House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Memorandum by Sustrans (WP 02)

SUMMARY

Sustrans welcomes the Public Health White Paper "Choosing health: Making healthy choices easier". We see it as a significant step towards a future in which government funds are used to promote health and well-being right across the population, rather than treating people after they have become unwell.

We do however have real concerns about the delivery process, based on the white paper itself and what we have seen to date of the developing plans for its delivery. In a nutshell, our concerns are:

— that responsibility for delivery of the white paper as a whole may be pushed out to the local-level bodies of the NHS, to be executed through their local strategic partnerships, but without adequate support, performance management or resources from the top of the partner sectors; and

— that the physical activity element may be narrowed down to sport and recreation, and so largely devolved to the Department of Culture, Media and Sport (DCMS) and the sport sector.

We strongly urge that the other government departments whose programmes influence public health and in particular physical activity should step forward and ensure that both are central, measured objectives in all their work. These departments include:

— Department for Transport (DfT)

— Department for Education and Skills (DfES)

— Home Office (HO)

— Office of the Deputy Prime Minister (ODPM)

— Department of Trade and Industry (DTI)

— Department of Work and Pensions (DWP)

— Department for Environment, Food and Rural Affairs (DEFRA)

— Department for International Development DfID)

— HM Treasury (HMT)

— As well as the Department of Health (DH) and DCMS.

COMMENT

1. Sustrans is a practical transport charity, which works to change the environment so that sustainable, physically active ways of travelling are more accessible. Sustrans has over 25 years experience in creating environments for physical activity, such as the National Cycle Network (NCN) programme, and changing the transport culture to make it possible, as with Safe Routes to Schools (SRS).

2. We work in partnership with the DH, DfT, DfES, ODPM and others, national and regional agencies, community groups, schools and business, and also with international bodies. Our programme helps to deliver on government's policies and strategies in areas including public health, communities, regeneration and quality of life, and climate change.

3. Our comments below are restricted to our areas of expertise—transport, planning, physical activity and communities—in consideration both of the white paper itself and of its potential for effective implementation.

4. Over the last two years, we have worked closely with government departments and a wide range of bodies, to assist with the development of the Public Health White Paper and associated policies, such as the DfT's excellent "Walking and cycling: an action plan". In our view, the inter-sectoral and cross-government collaboration which informed the development of the white paper was its greatest strength; this gives reason for optimism regarding delivery.

5. Our response to the white paper itself is a positive one. It seems to build on the powerful arguments advanced both by Derek Wanless and by reports from your own committee, and to recognise two central facts:

— that both public health and economic arguments make it imperative to move from a "national sickness service" to a health promotion service

— and that only through a joint commitment across many sectors of government and society can the big public health issues be addressed with any real impact.

6. We are pleased to see a number of references to the importance of the environment in determining people's levels of physical activity, in terms of transport choice and also other lifestyle choices. The white paper refers to the role of various delivery partners in creating a more activity-friendly environment, and we support this.

7. We specifically welcome the recognition of Sustrans' flagship project, the National Cycle Network, as playing a public health role. Since we reported to your obesity inquiry, the NCN has grown by a third and usage has doubled to over 125 million walking and cycling trips per annum in 2003.[3] The 2004 results will be published in Spring; this year the NCN will reach 10,000 miles in length, and we expect usage to grow still further.

8. The DfT has made a one-off investment this year, in a programme of links to schools from the NCN, in partnership with local authorities. We expect these new local routes to create new walking and cycling trips across the whole community, not just for the school journey. The reference to this investment in the white paper gives the impression of a multi-year programme, which could eventually address thousands of schools. We urge that DfT should continue the investment in this way, and that the other relevant departments and sectors, notably DfES, ODPM and DH, should support it.

9. You have asked contributors to consider whether the proposals within the white paper will enable the achievement of public health goals, be appropriate, be effective and be good value. Here, we find ourselves unable to respond, because in our sectors the white paper does not list sufficient detailed proposals. It lists a number of examples of interventions which, in the main, we support.

10. Our most significant concern is that the white paper does not specify how other government departments and agencies will assume their responsibilities for improving public health. This deficiency has been yet more marked in the first stages of the process towards delivery, which has disproportionately focused on the role of local NHS bodies, working through local strategic partnerships. The NHS at local level will doubtless play a very significant role in improving public health in many of its facets. However, it is most unlikely to be able to bring about significant and sustained change in areas such as the choice of active travel or the active use and enjoyment of community space, unless supported by national policies and programmes. The relevant government departments will need to create new legislation, new guidance, new performance management targets, and new or expanded financial commitments.

