HC 1048-III Health CommitteeWritten evidence from Sustrans (PH 08)

About Sustrans

Sustrans makes smarter travel choices possible, desirable and inevitable. We’re a leading UK charity enabling people to travel by foot, bike or public transport for more of the journeys we make every day. We work with families, communities, policy-makers and partner organisations so that people are able to choose healthier, cleaner and cheaper journeys, with better places and spaces to move through and live in.

It’s time we all began making smarter travel choices. Make your move and support Sustrans today. www.sustrans.org.uk

Key Points

Sustrans is a major player in improving public health, through programmes which bring a shift to walking and cycling for local trips;

we welcome the Government’s recognition, in the Healthy Lives, Healthy People white paper, that “it is not better treatment but prevention […] which is likely to deliver greater increases in healthy life expectancy”, and hope one day to see a Secretary of State for public health, with influence across all relevant Departments. Public Health England also needs the power to influence those sectors responsible for major health determinants;

we would like to see a commitment to grow the percentage of health budgets committed to public health, year on year;

we welcome the relocation of public health functions into local government, but are particularly concerned that the issues of transport, planning and public health may be marginalised in Health and Wellbeing Boards, and in the JSNA process;

there is a significant potential for shift to active, health-enhancing travel choices for local trips, benefiting health, sustainability and the climate agenda, and health equality. We hope to see DH, DfT and CLG working together to ensure planning and transport policies and investments are focused on all these objectives;

and so, it is important that the Public Health Outcomes Framework should reach into the planning and transport sectors; and

in particular, we would like to see DH and DfT jointly committing to:

incorporate public health criteria more fully into transport investment planning, including the Local Sustainable Transport Fund and Local Transport Plan processes;

publish an updated and reinforced Active Travel Strategy;

and oversee the implementation of NICE guidance, such as Physical Activity and the Environment and Prevention of Cardiovascular Disease (and the forthcoming walking and cycling guidance, of course); and

we are surprised that the white paper did not mention the National Cycle Network, a world-class, voluntary-sector-led, public health programme which deserves endorsement from the DH.

1. Sustrans Background

1.1 Sustrans is the UK’s leading sustainable transport charity. We deliver national programmes of practical intervention which promote regular walking and cycling. These programmes raise physical activity levels and improve public health, reduce climate change emissions, improve road safety and enhance wider quality of life.

1.2 Our comments therefore address public health and the Committee inquiry only from the point of view of physically active living and active travel. We have in general taken the Healthy Lives, Healthy People white paper as our starting point for comment.

1.3 The significance of active travel – walking and cycling for daily travel purposes – is clearly evidenced in the mainstream of public health policy and evidence review. We base our strategies and project design particularly on “At Least Five a Week”,1 the “Foresight Tackling Obesities”,2 report, guidance from the National Institute for Health and Clinical Excellence (NICE) such as “Physical activity and the environment”3 and “Prevention of cardiovascular disease”4 and our own, published, evidence review.5

1.4 Work that we have done for DfT and the Passenger Transport Executive Group (pteg), as well as work by others, makes clear that there is a significant potential for growth in walking and cycling for local trips (see para 5.5, 5.6).

1.5 Sustrans’ programmes have a significant impact on public health.6

the National Cycle Network carried 407 million walking and cycling trips, by 3.1 million individuals in 2009, with over two thirds of users reporting increased activity levels thanks to their local routes;

our Bike It programme doubled regular cycling to school, and has now worked with over 400,000 children;

our Personalised Travel Planning team has worked with over 250,000 households, providing travel information and support and consistently achieving shifts of between 10% and 15% of car trips to walking, cycling and public transport; and

we lead the Travel Actively consortium – all of the national walking and cycling groups, jointly delivering 50 projects across England, with a target to get 1.8 million people more active through walking and cycling.

1.6 A number of Sustrans’ local projects are delivered in partnership with NHS bodies, particularly Primary Care Trusts (PCTs), commissioned as part of the PCT public health function; we are working with these public health teams and others, to seek the best possible results from the move of public health into local government.

