There are several areas where the Localism Bill meets the Health and Social Care Bill in largely unfamiliar territory that could play a significant role in defining the future of the built environment and its impact on improving population health outcomes.
Dealing with public health is typically one area of cross party consensus, despite the political differences in meeting the challenges. One of the new policies of the Conservative led government is the separation of public health policy from the NHS and in doing so it is promoting a much greater focus on preventing people from needing to access the wider NHS system.
As part of the new approach, responsibility for public health will be moving to local council control and medical treatment is moving to independent GP led consortia, both of which are localism strategies.
As a consequence, it is very likely that issues relating to planning, housing, transport, open spaces, industrial buildings, retail, leisure and environmental concerns will be some of the factors that will form part of the wider public health debate from later this year, as the Health and Social Care Bill 2011 nears enactment and the Public Health England Bill, currently at White Paper stage, emerges as a consequence.
Anyone involved in the property sector will need to start taking an active interest in public health policy and health inequality policies, not least because all publicly funded projects will need to do so.
[NB: this and related policy posts are written around a fast-moving political and policy environment that will continue to change until HoC Bills become law]
Planning for public health
With Eric Pickles indicating at a recent RICS presentation that the Localism Bill could be given Royal Assent in the Autumn of 2011, the increased prominence of local council elections will become more significant by the end of 2011.
Planning already carries local political ramifications requiring senior planners to take account of such factors, but now councils will see new pressures to have a greater say in considering the public health outcomes from planning considerations, this being just one area of potential future public health oversight. This raises, for example, the importance and broadening the remit of pre-planning application assessments and feasibility studies.
Local governments will also have to consider the public health impact of projects within local enterprise partnerships and across boundaries, just as central government will need to consider projects that are to be part of any national planning framework. This is one of the cross-over points for ensuring public health issues are prioritised and are consistent across all governments agencies involved with the built environment and community matters.
Bob Neil, the Parliamentary Under Secretary of State at the Dept. of Communities and Local Government, commented at a planning conference that sustainability is a priority for the government and planning policies will reflect that as part of its drive for more growth in the construction and housing sector; ‘presumption in favour of development is in the context of sustainable development principles’. The Marmot Review, which the new public health policies are being framed around, also highlighted sustainability as a key public health issue, so this is one of the major points of policy that the property industry can positively influence:
It is the view of all of us associated with this [Marmot] Review that we could go a long way to achieving that remarkable improvement by giving more people the life chances currently enjoyed by the few. The benefits of such efforts would be wider than lives saved. People in society would be better off in many ways: in the circumstances in which they are born, grow, live, work, and age. People would see improved well-being, better mental health and less disability, their children would flourish, and they would live in sustainable, cohesive communities.
Local councils and the people ultimately responsible, elected councillors, will gain the added remit of being judged on the health outcomes of the population in their areas. Once councillors gain accountability for poor public health to their list of priorities, we can expect them to look harder at the planing and local environmental issues affecting their figures and the council tax impact of needing extra services due to worsening preventable public health outcomes.
The PM’s motivation for change
As David Cameron nears his first year in power, Parliament is full of new Bills and White Papers that reflect campaign manifesto pledges. Within these new policies, there are several themes which coordinate the most controversial and radical outcomes of the new laws, all of which are intended to profoundly impact the way government, local councils and communities will work in the future:
- Decentralisation
- Localisation
- Transparency
- Competition
- Inequality
These are the broad themes that David Cameron has recently restated that he feels ‘passionately about’ and form part of his top priorities for the future direction of the country. He has argued that many of these radical changes are not new ideas, but Conservative policies developed during many years in opposition; and countering the view that it is all too fast too soon, he believes that making sweeping implementation is necessary to prevent internal public sector bureaucracy and lobbying from preventing ‘essential’ change from taking place.
