You can now watch a new 35 minute film introducing the Healthy Streets Indicators and tools
I have just returned from a very busy two week tour of New Zealand giving presentations and running Healthy Streets workshops in Auckland, Wellington, Christchurch and Palmerston North with a wide range of stakeholders.
You can watch my Auckland Conversations presentation again here
You can listen to my interview on Radio New Zealand here
And you can read my New Zealand Herald interview here
Transport is one of those things that most people agree is important but struggle to get particularly excited about. If you ask an expert ‘what is transport?’ you will usually be given an answer about moving people and things around. If they are a particularly enlightened expert, instead of focusing on the arbitrary activity of movement, they may talk of purposeful movement enabling people to access what they need when they need it. So far, so boring, yes?
This definition is boring because it describes transport as an isolated activity, suggesting that it happens in empty space. In reality, most transport happens on streets in urban areas – to think of it as an isolated activity misses the central impact it has on each of our daily lives. Transport is happening in the same places that billions of people live, grow, learn, work, play, share, laugh and cry.
In urban areas, streets typically make up 80% of public space, and the vast majority of transport happens in these public spaces. Considering transport in the urban context shows us that it is much more interesting and important than we might previously have thought. How this supposedly benign activity is conducted intimately affects our daily lives in many ways, including significantly impacting on our health.
In most urban areas, transport affects our ability to build physical activity into our daily routine, the quality of the air we breathe, our risk of being injured or killed in a collision, our exposure to the health impacts of noise and how we access the people, places and services we need. All of these are vitally important to being able to live well, so reducing transport’s negative impacts on our health is a clear priority.
If we want to reduce or eliminate the negative impacts of transport on our health we need to involve a range of people who have a role in how streets look and feel. This includes residents, business owners and their employees, planners, police, architects and designers, engineers, entrepreneurs, politicians and artists, to name just a few.
It is therefore not especially helpful to talk in the language of health or transport in this context. Instead, we must engage people by talking in a way that we can all relate to. Most people don’t think of their lives as a collection of serious health risks to avoid. They also don’t think about their lives as a string of ‘transport choices’ or see themselves as a ‘motorist’, ‘pedestrian’ or ‘service user’.
The preferred languages of the health and transport communities are not likely to resonate with the wide range of people who have a stake in the issues. Most of us are thinking about the daily grind of our lives, getting things done, making life easier and finding pleasure wherever the opportunity arises. It follows that we should frame our approach to complex social determinants of health – like transport – in terms of creating an environment in which people can do what they need to do in an easy and pleasurable way.
The Healthy Streets Approach sets out 10 Healthy Streets Indicators, which describe the key ingredients for an environment in which people can do just this. I developed these indicators from an evidence base for the impacts of the built environment on health, inequalities and travel choices. This means that at the centre of this approach are the primary goals of the health community (healthy environment and healthy behaviours) and the transport community (using the most efficient mode of transport suited to each trip). The language, though, is focused on how the human experience can be made both easier and more pleasurable by changing the urban environment to put people and their wellbeing first.
The success of this framework is that it is positive, relatable and achievable. We can all visualise how these Healthy Streets Indicators could improve our environment, making life tomorrow a little easier than it was today.
A paper I co-authored has just been published in the Journal of Transport and Health. This research analysed travel data for London to see which factors influence whether people leave their house on a given day. While people can have happy healthy days staying at home there can be benefits in terms of physical activity and social interaction from going out.
Looking at huge data sets for London’s population enables us to see patterns in who is and who isn’t going out. These patterns show us that older people are much less likely to leave their house on a given day than younger people and it is not all down to no longer being employed or to increasing disability. Even when these factors are controlled for in the analysis older people are less likely to go out.
