HC 1048-III Health CommitteeWritten evidence from Living Streets (PH 101)


Walking is the one form of physical activity that is open to all. In focusing on getting sedentary people active as a key priority of the public health agenda, walking must be promoted as a first step or gateway to more active lifestyles. The promotion of walking through behavioural change initiatives, investment in quality public realm and planning for liveable, compact neighbourhoods is a highly successful, proven and cost effective way to prevent illness and reduce mortality rates and should be promoted throughout public health policy.

The creation of a dedicated public health body in Public Health England and the devolution of public health responsibilities to local government are welcome, and should be used as an opportunity to ensure that public health is well resourced, that public health professionals have the influence they need to drive change and that the new governance arrangements at local and national level bring together professionals from across disciplines, including planning and education, to ensure a coordinated approach.

Budgets for public health must be sufficient to address the issues effectively and meaningfully. Whilst flexibility of budgets has great potential in seeing budgets go further to meet multiple objectives, budgets should not be used to fill funding gaps in existing local authority activities such as leisure or environmental health services.

The implications of poor streets and public realm on health inequality, and the availability of walking to people of all economic backgrounds, make public realm investment an ideal vehicle to help close the health inequalities identified in the Marmot Review.


1.1 Living Streets is the national charity that stands up for pedestrians. With our supporters we work to create safe, attractive and enjoyable streets, where people want to walk.

1.2 We have been the national voice for pedestrians throughout our 80-year history. In the early years, our campaigning led to the introduction of the driving test, pedestrian crossings and 30mph speed limits. Since then our ambition has grown. Today we influence decision makers nationally and locally, run successful projects to encourage people to walk, and provide specialist consultancy services to help reduce congestion and carbon emissions, improve public health, and make sure every community can enjoy vibrant streets and public spaces.

1.3 Public health remains a hugely significant issue, particularly with an aging and more overweight population that is widely predicted to impose an unsustainable burden on the public coffers and the NHS by 2050. In setting out Living Streets’ ideas on the Government’s proposals, particularly focussing on the need to deliver results for a minimum financial outlay relative to benefit, this response emphasises the credentials of walking as a cost-effective and sustainable public health solution, open to all and a natural gateway to further preventative health measures. At their best, planning-based and behavioural change strategies to improve public health anticipate and address lifestyle trends that, if left unchecked, could necessitate preventative health measures at a later stage, incurring a higher human and resource cost.

1.4 This submission focuses on four of the key points raised by the Committee: the creation of Public Health England, the future role of local government, the purpose of the Public Health Outcomes Framework and the Government’s response to the Marmot Review.

The creation of Public Health England within the Department of Health

2.1 Living Streets broadly welcomes the creation of Public Health England as a means of sharing evidence and best practice on public health problems and interventions.

2.2 We strongly believe that alongside the general move towards a more localist approach, the Department of Health will need to maintain a significant role in coordinating public health and supporting local delivery. Public Health England must be sufficiently well-resourced and influential to achieve this; the body must have operational independence and act as a body which provides advice and recommendations in its own right.

2.3 Public health is an outcome of almost all government activity, as well as a specific function in itself. There needs to be clear, high level responsibility for public health across departments. As we have stressed in our responses to the relevant NHS White Papers, the effective coordination of public health will require cooperation between several departments and agencies, involving, for example, the Department of Communities and Local Government and the Department for Transport to ensure that planning and transport policy, including the National Planning Policy Framework, promote public health through such measures as ensuring good air quality and making active travel the natural choice. It is vital that Public Health England and the Department of Health ensure that this inter-departmental working occurs effectively.

2.4 Public Health England should have a role in assessing wider Government policies and programmes for their impact on public health and wellbeing. As part of this effort it may be helpful for Public Health England to publish definitive standards on public health outcomes which can be promoted for application across departments, ensuring some continuity if the political landscape changes.

2.5 In order to perform this coordination role effectively, Public Health England should contain expertise and knowledge of planning, urban design, transport and education in order to ensure a coordinated approach to creating and maintaining healthy environments.

The future role of local government in public health

3.1 We broadly welcome the integration of public health responsibilities and functions within local authorities as a way to increase democratic legitimacy and promote interventions that are better tailored to the needs and characteristics of specific communities. With regard to active travel, decision-makers at this level should be better placed to know which initiatives will improve the walking environment and reduce obstacles, both physical and perceived, which act as a deterrent to walking, within an particular area. We would stress, however, that the increased involvement of local government should also be a vehicle to acknowledge and further the strong links between planning, housing and transport policy and health and wellbeing.

