted to hospital with Covid-19. 

The 2018 Design council report found in its survey of practitioners that focus was given far more to outdoor space than to indoors, as it was easier and more cost effective to make changes that could produce demonstrable impacts (an increase in cycling, for example). But the pandemic and the increased time we have been forced to spend indoors has encouraged designers and urban planners to think even more creatively about quality space in their developments.

Where now?

Public Health England (PHE) which for many years was a strong voice in the conversations around healthy placemaking has been disbanded and will be replaced by a National Institute of Health Protection. It remains to be seen how, or if this new organisation will fit into the conversation going forward. But reflecting on recent reports on the significant public health crisis facing the UK in the long term, it is clear that the work must continue, driven collectively by those in planning, urban design and public health.


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‘Bending the Curve’ of biodiversity loss – could Covid-19 be the catalyst for change?

dead forest pic

“The evidence is unequivocal – nature is being changed and destroyed by us at a rate unprecedented in history” (WWF)

The latest Living Planet report from the Worldwide Fund for Nature (WWF) finds that 68% of the world’s wildlife populations have been lost since 1970 – more than two thirds in less than 50 years – with the most striking result a 94% decline in tropical subregions of the Americas. The report says this ‘catastrophic’ decline shows no signs of slowing. The cause – human activity.

Until 1970, the ecological footprint of the human population was less than the rate of the Earth’s regeneration. Explosive growth in global trade, consumption, population growth and urbanisation means we are now using more of the world’s resources than can be replenished:

“To feed and fuel our 21st century lifestyles, we are overusing the Earth’s biocapacity by at least 56%.” (WWF)

The environmental impact of human activity is hardly a new topic but the numerous warnings over the years haven’t had the desired effect of changing society’s trajectory. The stark warnings from recent reports including the 2018 IPCC (Intergovernmental Panel on Climate Change) special report on the impacts of global warming, and popular programmes such as the Blue Planet II series which highlighted the devastating impact of pollution on the world’s oceans, have certainly helped heighten awareness and action has been taken across the world to address the climate emergency. Unfortunately, the progress made so far is not enough to reverse the current declining trends.

But the new report raises hope in that times of crisis new ideas and opportunities for transformation can arise and that the current Coronavirus (COVID-19) pandemic could perhaps be the catalyst for such change.

‘People and nature are intertwined’

COVID-19 has undoubtedly injected a new sense of urgency, emphasising again the interconnectedness of humans and nature. It has provided a stark reminder how unparalleled biodiversity loss threatens the health of both people and the planet.

Factors believed to lead to the emergence of pandemics – including global travel, urbanisation, changes in land use and greater exploitation of the natural environment – are also some of the drivers behind the decline in wildlife.

The report emphasises that biodiversity loss is not just an environmental issue, but also a development, economic, global security, ethical and moral one. And it is also about self-preservation as “biodiversity plays a critical role in providing food, fibre, water, energy, medicines and other genetic materials; and is key to the regulation of our climate, water quality, pollution, pollination services, flood control and storm surges.”

As well the pandemic, a series of recent catastrophic events are used to underline the intrinsic links between human health and environmental health, including: Africa’s plague of locusts in 2019 which threatened food supplies, caused by the unusually high number of cyclones; extreme droughts in India and Pakistan in 2019, leading to an unknown death toll; and Australia’s most intense bushfire season ever recorded, made worse by unusually low rainfall and record high temperatures, as well as excessive logging.

Alongside this, the “extraordinary gains in human health and wellbeing” over the past century, including reduced child mortality and increased life expectancy, are highlighted as a cause for celebration but the study warns that the exploitation and alteration of the natural environment that has occurred in tandem threatens to undo these successes.

Biggest threats to biodiversity

Clearly, biodiversity is fundamental to human life and it is vital that the drivers of its destruction are addressed; and quickly.

Drawing on the Living Planet Index (LPI), which tracks the abundance of mammals, birds, fish, reptiles, and amphibians across the globe, using data from over 4,000 different species, the report identifies the major threat categories to biodiversity:

  • Changes in land and sea use
  • Invasive species and disease
  • Species overexploitation
  • Pollution
  • Climate change

It may be surprising to learn that climate change has not yet been the main driver of biodiversity loss. In fact, globally, climate change features lower on the scale of threats than the other drivers in almost all regions. Changes in land and sea use is the biggest proportional threat, averaged across all regions, at 50%. This is followed by species exploitation at 24% with invasive species taking third place at 13%. Climate change accounts for 6% on average.