London, like many cities around the world, is seeing growth in the older population (by 2035 there will be 750,000 Londoners aged over 75). This research is an important reminder of the need to take the Healthy Streets Approach to ensure older people have the transport options to enable them to stay healthy and socially connected. In London older people have universal free travel on the public transport network. Healthy ageing depends on greater priority being given to improving the quality of the experience for older people when walking, cycling, using public transport and spending time on streets.
You can read the full paper here
‘Use the Healthy Streets Approach to prioritise health in all planning decisions’
This week the 25 year spatial development strategy for London, the London Plan, was published for consultation. The Healthy Streets Approach is a key theme, recognising the central role that the planning system plays in creating a healthy city.
The relationship between Healthy Streets and spatial planning was set out earlier this year in Healthy Streets for London:
“Developing housing around stations and improving connections to town centres will mean more people have the things they need within walking or cycling distance, while destinations further afield will be easily accessible by public transport. By establishing clear policies in the London Plan and by working with developers and local authorities, we can ensure that new development and regeneration embeds the Healthy Streets Approach from the outset.”
“… embedding the Healthy Streets Approach here will ensure that it becomes an integral part of future land use planning policy. Land owners and developers will be required to contribute to the health of their neighbourhoods when planning and building their developments. City planners will be required to prioritise walking, cycling and public transport use through high-density, mixed-use developments with good public transport access. The London Plan will ensure that the health and wellbeing of Londoners are essential considerations as the city develops in the future.”
Given this commitment it is fantastic to see that up front the London Plan makes it a requirement that those involved in planning and development must ‘Use the Healthy Streets Approach to prioritise health in all planning decisions’
The transport chapter starts provides a more detailed description of Healthy Streets and set out the Healthy Streets Policy T2:
A Development proposals and Development Plans should deliver patterns of land use that facilitate residents making shorter, regular trips by walking or cycling.
B Development Plans should:
1) promote and demonstrate the application of the Mayor’s Healthy Streets Approach to: improve health and reduce health inequalities; reduce car dominance, ownership and use, road danger, severance, vehicle emissions and noise; increase walking, cycling and public transport use; improve street safety, comfort, convenience and amenity; and support these outcomes through sensitively designed freight facilities.
2) identify opportunities to improve the balance of space given to people to dwell, walk, cycle, and travel on public transport and in essential vehicles, so space is used more efficiently and streets are greener and more pleasant.
C In Opportunity Areas and other growth areas, new and improved walking, cycling and public transport networks should be planned at an early stage, with delivery phased appropriately to support mode shift towards active and public transport travel. Designs for new or enhanced streets must demonstrate how they deliver against the ten Healthy Streets Indicators.
D Development proposals should:
1) demonstrate how they will deliver improvements that support the ten Healthy Streets Indicators in line with Transport for London guidance.
2) reduce the dominance of vehicles on London’s streets whether stationary or moving.
3) be permeable by foot and cycle and connect to local walking and cycling networks as well as public transport.
This policy will mean planners and developers will have to carefully consider health and health inequalities in their decision making. They will need to demonstrate they are delivering improvements against the 10 Healthy Streets Indicators. Many other policies in the Plan will also serve to deliver the Healthy Streets Approach. There are important policies in the transport chapter on car and cycle parking, freight and servicing. More broadly policies throughout the plan will influence how London functions and its ability to deliver the 10 Healthy Streets Indicators. For example mixed landuse, higher residential density, social infrastructure such as community health services and public toilets, active frontage of buildings and protection of heritage all contribute.
Coordinated efforts are needed by all those who have a role in shaping the city and this plan will be extremely valuable in making it happen in London.
If you would like, you can share your views on the London Plan here
Go here to learn more about how the Healthy Streets Approach is being embedded in policy
Transport for London (TfL) has just published the Healthy Streets Check for Designers. This technical tool is a spreadsheet of 31 metrics that can be precisely measured for any street. The output is a Healthy Streets score that indicates how that street’s engineering layout and management of traffic performs against the 10 Healthy Streets Indicators. It can be used to assess an existing street or a plan for a new layout.