1.7 We also contribute to the development of policy (for example, working with DH on the Responsibility Deal for Public Health), guidance (eg work on NICE guidance development groups) and capacity (founder member and board of the Physical Activity Alliance; co-founder of the Take action on active travel alliance). In this we collaborate with most of the national public health organisations.

2. General Comments on Public Health Restructuring

2.1 Sustrans wholeheartedly supports the Government’s recognition, in the Healthy Lives, Healthy People white paper, that “… it is not better treatment but prevention […] which is likely to deliver greater overall increases in healthy life expectancy”. This recognition should drive future health investment planning, in order to get on top of the growth in healthcare demand and to achieve the best possible quality of life for individuals.

2.2 We support the government’s decision to make public health a true cross-government priority and create a Cabinet sub-committee.

2.3 We support the relocation of public health functions into local government. This restructuring is likely in our view to make health promotion more effective.

2.4 In our opinion, the Government should commit to an ongoing increase in the percentage of the total health budget focused on health promotion and the prevention of non-communicable diseases. Otherwise, the demand for healthcare must become unaffordable, while collateral issues, such as the declining health of the national workforce, will also create ever greater economic strain.

2.5 The white paper also recognised – and we welcome this clarity very much – that active travel can contribute to better health, sustainability and the climate agenda, and health equality. This is a strong argument in favour of cross-government and inter-sectoral collaboration, and joint investment strategies.

3. Issues Considered by the Inquiry

3.1 We consider that public health should be a prime concern of the Department of Health – that the provision of many aspects of healthcare should come to be regarded as the regrettable but necessary intervention of society when health promotion has been unsuccessful. In an ideal world, we would like to see a Secretary of State for Public Health, whose role and influence would cut across the whole of government.

3.2 Regarding the creation of Public Health England (PHE), from our perspective the most important issue is that PHE should have influence much more widely than just through the public health system as historically understood. Many of the determinants of individual lifestyle choices fall within the remit of other government departments and their sectors, and for PHE to be able to affect these determinants in a positive way it needs to be able to steer, directly or indirectly, factors such as planning policy and practice, and transport investment planning.

3.3 We are pleased to see that the inquiry raises the issues of the Health and Wellbeing Boards (HWBs) and of Joint Strategic Needs Assessment (JSNA). Over April and May this year, Sustrans has surveyed Directors of Public Health (DsPH) to investigate their views on the importance of active travel as health promotion, the extent of their engagement with their transport peers, and their future plans in this area. The results (interim) are worrying:

85% of DsPH regard physical activity as important or very important;

45% feel they have a strong or very strong relationship with their transport colleagues;

and 76% collaborate to at least some extent with transport in active travel promotion;

but only in 23% of cases will transport feature more than generically in the next round of JSNA;

and 66% expect transport to be unrepresented on the HWB;

only 48% of respondents had contributed more than a stakeholder consultation response to their local authority’s Local Transport Plan 3 (the current round);

and only 44% were involved to this level in their council’s bid to the DfT Local Sustainable Transport Fund – which is ideally suited to behavioural interventions promoting a shift to active travel; and

this implies that, although many individuals “get” the shared public health and transport agenda, the system is obstructing good collaboration and, above all, that the opportunities for public health to help steer transport policy and investment planning are being missed.

3.4 We would like to see concerted action by the three Government departments involved in this area – DH, DfT and CLG – to ensure collaborative work, at the highest level of local government, between public health, planning and transport. This should include a specific focus on HWBs and JSNA. No doubt you will have heard from the expert public health bodies of a concern that when DsPH move into local government, they must be located in roles of sufficient seniority to ensure their voice is heard across the other, relevant areas of local decision making: this is a concern we share.

3.5 The inquiry mentions public health involvement in the commissioning of NHS services. We would draw your attention to the reverse of this question – GP commissioning of health promotion, including commissioning from providers outside the traditional health sector, such as Sustrans. Under the current proposals, GPs will continue to have an important role in referring individuals whose lifestyles are insufficiently physically active to programmes which promote physical activity, such as through walking and cycling. There may be an issue as to how such physical activity promotion is paid for, if GP commissioning budgets do not include a public health element. We hope that the development of Public Health England, the establishment of public health budgets within local authorities and the relationships of these with GP consortia will take such issues into account.