Giving power to the people
Over the past few months, the property press has been full of news and views on the changes to the planning system, or ‘rebooting’ as Minister for Decentralisation Greg Clark calls it. The Localism Bill and the few sections that profoundly impact on planning laws, has, quite rightly, captured a lot of attention and the RICS is just one of the professional bodies heavily involved in unbiased political policy reviews, government lobbying, calls for evidence and a wider working or networking with interested parties and organisations.
However, the wider localism objectives really are radical, as Eric Pickles MP outlined in a recent speech to the third sector:
- The right – through neighbourhood planning – to have a meaningful say over what your home town will look and feel like in the future.
- The right to challenge the way local services are run – such as children’s centres, social care, or even transport.
- The community right to buy – with time to come up with a business plan, and find the cash, to run resources like leisure centres and libraries.
- You know the neighbourhood, you know what people want, you know what’s going to work.
- The fact is that public services have been run on the Gospel according to the Government for too long. It’s stifled innovation and stopped us getting the best results.
- So whether parents want to run a new school, residents want to take over the community centre – or big voluntary groups want to run whole public services. We’re not just grudgingly allowing it – we’re positively encouraging it.
The government is pushing out virtually all decision making, including community regeneration and direct housing finance, from the centre to local councils and to the community. In this new era of localism and the Big Society, businesses and organisations will have no choice but to start thinking locally to a much greater degree, in particular to avoid objections from local communities.
Happiness politics
While Ministers have individual policy responsibilities such as the Localism Bill and the Health Bill, the Cabinet is seemingly joining up many policies to improve the nation’s overall well-being, behind the unpopular front line focus on budget cuts and improving economic recovery (or making it worse as the Labour leader Ed Miliband would argue).
David Cameron declared his intentions to pursue policies on societal well-being as far back as 2006, well before the September 2007 run on Northern Rock and the start of the recession in 2008. So there is some plausibility that this joining up of policy for societal well-being and the Big Society is not a cover for cuts or ideology over the size of government, even if they are convenient bedfellows, but the first time a Conservative led government has taken such a strong approach on traditional Labour and Liberal Democrat social fairness doctrines.
In an interview in May 2006 with the BBC, David Cameron said on societal well-being:
- Improving society’s sense of happiness is of the utmost importance.
- Improving our society’s sense of well-being is, I believe, the central political challenge of our times.
- It’s time we admitted that there’s more to life than money, and it’s time we focused not just on GDP, but on GWB – general well-being.
- Well-being can’t be measured by money or traded in markets. It’s about the beauty of our surroundings, the quality of our culture and, above all, the strength of our relationships.
This explains why the ONS has been working, since November 2010, on plans to measure the nation’s happiness. To understand what the ONS was doing , we met with Paul Allin, measuring national well-being programme director at the ONS and discussed the rationale and some of the work behind the happiness policy.
It was evident from the start that creating a happiness index was a long-term project and to ensure its robustness the ONS were taking their time and recruiting some of the best minds in the field, as well as heavyweights from the wider business community.
Measuring well-being is a serious endeavour, now out of the hands of government (the ONS is independent) but influencing future government policy, just as measures of GDP and inflation do at present. In particular, well-being is slated to be linked with all policy evaluations with a view to reducing inequality and health inequality, which the Prime Minister cites as being ‘as wide as they were in Victorian times’.
Well-being is set to become a way for everyone in central and local government, not just those focused on health, to measure the non-economic outcomes from local, regional and national decisions. Having been tasked with the objective, the ONS’s view is that governments will need a “detailed measurement of well-being to show the costs and benefits of different allocation decisions.” Or in other words, influencing decisions about where public money and effort is invested.
Even China, the last country anyone would consider as airy-fairy with its questionable record on human rights, announced on 2 March that it was to measure the Gross National Happiness of its population and its local and national officials would be judged by how happy the Chinese people were.
All of this growing national and international emphasis on well-being raises the importance of this seemingly frivolous pursuit to one of the changes that the wider property industry needs to understand and watch very carefully.