However, the report warns projections suggest the tables are set to turn with climate change overtaking all other drivers in the coming years.

But all is not lost yet. The report argues that it is possible to reverse these trends and calls for action to do so by 2030.

Bending the Curve’

This year’s report highlights findings from significant new research, the Bending the Curve initiative, which uses pioneering modelling of different human behaviour scenarios aimed at restoring biodiversity. It argues that this has provided ‘proof of concept’ for the first time that we can halt, and reverse, the loss of nature while feeding a growing population:

“Bending the curve of biodiversity loss is technologically and economically possible, but it will require truly transformational change in the way we produce and consume food and in how we sustainably manage and conserve nature.”

2020 has certainly made the whole world stop and think. And it has provided an opportunity to reset humanity’s relationship with nature. Encouragingly, there has been widespread talk of a ‘green recovery’ from the pandemic and the British public have recently backed a “fairer, greener Britain” amid concerns the government might be rushing the country back to a ‘business-as-usual’ model.

Achieving a balance with nature will clearly require systemic change, as the Living Planet report shows. In the words of Sir David Attenborough, above all it will require a change in perspective”.


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The Covid-19 knock-on: public health and the impact of delays in non-urgent treatment and diagnosis

Since the beginning of the pandemic, concerns have been raised about the wider public health impacts of coronavirus. In addition to strains on acute NHS care services on the frontline, there are warnings about the additional public health impacts of delays to preventative healthcare measures like screening and routine medical care in the form of pre-planned operations for long-term chronic and non-urgent conditions.

At the outbreak of the pandemic many hospitals took the decision to delay or stop entirely routine pre-planned surgeries and preventative screening and diagnostics. Some even suspended treatment for more urgent care like cancer treatment on a short term basis. While many of these services have resumed since the beginning of the pandemic, albeit with a backlog of patients now to be seen, significant strain on the NHS as we come into the winter months because of  coronavirus is still anticipated. As a result, many hospitals are not working at full capacity in order to prepare for potential increases in admissions due to coronavirus or staff shortages over the winter.

In many areas this has led to a backlog of care, both for those patients already in the system awaiting routine surgeries, as well as those who are yet to be diagnosed but would have been through preventative screening programmes run by the NHS.

Delays in healthcare and routine screening programmes 

Even before the coronavirus pandemic took hold, many NHS hospital trusts were under criticism because of the significant length of waiting times for people who required routine operations, which in some parts of the UK can be as long as three years. Doctors across the UK are now warning that these delays could be increased further unless the NHS receives additional support to increase capacity across all areas of care  not just urgent care in the coming months.

Data released by NHS England in October 2020 showed the numbers waiting over a year for hospital treatment have hit a 12-year high, with almost 2 million patients waiting more than the target time of 18 weeks for routine care.

It has been suggested that delays in diagnosis and routine treatments could lead to an increased number of hospitalisations further down the line, requiring higher levels of care, longer lengths of stay, and increased hospital readmissions.

A reluctance to visit hospitals and use primary care services

Government messages to ‘protect the NHS’ may have had the unintended consequence of discouraging people from seeking urgent medical care when it was required for fear of using services unnecessarily or for fear of contracting the virus when attending hospital or primary care settings.

Research from the Health Foundation found that there had been a significant reduction in the number of GP consultations since the start of the pandemic which has led to concerns about the care of non-covid patients, patients with long term health conditions and also the potential for delayed diagnosis. Primary care consultations also reduced and have remained low consistently since the beginning of lockdown.

Figures have also shown a reduction in the number of referrals, medical tests, new prescriptions and immunisations. While some of these reductions are the result of advice to delay routine referrals to free up capacity for hospitals to deal with the potentially large number of cases of Covid-19, routine referrals have still not recovered to pre-lockdown levels.

 

A potential future crisis for the NHS and a ticking time bomb for public health

Doctors are now warning that the treatment backlog which has been caused by the coronavirus pandemic, in addition to diagnostic delays and screening programmes, may lead to a future crisis of care or significant delays in care for people waiting to receive more routine treatment.