3.6 And there may be a training issue: GPs and the commissioning specialists in consortia may not be as expert in health promotion – and specifically in areas such as active travel – as they will be in the commissioning of medical and clinical services.

3.7 Regarding the Public Health Outcomes Framework, our view is that the breadth of public health activity and the wide range of bodies and sectors involved in delivery of health promotion mean that Public Health England will need to work in wide cross-sector partnership so as to collate all the available evidence. Some effective actors in health promotion are a long way outside the health world, and may not even be aware of the Outcomes Framework. They may use different measures, and often may only determine intermediate outcomes (such as more children walking and cycling to school). And of course in the transport field the standard approach to economic assessment is Cost Benefit Analysis, which doesn’t fit with the approach in health.

3.8 In the field of active travel, Sustrans has a Research and Monitoring Unit (RMU) producing high quality evidence based on our own practical programmes and those of others, including the Travel Actively consortium, the Cycling Demonstration Towns (CDT) and Sustainable Transport Demonstration Towns (STDT) in England. The RMU works with DfT, as well as with WHO, National Obesity Observatory and others.

3.9 We recommend that the research, monitoring and evidence strategies of PHE should explicitly set out to create cross-governmental and inter-sectoral evidence partnerships, with DfT, with Sustrans and with other transport specialists.

3.10 We also recommend that PHE should be explicit about the need for evidence on the environmental determinants of individual behaviour, and on the impact of environmental intervention. Some evidence and policy specialists seem to assume that public health programmes are exclusively about individual focused motivational and marketing approaches: the behavioural impact of the National Cycle Network (see para 4.3) illustrates just how significant an environmental improvement can be.

4. The Environment Conditions Behaviour

4.1 Healthy Lives, Healthy People notes that “improving the environment in which people live can make healthy lifestyles easier. When the immediate environment is unattractive it is difficult to make physical activity […] part of everyday life. Unsafe or hostile urban areas that lack green spaces and are dominated by traffic can discourage activity.”

4.2 We consider the environment as a central determinant of people’s lifestyle choices. Until the environment itself “nudges” individuals towards, rather than away from active lifestyles, we cannot expect significant and lasting behaviour change. In the Netherlands, 25% of trips by the over-60s are made by bicycle7 – that is the type of environment we should be creating here.

4.3 So we draw your attention to the National Cycle Network, which in 2009 carried 407 million trips by 3.1 million individuals – 50:50 on foot and by bike (303 million in England). Over two million of these users say the existence of the Network has led them to increase their levels of physical activity, and more than half were below the recommended 5X30 minutes of physical activity per week. This is a world-class, voluntary-sector-led, public health programme, perhaps the largest public health intervention currently underway, and deserves explicit Government endorsement as such.

4.4 Again, Healthy Lives, Healthy People says that “the DH will support local areas … for example by sharing learning from the experiences of the nine healthy towns as well as sustainable travel towns and cycle towns”, and that “local sustainable transport, including active travel, will be supported through the DfT £560 million Local Sustainable Transport Fund”.

4.5 In Sustrans’ view the commitment to cross government policy-making and delivery needs to be much greater. Public health needs to be centre stage in transport, and indeed in planning policy. We would have liked the white paper to explain how these other policy fields will ensure growth in walking and cycling, and how the growth will be resourced.

4.6 It will be of critical importance that the local Director of Public Health and colleagues are able to influence and steer local transport strategies and investment. Sustrans and others have urged DfT to make public health objectives central to planning and transport policies and strategies, and above all to investment planning objectives.

4.7 DH and DfT collaborated effectively on the Active Travel Strategy, published in early 2010. The loss of this strategy with the change of government is unfortunate. We hope for a commitment to publish an updated, improved and more delivery-focused version.