This new tool should be a great help to designers, prompting them to consider the fundamental issues that they can shape to influence the human experience of being on that street. It should also enable decision makers to compare the relative performace of different streets.
I have worked for months with colleagues in TfL to develop a robust, valid, useable tool but a simple, precise and objective quantitative Healthy Streets scoring system is not easy to deliver. The Guide to the Healthy Streets Indicators shows that there are so many different factors influencing the human experience of being on a street, they change throughout the day and throughout the year and fall under the control of many different individuals and agencies.
This Healthy Streets Check for Designers is quite deliberately limited in scope to those factors that fall under the influence of the traffic engineer or designer and those elements of design with a clear link to human health and wellbeing. The management of motorised vehicles is of course central to this but the designer can do a lot to make streets inclusive and pleasant places for the whole community to walk, cycle, access public transport and spend time.
There is scope to develop Healthy Streets Checks for other professional groups with influence over streets including planners and developers. So watch this space for new Healthy Streets tools.
The Guide to the Healthy Streets Indicators should be the first stop for anyone who wants to know more about the Indicators and how to qualitatively assess them.
If you want to quickly identify what could make a street healthier, then you can just run through the prompt questions and you should find ideas for what changes are needed.
And if you’re embarking on a new project, this guide should help you to consider the diversity of human needs that must be met for a street to be successful.
An important aspect of this guide is that it considers the many different ways that the human experience of using a street can be improved. It does not just focus on the engineering and layout but also the policing, cleaning, maintenance, community and business engagement.
For some inspiration as to what can be done to improve a Healthy Streets Indicator there are examples from a range of different kinds of streets in London. But the Healthy Streets Approach applies to all kinds of streets in all kinds of towns and cities around the world so wherever you are, you should find this Guide useful.
In February 2014 Transport for London published the world’s first transport health action plan. I wrote this plan and oversaw its delivery over the past three years. This marked a transition from ‘health’ as a policy topic in a transport sector organisation to improving public health becoming the driving force for the long-term strategy.
The document was a major milestone. Transport for London became the first global city transport authority to commit to taking my Healthy Streets Approach. This is a radically different approach to transport planning that takes a whole street approach rather than choreographing a competition between transport modes. It was well received by local stakeholders and the international community, winning several awards including from the UK Chartered Institute for Highways and Transportation and the International UITP.
Each year a report was published setting out the progress made in delivering the three year action plan. This included generating new evidence of the relationship between transport and health in the city, training staff to monetise health benefits of transport projects and building health into policies. Certainly a dry read, but these reports document the foundations being laid for mainstreaming health in transport. Digging into the detail of these reports reveals a story that could be replicated across the many other areas of public policy making that could and should be embedding public health considerations.
Public health is described as ‘the science and art of promoting and protecting health and wellbeing, preventing ill-health and prolonging life through the organised efforts of society‘. To deliver improvements in public health therefore, it is essential that it is seen as ‘everyone’s business’ and systematically built into policy and governance of organisations across sectors, not just the health sector. When Transport for London published their transport health action plan they embarked on the process of building considerations of public health into their ‘organised efforts’.
The three annual progress reports on delivering this action plan chart the beginning of that process of building health considerations into transport sector decision making. This is much more than the cursory references to the health benefits of active travel that the transport sector has been making for many years. This is taking ownership of the huge impact that transport has on health by changing practices, investments and decision making to deliver real improvements in population health.
Embedding public health in any sector is not a simple and straightforward process. It requires a realisable but ambitious vision, a coherent and robust framework for action, skillful employment of technical expertise, engagement and coordination of a wide range of players, political commitment and a solid evidence base. It is a process of changing the way a whole range of people think and giving them the skills and tools they need to change the way they behave.