11. While other government departments, such as the DfT, have lead responsibility each in their own area, there is a need for clear statements of commitment as to their relationship with the DH—for example, in sharing funding flows and performance management.

12. Therefore, to address your third area of interest, while we have no qualms about the quality and authority of the existing public health infrastructure and mechanisms, we note that these pre-date the multi-disciplinary approach to public health which pertains today. To address the issues of public health today, a number of sectors must act, jointly and severally, from government down to the local level. We address below areas of activity for each.

13. ODPM, planning bodies and professionals and local government need to address the location and accessibility of services and the removal of barriers to physically active travel. People need access to key services including healthcare, shops, work, schools and social activities.[4] The location of services where access is only easy by car promotes a sedentary lifestyle and helps to `lock in' car dependence. This also worsens social exclusion.

14. Measures should be taken by the above, with DfT and the transport sector, to make the street environment safer and more pleasant for pedestrians and cyclists and a place for children to play. The development of Home Zones in residential areas and other such urban redesign should be made a priority. The perception of traffic risk is a major impediment to cycling, in particular, for many people, and our failure as a society significantly to reduce the incidence of death and injury among cyclists and pedestrians suggests that the individual risk assessment is well founded.

15. The HO and police forces should move to more complete and stringent enforcement of traffic laws, reducing the danger and—as important—the threatening nature of the road environment, which suppress walking and cycling. Illegal and inappropriate speed, drink driving and the use of mobile phones, pavement parking and a still widespread disregard of vulnerable road users combine to dissuade all but the hardiest from cycling, in particular.[5]

16. In this context we very warmly welcome the excellent new Roads Policing Strategy statement by the Association of Chief Police Officers, the DfT and the HO.[6] We urge the three bodies to do all in their power to deliver on it, and in addition we recommend a communication programme, to address the often negative and ill-informed media treatment of measures to improve enforcement and save lives.

17. The HO and police forces should continue and redouble their offensives against other forms of anti-social behaviour, which deter many people from using public space. Please note that the public themselves identify speeding traffic as the anti-social behaviour that most affects them, and inconsiderate parking as their number two concern.[7]

18. Since you considered similar issues in your obesity inquiry, the DfT has abandoned the targets in the National Cycling Strategy for increased cycling levels in the UK. The failure of successive administrations to commit adequate resources to their achievement has meant that the targets are now unlikely to be met. However, levels of cycling in comparable European countries are significantly higher than in the UK,[8] and there seems no real reason to doubt that we could match them. The National Cycling Strategy Board has assembled a detailed plan to address the promotion of cycling at a national level.[9] We recommend that the DfT should adopt and fund this programme, reintroduce national cycling targets, and performance manage its agencies and local government on their achievement, and that the remainder of the transport sector should assist.

19. Similarly for walking, we urge the DfT to set targets for walking growth, and work with the rest of the transport sector to meet them.

20. In both of these cases, the targets should be integrated with the public health targets to increase levels of physical activity.

21. The above, and particularly a planned programme to increase levels of walking, will require improvement to the current systems and methods used to measure travel choices. We are presently working with statisticians at DfT and other bodies to address this question and, we expect, to introduce more robust and accurate methodologies to monitor and evaluate walking and cycling. DfT and others should give this priority.

22. We do welcome the awareness of public health in the new Local Transport Plan guidance to local highways authorities from DfT, which states "many Local Strategic Partnerships identify public health outcomes as key local priorities and LTPs should contain evidence that authorities are reflecting such"[10]. We agree: the LTPs should contain this evidence, and the DfT should take care to reward highway authorities which do so, and prompt thosewhich do not.

23. We strongly welcome the commitment to build on the DfT's Sustainable Travel Towns pilots, but recommend a much stronger follow up to these pilots than the "guidance" proposed in the white paper. The failure of the DfT and DH to ensure the inclusion of strong health promotion elements in the three pilot towns is a sad missed opportunity, which will undoubtedly mean that the beneficial outcomes identified by the Health Impact Assessment will be less than they could have been. This should now be addressed by at least one intensive "healthy travel town" intervention, involving significant change to the physical environment as well as behavioural measures, which should be co-funded by the two departments.