Measuring happiness
From April 2011, the ONS will cease its public consultation and begin to officially measure national well-being. Each year, the ONS will be using its £2m well-being funding budget to ask 200,000 people a handful of questions and their responses, along with a selection of already measured objective household data, will be released every quarter from 2012 in what is to become a ‘well-being index’, which is yet to be fully defined.
What is expected to follow from this is a requirement for well-being to be included in the Green Book, the HM Treasury guidance for central government, which sets out a framework for the appraisal and financial evaluation of all future laws, policies, programmes and projects.
Once ‘well-being’ officially makes it into the Green Book, all government decisions and spending plans will be tied to well-being evaluations and outcomes, in some form, or as the Prime Minister put it:
Every day, ministers, officials, people working throughout the public sector make decisions that affect people’s lives, and this is about helping to make sure those government decisions on policy and spending are made in a balanced way, taking account of what really matters.
From 2012, it is likely that bidding for a public sector contract, or private projects that impact public policy or whose scale affects a large proportion of the community, will require consideration and evaluation of the project impact on community well-being and health inequality, in addition to any local issues such as neighbourhood development plans and local public health policies.
There will also be indirect pressure for Commonwealth countries to consider adopting measures of national happiness and one of the points of difficulty being reviewed by the ONS team is devising an well-being index which can be implemented by other countries. Paul Allin’s initial view is that an index may have to be built around available data that is produced by other European countries and could be produced by Commonwealth countries, although most countries are expected to wait and watch how the well-being initiative filters through to government actions.
The trouble with happiness
Science has shown, through evidence based research, that happiness matters a great deal to health, life expectancy and disability free life expectancy. This is the reason why governments around the world are taking notice of the decades of research that are now converging around societal well-being and government policies.
The trouble with measuring happiness is that you can’t accurately do so with any significant meaning. Take this example, while economic growth has risen steadily since the 1970s, happiness has stayed about the same, with a few blips during the previous three recessions.
People’s level of happiness and life satisfaction changes with time and research has shown that it fluctuates substantially once people get married and take on the responsibilities and commitments of family life. So measures of national happiness will tend to show aggregate levels of satisfaction over time for the whole country, which will be, on average, about the same year in, year out.
Where you live, affects how long you live
Measuring well-being is a good idea, as the think tank ‘nef’ have evaluated, but the more relevant measure of well-being, for public health policy, is health inequality or differences in life expectancy and disability free life expectancy according to local authority responsibility. Professor Sir Michael Marmot, an advisory member of the ONS panel measuring well-being, has commented on officially measuring happiness that ‘…health is a better measure of well-being, than well-being.’
The science behind what causes health inequality is the basis upon which the government is to create Public Health England, the umbrella for local council public health officials that will be tasked with improving health and reducing the number of people requiring access to the NHS and delaying as long as possible, through improved health, the time when people need assisted elderly care.
What has been known for some decades is that life expectancy varies according to where you live, a factor that directly crosses into the built environment. Across England, male life expectancy between the poorest and most affluent areas within each local authority exceeds nine years for around half of the authorities; the comparable figure for female life expectancy is six years. However, more recent efforts have been made to identify differences in life expectancy within local authority areas, official regional boundaries and across cities.
These new measures and findings show that, for example, Westminster has the widest within area life expectancy, 17 years, for men; for women, the gap is widest in Halton and Newcastle upon Tyne at just over 11 years. When factoring some form of disability that affects overall quality of life, such as diabetes or strokes, the Wirral has the widest level of inequality in disability free life expectancy for both sexes, 20 years for men and 17 years for women.
Nationally, Glasgow has a male life expectancy of 54 years in the poorest parts (Calton), compared to 82 in the more affluent parts (Lenzie).
From the overall data on health inequality by local authority, the central line shows that there is a gradient to life expectancy according to where people live, both across England and within an area.
The factors affecting life expectancy are not limited to contrasting measures of the richest and poorest in society; the range includes the middle classes, from white collar middle mangers in clean office jobs to higher grade mangers in industry, all in the middle will yield several years of life expectancy to the most affluent in society.