The Transport for London transport health action plan has now come to a close. The final progress report has been published setting out how public health has become mainstream in the organisation and built into the governance. The Healthy Streets Approach has been adopted as the overarching framework of the draft Mayor’s Transport Strategy which includes ambitious targets for improving population health and reducing health inequalities (another world first). The organisation is producing the tools for embedding the Approach in their business as usual and supporting the other players involved in how streets are designed and managed to change their practices too.
The world’s first transport health action plan can be seen as a blueprint for laying the foundations of changing practice to deliver real improvements in population health. This is transferable to the transport sector in other cities – and to other sectors too – so I am wondering which city will be publishing the world’s second transport health action plan?
It is an exciting week for Healthy Streets. The first Healthy Streets Conference was held on Thursday and this Monday the consultation period closes for the draft London Mayor’s Transport Strategy which is framed around the Healthy Streets Approach. It was therefore timely to use my keynote at the Healthy Streets conference to reflect on the evidence base for taking the Healthy Streets Approach.
In the article below, published in Local Transport Today in July 2017, I summarised the health evidence for London and the UK, needless to say a similar story can be told for most urban areas around the world.
Mayor of London Sadiq Khan has placed the Healthy Streets Approach at the heart of his 25-year Transport Strategy. This will require all transport decisions and investments to benefit health by improving the 10 Healthy Street Indicators. Making public health the driving force behind a transport strategy may seem a bold a step for a city to take, but a brief look at the circumstances in London show that this people-centred approach to transport planning is long overdue.
The levels of nitrogen dioxide (NO2) in London, while falling in recent years due to measures including cleaner vehicles and the Low Emission Zone, are still the highest in the UK.[i] This affects the health of every Londoner and contributes to shortening life expectancy for the most vulnerable people. Air pollution is not just a London problem; there are 37 zones across the UK that exceed the annual mean limit values for NO2.[ii] Small particulates in air pollution are within legal limits but there is no safe level from a health perspective and they account for nearly 5% of deaths in England.[iii]
Road danger and its health impacts
While air quality is considered by some to be a new health issue associated with transport, one issue we have been grappling with for decades – road danger – is still a major cause for concern. In 2015 over 2,000 people were killed or seriously injured on London’s streets.[iv] The national picture is also not good, with nearly 24,000 people killed or seriously injured on the roads in the same year.[v] It is shocking that violent life-changing events that ripple out to affect whole families and communities are an accepted part of our daily lives. This is a damning reflection of our priorities as a society.
The health impacts of road danger are more far reaching than injuries. In London it is estimated that 62% of journeys by motorised transport could be cycled. The majority of these are made by car[vi], but ‘too much traffic’ and ‘fear of being in a collision’ are the top reasons people give for not cycling.[vii] For their health, car owners desperately need safe, attractive streets for them to leave their vehicles at home more often. Car ownership in London is the strongest determinant of whether people are travelling actively each day, regardless of whether they live in the suburban fringes of outer London or the urban areas of inner London.[viii]
Active travel relieves the disease burden of inactivity
Across England 43% of adults do not manage to achieve the minimum recommended levels of activity each week (150 minutes in 10-minute periods). Even more shockingly, one in three adults do not manage even three 10-minute periods of walking or other ‘moderate intensity’ activity over the course of a week.[ix]
The easiest and most sustainable way for people to build physical activity into their lives and stick with it is through walking and cycling as part of their daily travel.[x] Research from the UK and mainland Europe shows that people who do any active travel in a day are likely to meet their physical activity requirements.[xi] This is why the public health community has championed active travel for so long. It really is seen as our best bet for reversing the huge burden of disease that has arisen over recent decades as a result of sedentary lifestyles.[xii]
While sport and leisure activities can greatly enhance individual lives and support communities, active travel is the affordable, sustainable and inclusive solution to ensuring everyone moves their body a bit every day of their lives.