4.8 The Cycling Demonstration Towns programme, whose success the White Paper acknowledges, has been halted by DfT. It should be reinstated – quickly enough for the existing momentum to be maintained – on public health grounds alone, although of course it also addresses government objectives on climate, congestion, quality of life etc.

4.9 And we recommend cross-governmental work to ensure that existing public health guidance from NICE, such as PH08 Physical Activity and the Environment and PH25 Prevention of Cardiovascular Disease, is implemented by local authorities and the other groups named by NICE. We would like to see DfT put its own logo onto guidance like this – whether jointly with NICE or by republishing under the DfT brand. NICE has just begun the development of guidance on the promotion of walking and cycling (due October 2012) – this would be an ideal place for DfT to start co-branding.

5. The Potential of Active Travel to Benefit Health

5.1 Many authoritative voices have made clear the importance of active travel in healthy lifestyles. Back in 2004, this committee considered evidence on the obesity epidemic. It reported: “If the Government were to achieve its target of trebling cycling in the period 2000–2010 (and there are very few signs that it will) that might achieve more in the fight against obesity than any individual measure we recommend within this report”.8

5.2 Foresight, in 2007, said “the top five policy responses assessed as having the greatest average impact on levels of obesity [include] increasing walkability/cyclability of the built environment”.9 the Chief Medical Officer called for “national targets … to double travel on foot in England’s towns and cities, and to increase travel by bicycle eightfold”.10

5.3 The Cabinet Office calculated the costs associated with our current approach to transport, including cost of congestion, physical inactivity, CO2 emissions, other pollutants, noise and accidents, to £38-48 billion in England.11 Physical inactivity contributed £9.8 billion to this, and other areas directly related to public health included air quality (£4.5–10.6 billion), road casualties (£8.7 billion) and noise (£3–5 billion).

5.4 The same Cabinet Office research project showed that people could replace 78% of their local car trips under five miles with walking, cycling or public transport.12

5.5 Studies by Sustrans for the Department for Transport (DfT) on the STDT programme correlate well with this. In the three demonstration towns (Darlington, Peterborough and Worcester) almost 50% of local car trips could have been made by at least one other, more active and sustainable, mode of transport.13

5.6 More recently, we worked with pteg to model the potential for increasing cycling in the six city regions (population 11 million). We found that an area-wide approach similar to that piloted in the CDT programme could generate 96 million additional cycle trips per annum from an investment of £337 million spread over three years. The best estimate benefit value of this travel behaviour change would be over £700 million (good value for money in transport terms). Annual health benefits are modelled at £62 million, and the savings to the NHS alone, over ten years, at £196 million.14

May 2011


1 Department of Health, 2004 At least five a week. Evidence on the impact of physical activity and its relationship to health. A Report from the Chief Medical Officer

2 Government Office for Science, 2007 Foresight Tackling Obesities: Future Choices project report

3 National Institute for Health and Clinical Excellence, 2008 Promoting and creating built or natural environments that encourage and support physical activity

4 National Institute for Health and Clinical Excellence, 2010 Prevention of cardiovascular disease

5 Sustrans Active Travel information sheets at http://www.sustrans.org.uk/what-we-do/active-travel/active-travel-publications

6 Sustrans, 2010 Moving forward: a year of delivering smarter travel choice

7 Ministerie van Verkeer en Waterstaat NL Facts about cycling in the Netherlands

8 Stationery Office, 2004 House of Commons Health Committee, Obesity, Third Report of Session 2003-04

9 Government Office for Science, 2007 Foresight Tackling Obesities: Future Choices project report

10 Department of Health, 2010 On the state of public health: Annual report of the Chief Medical Officer 2009

11 Cabinet Office, 2009 The wider costs of transport in English urban areas in 2009

12 Cabinet Office, 2009 An analysis of urban transport

13 Sustrans, 2005 Travel Behaviour Research Baseline Survey 2004: Sustainable Travel Demonstration Towns

14 Sustrans, 2011 Cycling in the city regions and Annex 1: Modelling the Impact of Step Changes in the Delivery of Measures to Support Cycling in PTE Areas: Technical Report

Prepared 28th November 2011