Delays in care have not only been reported in cases of physical health. There have also been significant delays in referrals for those seeking treatment for a mental health condition, an area of the NHS which was already facing significant delays in referral and transfer of care even before the pandemic. Research suggests that incidence of mental illness during the coronavirus pandemic increased. However, the numbers of people accessing services and being referred for treatment have not increased proportionate to this. People with mental health conditions may have been unable to access appropriate support through primary care pathways, which could potentially impact on their long term health and care.

Finally, concerns have been raised about the wider social determinants of health such as employment and poverty. Public Health England (PHE) published a monitoring tool which looks at the wider impacts of the Covid-19 pandemic on population health, and it is likely that the knock-on impact of the virus could have far reaching consequences for public health in the future as the health implications of lockdown, lack of social interaction and rising unemployment could be significant. 

Where next?

While the challenges of the coronavirus pandemic for the NHS will not be going away anytime soon, it is clear that it will be necessary for the NHS and other supporting services to act now to prevent a longer term public health crisis. It is critical that we not only focus on the acute care of Covid-19 patients, but also proactively manage patients without Covid-19, particularly those with time-sensitive, complex and long term conditions who are postponing their care. We must also consider the knock-on impacts of delayed diagnosis for those people who missed out on routine screening or who were unable or too afraid to visit their GP or hospital. This is important not only to sustain health and life, but to preserve hospital and NHS capacity in the future.


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How the COVID-19 homelessness response shows opportunities for future progress

Before the UK entered lockdown in March 2020, there were already discussions around how the spread of COVID-19 would impact some of the most vulnerable people in our society. There was an acute awareness not only of the significant levels of homelessness in our towns and cities but that the number of people who needed support was growing at an alarming rate. Strategies for prevention and outreach programmes to help break the cycle of homelessness through a network of support systems for homeless people were helping to a certain extent in some areas, but the problem was (is) chronic and the concern among people who worked in, and had experience of, the sector in relation to the potential impact of COVID-19 was growing.

Homelessness during the COVID-19 pandemic

Surprisingly though, in many areas the response to support the UK’s homeless populations was swift, definitive and all encompassing. Partnerships were formed with local hotel chains – the GLA partnership with multiple hotel groups as part of the Pan London Placement scheme is probably the best publicised but individual arrangements have sprung up across the country and people were moved from the street into accommodation which was self-contained and would allow them to effectively isolate if they showed any symptoms of COVID-19.

In March, minister Robert Jennick announced £3.2 million of funding for councils to help them protect local rough sleepers from the pandemic and MHCLG, councils, the voluntary sector and those who work within homelessness outreach specifically have all mobilised to form an effective network of support for many people who had previously been sleeping on the streets.

The response to moving those who were sleeping rough off the streets has been unprecedented, as is the volume of people who have been helped. Many people have been accommodated regardless of their “local connection” or their “recourse to public funds”, something which previously was a significant barrier to many people being housed in temporary accommodation by their local authority.

A new wave of homelessness?

However despite the significant progress made, there are growing concerns about a “second wave of homelessness”- people who become homeless off the back of the stagnation and collapse of some areas of the economy, particularly those in low paid and precarious work i.e. hospitality and retail sector. Additionally, there are signs that some especially vulnerable groups have not engaged with the process or that some people have became homeless after the initial offer of support was rolled out. These include people from migrant backgrounds, and people with acute and severe mental ill health.

Things can’t go back to the way they were

One thing is clear, according to professionals, things can’t be allowed to return to the way they were. In some instances this is for practical reasons, and in other instances because we have been able to see what it is possible to achieve when people co-operate and there is a collective will to progress.

The use of communal shelters, one of the main ways of delivering emergency accommodation for many years may have to stop, or at least be re-organised to avoid multiple people sharing facilities like bathrooms or sleeping in rooms with multiple beds. A move towards more “pod style” contained living may be a way forward, but it will take a shift in design to accommodate people safely in the future.

The response has shown that it is vital to develop links between housing and health, and that the integration of services with public health to create wrap-around care (which is something which is currently being co-ordinated in response to the pandemic) should be maintained going forward.

The pandemic response has also shown that multiple organisations can work well effectively together and that the red tape, perceived layers of bureaucracy and challenges of different ways of working can be overcome if there is collective understanding and will. These barriers can be overcome to create really effective and much needed services and support for some of our most vulnerable citizens.