Putting the most vulnerable first
Many of the ‘inactive’ population are older people. As people age, while they still need the same level of daily activity, they become more inactive.[xiii] Research with older people shows that they find it more challenging to walk even short distances to local shops and services due to uneven paving, lack of seating at regular intervals and intimidating crossing points.[xiv] Clearly, we need to raise our standards if we care about supporting our older population to remain active and independent in later life. And with the costs of health and social care spiralling upwards it is in everyone’s interests to act with urgency to ensure our communities are supportive environments for people who are living with complex needs and long-term conditions.
While the inactivity statistics for adults are dire nationwide, the statistics for children are almost unbelievable. Children need much more activity than adults to stay healthy, at least an hour a day. Currently only 22% are meeting that minimum standard.[xv] This used to be fairly easily achieved through ‘playing out’ and children travelling independently on foot or by bicycle for short neighbourhood journeys. Now this is a rare sight in many communities due to road danger and ‘stranger danger’. Both could be ameliorated by a shift in our street environments from being vehicle-dominated to ‘people places’, with the natural surveillance of eyes on the street.
The decisions made in local transport departments every day affect the health and prospects of communities today and for decades into the future. ‘Transport Strategy’ belies the great importance that a plan for changing the way that streets look and feel changes the trajectories of people’s lives. The evidence is clear that the challenges facing people in London hold for communities across the country. The root of many of the health and social challenges faced by our villages, towns and cities can only be addressed through transport strategies that put the needs of the most vulnerable people first. It is time to recognise the huge responsibility for health and wellbeing that lies with the transport planner. So, is it not time for the 10 Healthy Streets Indicators to be the goal for all our streets?
[i] Improving air quality in the UK: tackling nitrogen dioxide in our towns and cities Draft UK Air Quality Plan for tackling nitrogen dioxide (May 2017) DEFRA and DfT p.58 and p.31
[ii] Improving air quality in the UK: tackling nitrogen dioxide in our towns and cities Draft UK Air Quality Plan for tackling nitrogen dioxide (May 2017) DEFRA and DfT p.4
[iii] WHO Ambient (Outdoor) air quality and health (accessed July 2017) http://www.who.int/mediacentre/factsheets/fs313/en/ Fraction of mortality attributable to particulate air pollution (2015) in Public Health Outcomes Framework PHE http://www.phoutcomes.info/public-health-outcomes-framework#page/3/gid/1000043/pat/15/par/E92000001/ati/6/are/E12000004/iid/30101/age/230/sex/4 (accessed July 2017)
[iv] Collisions and casualties on London’s roads: annual report 2015 (2016) Transport for London http://content.tfl.gov.uk/collisions-and-casulaties-on-londons-roads-annual-report-2015.pdf
[v] Reported road casualties in Great Britain: 2015 annual report (2016) Department for Transport https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/556396/rrcgb2015-01.pdf
[vi] Analysis of Cycling Potential Policy Analysis Report March 2017 (2017) Transport for London
[vii] Attitudes towards cycling (2015) Transport for London http://content.tfl.gov.uk/atc-online-autumn-2015-report.pdf
[viii] G. Fairnie, D. Wilby and L. Saunders (2016) Active travel in London: The role of travel survey data in describing population physical activity,” The Journal of Transport & Health, volume 3, issue 2 10.1016/j.jth.2016.02.003
[ix] Active People Survey (2015) in Public Health Outcomes Framework PHE http://www.phoutcomes.info/public-health-outcomes-framework#page/3/gid/1000043/pat/15/par/E92000001/ati/6/are/E12000004/iid/30101/age/230/sex/4 (accessed July 2017)
[x] Everybody active every day: An evidence based approach to physical activity (2014) Public Heath England https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/353384/Everybody_Active__Every_Day_evidence_based_approach_CONSULTATION_VERSION.pdf
[xi] E. Fishman, L. Bocker, M, Helbich (2015) Adult active transport in the Netherlands: An analysis of its contribution to physical activity requirements Plosone http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0121871
Belanger et al (2011) Age related differences in physical activity profiles of English adults. Preventive Medicine
[xii] Everybody active every day: An evidence based approach to physical activity (2014) Public Heath England https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/353384/Everybody_Active__Every_Day_evidence_based_approach_CONSULTATION_VERSION.pdf
[xiii] Health Survey for England (2015)Joint Health Surveys Unit of NatCen Social Research and the Research Department of Epidemiology and Public Health at UCL http://content.digital.nhs.uk/catalogue/PUB13218/HSE2012-Ch2-Phys-act-adults.pdf
[xiv] Older people’s perceptions of walking (2016) Transport for London http://content.tfl.gov.uk/older-people-walking-report.pdf
[xv] Health Survey for England (2015)Joint Health Surveys Unit of NatCen Social Research and the Research Department of Epidemiology and Public Health at UCL
Today Public Health England published new statistics on the link between children’s emotional wellbeing and physical activity. They reminded us of the shocking statistic that only 1 in 5 children aged 5-15 achieve the minimum physical activity levels they need each day to stay healthy.