3.2 We feel strongly that the responsibility on local authorities to support joint working on health should be statutory, and welcome the proposed establishment of Health and Wellbeing Boards and the proposed status of Directors of Public Health. In order to be effective across the breadth of the public health agenda, Directors of Public Health must have the professional independence to set out clear advice and guidance, and a status at the Executive Director/Board level of local authorities.

3.3 Whilst we are broadly in favour of a light-touch approach to these arrangements, we feel that the guidance around establishing such boards should explicitly recommend that boards include senior planning, housing and transport policy officers, as well as directors of learning and children’s services, senior stakeholders with responsibilities for local sports and recreation and senior stakeholders from primary and secondary education. This is in order to maximise the opportunities for local areas to implement cost-effective preventative measures such as the promotion of physical activity and quality health education, enhancing the general quality of life in addition to providing a basis for better health outcomes.

3.4 The involvement of planners and urban designers in local public health governance is particularly crucial to ensure the health-oriented planning of compact, mixed-use walkable neighbourhoods with good quality public realm. Generally, places displaying characteristics of walking-friendly urban form are associated with a 25-100% increase in people’s likelihood to walk. Our breadth of experience in providing consultancy services to local authorities, and in combining walking promotion with grassroots support for physical environment improvements through projects such as Living Streets’ Fitter for Walking programme, has consistently shown that getting the quality of the built environment right is crucial to making streets and places where people feel comfortable and safe and where they want to both walk and spend time. “The design and management of the built environment can create barriers to physical activity – or they can create opportunities for activity that make an active lifestyle an attractive and compelling choice”. Transport for London research has shown that the top three potential motivators for walking more included new and improved public spaces with new seating, new and improved crossing facilities at junctions alongside new and improved walks for pleasure.

3.5 The promotion of walking and of quality public realm also have notable social, environmental and economic benefits. Recent research both from the UK and internationally, for example, has demonstrated that investment in the walking environment can increase profits to local businesses, increase rents in certain areas, increase foot traffic and that local residents and business would be willing to pay more or contribute to part of the costs of improvement schemes. Links to such wider outcomes from interventions that promote health have crossover benefits such as reducing carbon emissions and improving air quality. These crossovers need to be reflected in the way that the public health agenda is managed at local level, with the responsibilities and remits of Directors of Public Health relating to a broader range of activities and programmes which impact on public health and wellbeing.

3.6 The decentralisation of responsibility should not be an occasion to reduce funding for public health, but rather to improve the way in which this funding is targeted and used.

The purpose of the Public Health Outcomes Framework

4.1 Living Streets broadly welcomes the structure and priorities of the Public Health Outcomes Framework.

4.2 It is important, however, that monitoring of outcomes is conducted at reasonable intervals. Behavioural change measures – particularly those which challenge entrenched habits such as car use – take time to take effect, paying dividends in the medium to long term, and monitoring practice needs to reflect this.

4.3 We support the inclusion in the Outcomes Framework of an additional criterion around the co-benefits of public health interventions – such as the social, environmental and economic benefits of investment in the walking environment – in order to ensure that cost-benefit decisions are made in the round and use resources to the best possible effect.

4.4 We also advocate the inclusion of a measure of walking activity, ideally one which allows differentiation between levels of walking and levels of cycling. If possible this should also include measures which assess perceptions of walking and the walking environment, as walking levels may be suppressed where the walking environment is unwelcoming or perceived to be unsafe or unattractive. Similarly, we advocate a measure of road danger in order to ensure that approaches to the reduction of road casualties genuinely address road safety, rather than deterring walking and cycling and causing a modal shift away from active modes which would conflict with broader preventative health goals.

How the Government is responding to the Marmot Review on health inequalities

5.1 Living Streets believes that a greater proportion of NHS spending should be targeted at preventative measures, and advocates walking promotion, road safety, air quality and improvement of the built environment as key areas in which effective interventions can have profound effects on health inequalities.

5.2 According to the Marmot Review, only 4% of NHS expenditure was spent on preventative measures. This is despite a rapidly growing need for such measures: for example, in 2005, almost 871,000 prescription items were dispensed in England for the treatment of obesity compared with just over 127,000 prescriptions in 1999 (an increase of 585%). Greater investment in preventative health – and within this in the proven and successful measures needed to promote walking – is the rational response.