Concerns have been raised around future funding, and in particular the risks of funding being stopped abruptly or the supply being removed at short notice, for example if hotels re-open and councils then struggle to identify appropriate accommodation for people to transition into. The sector has stressed that councils should be planning for this transition phase to prevent people returning to the streets and dis-engaging with services.

Opportunities to learn lessons

At an online event hosted by the Centre for London, which brought together professionals from within the sector in London to reflect on the response to COVID-19, somewhat surprisingly, the atmosphere was one of optimism that this could be the start of a new way of working. There is hope that a “can do” and “get things done attitude” which had been catalysed by the need for urgency because of the spread of COVID-19 can be harnessed and that this mindset should be embedded into practice going forward.

One of the main questions that appears to be raised is, if we can do it now, with such urgency, why couldn’t we do it before, and what steps need to be taken to ensure that the collective will and the government support doesn’t disappear post COVID-19? This is something local authorities, homeless outreach groups and other partners will have to grapple with over the coming weeks and months.

The response to the pandemic has been unprecedented. It has shown that with understanding, flexibility and effective partnership working to deliver coordinated services (as well as appropriate supply and funding) that tackling homelessness, or at least offering more to our homeless communities in terms of effective long term support, can be achieved.

There is a collective sense within the sector that the steps forward taken as a result of this pandemic should not be allowed to regress in the future, but should be strengthened and built upon to provide more effective support going forward for homeless communities across the UK.


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“Same storm, different boats”: addressing covid-19 inequalities and the ‘long term challenge’

MS Queen Elizabeth in Stornoway

The coronavirus pandemic has impacted upon almost every aspect of life.  However, this impact has not been felt by everyone equally. Some groups of people have been particularly badly affected – both by the virus itself and by the negative social and economic consequences of social distancing measures.  The phrase ‘same storm, different boats’ has been used widely to emphasise this.

The pandemic has exposed and deepened many of the deep-rooted inequalities in our society, including gender, ethnicity and income.  It has also shone a light on more recent inequalities too, such as the growth of precarious employment among sections of the population.

As we move out of lockdown, the long term consequences of the pandemic will continue to be felt unevenly across different sections of society, with those on the lowest incomes being most vulnerable.

As thoughts turn to recovery, there is a growing sense that now is the time to consider how we can create a more equitable society that benefits those most in need.

 

The long-term challenge

During a recent Poverty Alliance webinar, ‘Build Back Better: Poverty, Health and Covid-19: emerging lessons from Scotland’, Dr Gerry McCartney, Head of the Public Health Observatory at Public Health Scotland noted that the coronavirus pandemic was causing three concurrent public health crises:

  • the direct impact of the virus (through ill health and/or death);
  • the indirect impacts on health and social care services (e.g. reduced hospital admissions/referrals, delayed diagnoses); and
  • the long term unintended consequences of physical distancing measures

Dr McCartney’s recent research sets out the different groups at particular risk from covid-19 and outlines a number of ways in which the unintended consequences of physical distancing measures may negatively impact upon health via a complex set of pathways – including reduced physical activity, fear, anxiety, stress, boredom and loneliness, economic stresses related to reduced income and unemployment, the impact of the loss of education, as well as the risk of abuse and exploitation of children not in school, substance abuse, and domestic abuse and violence.

Dr McCartney has also been involved in a project that sought to quantify the direct impact of the pandemic in terms of years of life lost.  The results showed that, over 10 years, the impact of inequality on life expectancy is actually at least six times greater than the direct impact of the pandemic itself.

Dr McCartney referred to this as the “long-term challenge” and argues that in order to address these inequalities, it is crucial that society aims to ‘build back better’ following the pandemic.

Build Back Better

But what does this mean?  Put simply, Build back better argues that pandemic offers an unprecedented opportunity to refocus society on the principles of equity and sustainability.

A recent paper by the Wellbeing Economy Alliance (WEAll) sets out 10 key principles for ‘building back better’, covering a range of environmental, social and governance issues:

It highlights international examples of each of these principles in action, for example, speeding up the adoption of the doughnut economics framework in Amsterdam in response to the pandemic, and through the wellbeing principles implemented by the Wellbeing Economy Governments (WEGo) group, consisting of Iceland, New Zealand and Scotland (and recently joined Wales).