The strong focus on childhood obesity and the role of food and drink in driving that growing health crisis means that the important role of everyday activity is all too often overlooked. Enabling children to walk, cycle, scoot, play and explore in the streets around where they live is so important for their happiness, resilience, independence and healthy growth. My guest article in the UK Faculty of Public Health’s magazine Public Health Today set out why I think the Healthy Streets Approach is so desperately needed by our children……
The Healthy Streets approach delivers active children and healthy communities
Our efforts to tackle childhood obesity have focused on modifying diet, but the other side of the ‘energy in/energy out’ equation deserves careful consideration for the many co-benefits we can reap. A study by Mackett and Paskins (2004) assessed children’s energy expenditure during different activities and found that children burned the most calories when playing outdoors unsupervised or travelling actively. Neither activity is a routine use of time for the majority of children in the UK. Unlike past generations, most children in the U.K. do not spend several hours a day drifting around the streets looking for adventure and opportunity. Instead a car ride to organised activities, playing computer games and watching tv are more common.
There is good reason for this, over recent decades cars have filled our streets in ever increasing numbers. Now more affordable, convenient, comfortable and faster than ever their ubiquity means we don’t think to question their right to line our streets when parked and take precedence over other uses and users of the streets when they are moving. As a result many parents are reluctant for their child to walk with their friends to school, the park, the community centre or library and the sight of a child kicking a ball around in their street is rare. While many children living in urban areas live within walking distance of parks their ability to access them is constrained by the availability of an adult to accompany them. If we are to address inactivity amongst children then this is the issue we must face head on: how we will create street environments which are safe enough for children to travel on foot or by bike unsupervised.
Achieving this goal will deliver many wider health benefits. Streets in which car use is constrained (both in volume and speed) reduce road danger to all of us, improve air quality, reduce noise and are more accessible to the most vulnerable groups – older people, those living with illness and disabilities. These streets become welcoming spaces for everyone to walk, cycle and spend time helping us all to build some much needed activity into our daily routine and connect with our neighbours and communities. More eyes on the street helps reduce the fear of strangers that can further restrict children’s independent mobility.
I developed the Healthy Streets approach to deliver these outcomes. There are ten indicators of a Healthy Street, all are evidence-based to improve health, reduce inequalities and promote active travel. These indicators help to focus transport policy and decision making on what really matters: the human experience. The Healthy Streets approach moves us away from the passive acceptance of the dominance of motor traffic. We must consciously act to restrain motorised traffic through measures such as enforcing speed limits, ensuring pedestrian priority at crossings, reducing the convenience of driving short distances for trips that could be done on foot or by bicycle and installing cycling infrastructure that parents would be happy for their children to use unsupervised. Only through measures such as these, delivered at scale in villages, towns and cities across the country, can we provide an environment in which we can grow up and grow old healthy.