24. There are currently a number of incentives to unnecessary use of sedentary forms of travel, such as financial support for car use, free car parking etc. It is still, unfortunately, quite conventional for a hospital or school to provide free or subsidised car parking for staff or visitors, while offering no comparable benefit to people who travel actively. The costs of this to the business may not be identified, no management decision may ever have been taken, and no one may have considered how inequitable or unhealthy is the situation. This problem needs to be addressed, across the sectors of DfT / transport, DTI / industry, DfES / education, and of course the NHS should without delay put its own house in order.

25. In this context we strongly welcome two commitments in the white paper:

— the consultancy service to be provided to government departments by Sport England, on becoming "active workplaces"; it is most important that this should include active travel to work, and that it should be rolled out to all government buildings—national, regional and local; and

— the commitment to support the Sustainable Development Commission's "Healthy Futures" programme, which should if fully implemented tackle the current unintentional promotion of motor travel by the NHS.

26. We recognise and admire the initiatives taken by the DfES and education sector, including those in collaboration with the DfT and transport bodies, to promote physical activity and health in schools, including active travel initiatives. We urge these partners to redouble their efforts and to expand these activity initiatives into further education.

27. The white paper contains a number of references to the importance of sport; in principle we support this, but we are concerned that physical activity and sport are often treated as though they were interchangeable terms. Sport, in fact, despite having significantly higher profile and greater resources than other forms of physical activity, accounts for less than 10% of the activity enjoyed by the one third of the UK population currently physically active (see graphic below). It may be less attractive than other activities, such as walking or gardening, to the currently sedentary,[11] where the greatest health gain through physical activity is achievable.[12] The contribution of the various types of activity and their relative importance should be clearly recognised and stated.

28. In this context therefore, we are seriously concerned by hints that the promotion of physical activity may be devolved to the DCMS and the sport sector. We strongly urge the DH and other government departments to each assume the responsibilities of their sectors for public health—both physical activity and areas such as pollution reduction.

29. In the areas of transport and physical activity, as in a number of others outside our field, there are clear shared objectives with sustainability, emissions reduction and the battle against global climate change. Climate change, in particular, carries very significant public health risks for UK residents and the rest of the world. We therefore urge that the DEFRA and environment sector should work more closely with those now active in public health to achieve on these shared agendas.

30. We are concerned that legislative and taxation avenues seem to have been under-emphasised. We would urge that the Treasury review the tax regime on motoring and fuels, which have seen the real cost of motoring fall consistently over past decades. We also recommend that consideration be given to positive fiscal incentives to healthy behaviour—for example, schemes by employers to promote active commuting.

31. In the area of regulatory impact, we welcome the commitment to "build health into all future legislation by including health as a component in regulatory impact assessment". We trust this will include health impacts of legislation on transport and land use, traffic law, motoring and fuel taxes etc. These include traffic danger, local air pollution, accessibility of services by physically active travel modes, subsidy to sedentary modes, and so on.

32. Many of the trends in public health are international, and the UK has responsibilities with regard to public health beyond our shores. We urge that the DfID should incorporate public health impacts and measures more clearly into its work, and that the international aid and liaison sectors should give increased priority to considerations such as minimising air pollution and climate change emissions.

33. One concern we feel we should raise, across all sectors, relates to the scale of national implementation. Derek Wanless said "After many years of reviews and government policy documents, with little change on the ground, the key challenge now is delivery and implementation, not further discussion".[13] We feel that the time for local pilots and the selection of certain PCTs as "spearheads" may simply delay the delivery of the many benefits promised by the white paper, and so we urge full-scale implementation, by all relevant sectors, and a high level of investment; we believe that simple cost-benefit calculations can justify much more than the £1 billion figure currently mooted.

34. We look forward to clarification of the New Burdens Doctrine, and urge that it be made as strong and progressive as possible. Not only should local authorities be reimbursed for additional expenditure incurred in promoting public health, but those authorities which most actively take the lead should be rewarded with bonuses.

35. Across all sectors, a good example (including cycling and walking) should be set by political, administrative and business leaders.

36. Active, on-going promotion is needed of healthy and active behaviour, using promotional and media campaigns and individualised marketing interventions.

37. Intensive and transparent health impact assessment should be demanded on all transport and major land-use proposals and policies. All new projects should demonstrate real health benefits, taking into account not only their effect on pollution levels, traffic danger etc, but also their impact on the habits and lifestyle of affected people, both travellers and neighbours.

38. Sustrans wishes the committee well in its deliberations and would be happy to give oral evidence, or to provide any additional information required, in whatever form.

January 2005