Indeed, in Scotland, the independent Advisory Group on Economic Recovery, established by the Scottish Government, have recently published their findings on how to support Scotland’s economy to recover from the pandemic.  It states that “establishing a robust, wellbeing economy matters more than ever”.

Unequal employment impact

One of the guiding principles set out by the Advisory Group on Economic Recovery is to “tackle inequality by mitigating the risks of unemployment, especially among groups hit hard by the crisis”.

Indeed, unemployment following the pandemic is unlikely to affect everyone equally – women, young people, BAME individuals and the low-paid are predicted to suffer the brunt.

In a subsequent Poverty Alliance webinar, ‘Addressing unemployment after Covid-19’, Tony Wilson from the Institute for Employment Studies (IES) highlights the scale of the problem.  He states that unemployment is rising faster than at any point in our lifetimes (barring a blip in 1947), and is likely to increase by 3 million as a result of the pandemic.

Again, the impact of this will be uneven.  Anna Ritchie Allan, director of Close the Gap, discusses the impact upon women in particular.  As well as being more likely to work in a sector that has been shut down, women are also more likely to have lost their job, had their hours cut, or been furloughed. As women are also usually the primary carers of their children, they have disproportionately affected by the closure of schools and home learning.

A recent report by Close the Gap highlights how the impending post-covid downturn is different than previous recessions, as the restrictions imposed to tackle the virus have impacted most heavily upon sectors that employ large numbers of female (e.g. hospitality, retail, care), as well as services that enable women’s participation in the labour market (e.g. nurseries, schools, and social care). Young and Black and minority ethnic (BME) women have been particularly affected.

For example, Kathleen Henehan, Research and Policy Analyst at the Resolution Foundation, considers how young people’s employment prospects have been affected by the pandemic. She notes that young people leaving education are likely to be worst affected.  However, again, inequalities exist – with those with lower levels of qualifications being particularly affected, and women and BME individuals within those groups affected most of all.

According to Anna Allan, policy to address unemployment as a result of the pandemic needs to be both gender-sensitive and intersectional – taking account of the fact that women are not one homogenous group, and ensuring that any job creation is not just providing more ‘jobs for the boys’.  For example, recent research by the Women’s Budget Group shows that investing in care would create 7 times as many jobs as the same investment in construction: 6.3 as many for women and 10% more for men.

Building forwards

In a third webinar, ‘Disability, rights and covid-19: learning for the future’, Dr Sally Witcher, CEO of Inclusion Scotland, suggests that as well as exposing and deepening existing inequalities, the coronavirus pandemic has created the scope for new inequalities to be created – ‘faultlines’ created by the differing impacts of the virus.

Dr Witcher questions the term ‘build back better’ – she asks whether indeed we should want to build back, when the old normal didn’t work for a large proportion of people, particularly those with disabilities. Dr Witcher also questions ‘who’ is doing the building, and whether the people designing this new future will have the knowledge and lived experience of what really needs to change.

Dr Witcher suggests that for any attempt to ‘build back better’ to be meaningful, it needs to reach out to the people that don’t currently have a voice – the people who have been most heavily affected by the virus.  Not only do these groups need to be involved, but they need to be leading the discussion about what a post-covid future looks like.

A post-covid future

Whilst the coronavirus pandemic has had a massive, devastating impact on people and economies around the world, it has created an opportunity to reflect on what is important to us as individuals and as a society.

There is strong public demand for change. According to a new YouGov poll, only 6% of the public want to return to the same type of economy as before the coronavirus pandemic.

Building back better recognises that addressing the causes of the deep-rooted and long-standing inequalities in our society is critical to a successful post-covid recovery.

There is also a need to protect and enhance public services, address issues of low-pay and insecure work, and prioritise wellbeing and the environment through a ‘green recovery’.

As Tressa Burke, of the Glasgow Disability Alliance, states:

History will recount how we all responded to the coronavirus outbreak.  We need to ensure that the story told demonstrates our commitment, as a society, to protecting everyone from harm, particularly those most at risk of the worst impacts of covid.”


For further discussion of the wellbeing economy, you may be interested in our blog post ‘How well is your economy? Moving beyond GDP as an indicator of success

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