5.3 The Department of Health’s social marketing strategy (Changing Behaviour, Improving Outcomes) explains the value of preventative health campaigns and the dangers of reducing funding; following last year’s announcement of cuts, Change4Life’s new member rates fell by 80% (90% if considering calls only, Talk to FRANK calls fell by 22% (with a 17% drop in visits to the website), and the NHS Smokefree campaign’s user numbers were down 50%. These examples, which are widely viewed as having achieved some success, have demonstrated the value of preventative campaigns.

5.4 Preventative measures targeted at increasing physical activity have been shown to reduce costs to the NHS. Physically active lifestyles are associated with a 40% reduction in the genetic predisposition to obesity. Walking has been proven to reduce the severity of dementia (reduces risk by 50%), retain bone density and stability, as well as to reduce the risks of some cancers, cardiovascular diseases (reduced by up to 30%), obesity, depression and high blood pressure; and has even been shown to reduce overall mortality rates by up to 20%.

5.5 These levels of reductions on mortality alone, even without consideration of improvements to health and disease prevention in non-fatal or life threatening ways, represent a significant reduction in health costs nationally, year on year, in the longer term. The public purse also benefits more broadly: for example, there is strong evidence to suggest that physically active employees take far fewer sick days than inactive employees, with widely quoted research putting the differential as high as 27%. Walking also has an important role in secondary preventative health, the management of long-term conditions such as diabetes and in reintroducing physical activity during recovery from serious illnesses such as cancer. In his 2009 report, the Chief Medical Officer stated that “The potential benefits of physical activity to health are huge. If a medication existed which had a similar effect, it would be regarded as a ‘wonder drug’ or ‘miracle cure’.”

5.6 The Marmot Review stresses the importance of targeting walking as a preventative health intervention at children when young. This reinforces our proven belief: not only is infant/child obesity a problem (30% of children aged 2 to 15 were categorised as overweight or obese in 2007) but behaviours learned in childhood often remain into adulthood. Our experience in managing the national Walk to School programme, which reaches over 1.3 million children across the UK, has demonstrated the potential of building walking into daily routines from a young age: in an independent evaluation of Living Streets’ Walk Once a Week programme, 19% of children surveyed reported that they started walking to school because of Walk Once a Week, the proportion of children walking to school in schools running WoW was over 9% higher than the national average as determined by the National Travel Survey, and there were indications of an associated positive effect on the number of walking trips made by adults.

5.7 For both adults and children, walking is perhaps the mode of exercise best suited to tackling health inequalities. It is almost unique as a physical recreational activity in the fact that there is no financial outlay and, unlike gym-going in particular, can be participated in across financial divides. The cost-effectiveness of active travel as exercise further extends to the infrastructure needed.

5.8 Improvements to the built environment are among the best ways to address health inequalities. Poor, unsafe walking environments are a typical attribute of areas of deprivation. A recent, detailed statistical study of child road casualties found that children living in Preston are more than twice as likely to be injured on the road than the national average, and five times more likely than those in Kensington & Chelsea. The House of Commons Transport Committee’s report, Ending the Scandal of Complacency, drew out the disproportionate impact of road casualties on both children and young people and deprived communities, noting that “child pedestrians from the lowest socio-economic groups are 21 times more likely to be killed in a traffic accident than those from the top socio-economic group”.

5.9 Air quality is also correlated with deprivation. Environment Agency studies have conclusively found that “The most deprived areas suffer from the poorest air quality. They have the highest concentrations of nitrogen dioxide, airborne dust (fine particulates), sulphur dioxide, carbon monoxide, and benzene. People in the most deprived areas are exposed to 41% higher concentrations of nitrogen dioxide than people living in areas of average deprivation”. Achieving modal shift away from motor vehicles is a crucial aspect of addressing this inequitable situation, while local authorities should critically assess existing and emerging planning frameworks to ensure that deprived areas do not bear the brunt of major routes and traffic corridors.

5.10 Intimidating and badly maintained walking environments are a powerful reason for people to walk as little as possible, and this is an issue with profound psychological effects in addition to the negative impacts on physical activity and road safety. A focus group participant quoted in the Marmot Review said of their local neighbourhood, “You can see the deprivation. All you have to do is look outside. It is in your face every day – litter everywhere, rats and rubbish, it is a dump… It feels like people around you have no meaning to life. I keep my curtains closed at times. It doesn’t give you a purpose to do anything.” In aiming to get more people walking more often, the importance of good public realm, safer streets, cleaner air and intelligent mixed-use planning need to be placed at the heart of the local public health agenda.

June 2011

Prepared 28th November 2011