Cross-party support to improve health and save money
The new well-being policies are less about what makes people happy and more to do with creating policy decisions that make local people less unhappy over their lifetime. This is because the biology of unhappiness impacts productivity, creates sickness, reduces independence and causes an extra financial burden for the taxpayer in assisted care.
The Marmot Review, commissioned in 2008 by Alan Johnson, estimated that preventable health factors cost the taxpayer between £25 – £37 billion in extra welfare payments and NHS costs, with a further £31-£33 billion in lost productivity.
The objective of tackling health inequalities was addressed by Labour in 1977 and again by David Cameron in 2005. The Liberal Democrats have also shown a great deal of interest in health inequalities and Jo Swinson MP, Deputy Leader of the Scottish Liberal Democrats, has championed the cause for measuring well-being for several years.
Diane Abbott, the new shadow public health minister, has recently confirmed Labour’s support for the government’s introduction of Public Health England, while identifying differences between the parties on implementation:
The Labour Party supports the proposals to move public health into local government, who will have a ring-fenced budget and a local Director of Public Health. There will be a new national organisation called ‘Public Health England’, into which a variety of public health quangos like the Food Standards Agency will be incorporated.
So while the political parties have their own ideas and differences on how to approach the problem of health inequality, the fact that they all support tackling the issues means that it will become a major theme for future government decision making.
Multi-disciplined approach to tackling public health
What does this mean to the wider property industry? The underlying data on health inequalities links life expectancy to where people live, their neighbourhood: public health outcomes are linked to the built environment.
As a secondary part of the major overhaul of the NHS, expected to become law later this year, the government will create Public Health England, with an annual budget for local Health and Well-Being Boards for each council. These boards will be tasked with overseeing the future health and well-being of the nation by focussing locally and by doing so they will be required to reduce the numbers of people that need to access medical care or assistance.
From 2012, each council will have a Director of Public Health who will chair their Health and Well-Being Board, which will likely consist of a range of experts, including property professionals such as planners and estates officers, and other interested parties that will influence both local policies and the eventual downstream commissioning of NHS projects controlled by GP’s.
While it is a presumption that planners, at the very least, will be involved with public health policy, there is evidence that a recommendation along these lines will be made.
After commission the Marmot Review in 2008 and while awaiting its recommendations, a 2009 Parliamentary health committee reviewed the issue of health inequalities and commented on the built environment’s role in being a factor in health and well-being outcomes:
The built environment affects every aspect of our lives. During the inquiry we heard many concerns: high streets awash with fast food outlets, flagship health centres located ‘at random’ and planning policies which have created towns and cities dominated by the car, with out-of-town supermarkets and hospitals, which have discouraged walking and cycling. In our view, health must be a primary consideration in planning decisions.
The committee went on to recommend that ‘…PCTs should be made statutory consultees for local planning procedures.’
While Primary Care Trusts (PCT) are being wound down and will not exist from April 2013, their role in public health will shift to local council control, making the publication of a recommended ‘Planning Policy Statement on health’, that was to ‘…require the planning system to create a built environment that encourages a healthy lifestyle..’, seemingly unnecessary, at this time.
Joining up public health with local council politics
Speaking on the BBC’s ‘Politics Show’ in March about the NHS reforms, the Health Secretary, Andrew Lansley, clarified that local councils will be involved in “…agreeing what are the strategic needs in their area and that the GP commissioning groups plans meet those needs alongside the local authorities responsibility for health and social care.”
The new Director of Public Health will be answerable to elected councillors on health outcomes and everyone will be accountable to local people and central government. You can expect that they will have a strong say on everything that the evidence based health inequality research has associated with the built environment including adequate public spaces, transport, schools, sport, housing and high streets.
The shift in emphasis for preventative measures based on cooperation was first seen after the introduction of The Local Government and Public Involvement in Health Act 2007. This required Primary Care Trusts to work with local authorities and they began to do so under a framework called the Joint Strategic Needs Assessment (JSNA).
The JSNA provided for engagement with local communities and relevant stakeholders on identifying and targeting the needs of local communities, so it is expected to form the basis upon which the new local role of Public Health England will initially operate, a policy recommendation supported by the BMA following an initial review of the new public health proposals.
However, while it is the most likely starting point, the JSNA framework is just one of the possible starting points for a review of the close collaboration of council departments and the wider stakeholders, such as the new GP commissioning consortia in each region.
The overall indicative approach to public health and the new NHS framework was outlined from discussions at a public health meeting organised by the Chartered Institute of Environmental Health in February, where cooperation and coordination of efforts across council departments were seen as critical. This is also the view of Tim Baxter, one of the senior civil servants in the Department of Health, who is responsible for formulating much of the outline objectives and remit of Public Health England before Parliamentary debate.
While Public Health England is not due to begin formally (it seems to have cross-party support for its enactment) until April 2013 when its full remit and £4bn spending budget will be effective, the localism policy formulation and shadow roles in councils have already begun. Wandsworth council was the first in the country to appoint a Director of Public Health to ensure an effective transition and to begin the work of integration across council departments.
Local Government & Public Health
Towards the end of March, the Department of Health had noted that there were some 132 local authorities seeking to establish health and well-being boards, with much of their focus on closely examining the staffing requirements and the framework advice from central government and the health inequalities research team. By April 2012, Public Health England and all the local council Health and Well-being Boards will be established and have some operational mandates, along with shadow budgets.
How public health policies will be developed and enforced around a focus on deregulating planning is still to be considered, but there will be instances where local people and businesses will be advised that some elements of their neighbourhood plans are at not in their best health or, once the ONS index is released, well-being interests. One of the the localism ideology questions that arises is – do you allow people to proceed with plans that are not in their best health or well-being interests, after providing relevant information, or do you create regulation to veto certain aspects of what local people want? Tony Blair was fairly clear on this aspect of public health which may indicate central government’s overall future approach:
Small changes in the choices people make can make a big difference. Taken together, these changes can lead to huge improvements in health across society. But changes need to be based on choices, not direction. We are clear that Government cannot – and should not – pretend it can ‘make’ the population healthy. But it can – and should – support people in making better choices for their health and the health of their families. It is for people to make the healthy choice if they wish to. Choosing health sets out what this Government will do to help them.
We will build on the work of this White Paper at every level, from support for individuals right up to engaging the entire nation through events like the London 2012 Olympic Bid. I believe that Choosing health will be a major step in making the improvement of everyone’s health everyone’s concern.
Local government is still in the foothills of the new public health agenda, but many of the issues affecting health have been known and studied for many decades, so one can expect that the pace of change will be significant, especially once the costs to local government of not being proactive are highlighted by the new Directors of Public Health.
Pamela Chesters, the health advisor to the Mayor of London, Boris Johnson, who oversees the implementation of the London ‘health inequalities policy statement and strategy’ produced in April 2010, has an advanced idea of how London policies will be shaped to reduce health inequalities. From our recent discussions with Ms Chesters, it was very clear that the issues of health inequalities in London were of central importance to the Mayor and the GLA.
Some of the policies are already being tied to reducing the gap in life expectancy within London and improving health outcomes by promoting healthy activities (she noted the bike hire scheme as one example) and initiating reviews on how to begin looking at the role the built environment plays in causing or easing inequalities.
Health & wealth. Looking beyond the Localism Bill
While the Localism Bill is the hot topic of the property professions at the moment, the government is actually coordinating legislation that may affect the wider property industry and which is based around a broader set of public health issues.
The Prime Minister and the coalition government are seeking to ‘improve what matters most’, other than GDP, but GDP is still the top priority as the government attempts to ‘get the economy moving again.’ While we wait for that to happen, it is worth looking beyond the Localism Bill to see what the future may bring for the likely changing landscape of the built environment and the Vision for Cities.
Ahmed Zghari MRICS
