future health full report 0

8/14/2019 Future Health Full Report 0

1/53

1

Future healthSustainable places for health and well-being


2/53

2

Contents

Introduction 4

RecommendedreadershipWhyhealthandwhynow?Howtousethisdocument

Chapter 1Challenges and opportunities for our health, 6well-being and environment

1 Modern healthcare: more than hospitals 8

Improvinghealthoutcomes

Theuserexperience:howdotherapeuticenvironmentswork?Whereareservicesplannedwithincommunities?Anongoinginvestment

2 Well-being, positive lifestyles and the planned environment 12

ImpactofunhealthyenvironmentsPhysicalexercisePositiveinuencesonmentalhealthPublichealthwithintheplanningprocess

3 The sustainability link 16

EffectsonhealthofclimatechangeandenvironmentaldegradationTheroleofbuildingsandplacesThepotentialoftheNHStoinuenceplanningTheeconomicincentiveMakinganimpact

Chapter 2Best practice 19

InuencingthefutureoftownsandcitiesInuencingtheshapeandhealthofneighbourhoodsRunninganddeliveringhealthcarebuildings


3/53

3

Chapter 3

What needs to change 28

PlanningProcurementOvercomingsilo-thinkingUsingassetseffectively

Recommendations 30

Appendices 32

1Methodology 33

2Fur therresearchanddetailtosupplementtherepor t 34 i. Well-being 34 ii. Climatechange 35 iii. TheNHScarbonfootprint 38 iv. ThesizeandinuenceoftheNHS 39 v. NHSbuildingstock 40 vi. Researchintotherapeuticdesign 41 vii.Effectsofhospitaldesignonnursingstaff 42

3Toolkitsandkeyorganisations 44

4 Bibliography 49


4/53

4

Introduction

1 Ulrich,R.&Zimring,C.2004:The role of the physical environment

in the hospital of the 21st century: A once-in-a-lifetimeopportunity,CenterforHealthDesign,Concord,California

2 NaturalEngland2009:Headline Facts: The cost of obesityand physical inactivity[online].cabeurl.com/2n

3 DepartmentofHealth2005: Choosing Activity: a physical activity action

plan, Cm6374,London,DepartmentofHealth.cabeurl.com/2o4 DepartmentforBusiness,EnterpriseandRegulatoryReform,

CommunitiesandLocalGovernment,DepartmentforEnvironment,

FoodandRuralAffairs,DepartmentforCulture,MediaandSport&

StrategicForumforBusiness,2007:Draft strategy for sustainable

construction: a consultation paper.cabeurl.com/885 ThisgureisbasedonemissionestimatespublishedbyDefra(2008),

whichcalculatestheUKscontributiontoglobalcarbonemissionsas

approximately2percent(cabeurl.com/8q).However,thisgurehas

beenchallengedbyChristianAid(2007)whichclaimsthatexported

consumption,intheformoftheinternationalactivitiesofUKcompanies,

meansthattheUKsrealimpactonglobalcarbonemissionshasbeen

underestimated.ChristianAidclaimsthatamoreaccurategurewould

actuallybearound12-15percentoftheglobaltotal(cabeurl.com/8r).6 NHSSustainableDevelopmentUnit2009: Saving Carbon,

Improving Health: NHS Carbon Reduction Strategy forEngland,Cambridge,NHSSDU.cabeurl.com/6e

7 SustainableDevelopmentCommission&NHSSustainable

DevelopmentUnit,2009,Are you a good corporatecitizen?Cambridge,NHSSDU.cabeurl.com/8j

It is widely recognised that the designof the environment affects the healing

process. Evidence shows that designcan affect patient health outcomes, staffrecruitment and retention, and even theeffective provision of care.1 Recently inthe UK, major investment in healthcarebuildings has resulted in new hospitals,diagnostic and treatment centres andintegrated community settings for primaryhealth and social care. Healthcare is ina period of rapid transition as a result of

the UKs ageing population, higher publicand policy expectations, technologicaladvances affecting medical proceduresand information systems, and the demandfor more effective care. The need for thebuilt environment to provide safe, effectiveand high-quality places that can adapt tochanging care delivery patterns has neverbeen as clear.

Thevalueofthephysicalenvironmentinpromotingandimprovingpublichealthisnowbetterunderstood.

Withthishavecomecallsfortheplanningprocesstosupporthealthylifestylesthroughhealthiercitiesandneighbourhoods.Evidenceincreasinglysuggeststhatthewiderenvironmentcanreducestress,encourageexerciseandpromotegoodhealth.InEnglandalone,obesityandphysicalinactivitycostthecountry2.5billionand8.2billionrespectively.2Bycontrast,regularphysicalactivitycontributestothepreventionofmorethan20conditionsincludingcoronaryheartdisease,diabetes,certaintypesofcancer,mentalill-healthandobesity. 3Activetransport,provisionofgoodpublicopenspacein

whichtoexerciseandopportunitiestofostersocialcohesionareallfactorsthatshouldbeconsideredintheplanninganddesignofthebuiltenvironment.

Withinthiscontext,asustainableplanningapproachthattakesintoaccounttheinuenceofenvironmentsonhealthisurgentlyneeded.Thereis,forexample,considerablepotentialforthedesignofthebuiltenvironmenttominimisetheeffectsofclimatechange.TheconstructionanduseoftheUKsbuiltenvironmentinfrastructurecurrentlyaccountsfor

around50percentofnationalcarbonemissions4

and1percentoftotalglobalemissions. 5TheNHS,withthelargestpropertyportfolioinEurope,contributes3percentoftheUKstotalCO2emissions, 6andtheNHSCarbonReductionStrategy(2009)setsgoalsfortheNHStolowerCO2emissionsinlinewithgovernmenttargetsonclimatechange.TheSustainableDevelopmentCommissionhasalsoarticulatedhowNHSorganisations,locallyandnationally,havearesponsibilitytobegoodcorporatecitizens.7

Thisreportexploreshowthedesignofthebuiltenvironmentcanhelptodeliverthreekeypolicyobjectives:modernisinghealthcare,addressinghealthinequalitiesthroughlifestylechanges,andcreatinghealthy,sustainabledevelopment.Whilsteachoftheseisaspecialisttopicinitsownright,herewefocusonthepotentialfordesigntoaddressthemtogether.Weconcludethatthisdesignfocuscanproduceadditionalbenets.Asingledesigninterventioncanaddresstherequirementsofmorethanoneofthesepolicyobjectives:forexample,locatingservicesinthecommunitywithgoodtransport

connectionsmakesservicesmoreaccessible,reducesCO2emissionsandprovidesintegratedcommunityservicesandactivities.Inthisway,thedesignprocesscanbeacatalystforpolicychangeaswellaspracticalimprovementstothebuiltenvironment.
http://cabeurl.com/2nhttp://cabeurl.com/2ohttp://cabeurl.com/88http://cabeurl.com/8qhttp://cabeurl.com/8rhttp://cabeurl.com/6ehttp://cabeurl.com/8jhttp://cabeurl.com/8jhttp://cabeurl.com/6ehttp://cabeurl.com/8rhttp://cabeurl.com/8qhttp://cabeurl.com/88http://cabeurl.com/2ohttp://cabeurl.com/2n


5/53

5

Recommended readership

Thisdocumentwillbeusefultothosewhocanaffecthealthoutcomesorwhoshapeenvironmentsthataffecthealthandwell-being,including:

Policymakers: thosedecidingnational,regionalandlocalpolicies

forhealth,well-beingandsustainableenvironments.

Commissioners of healthcare: healthtruststhatrespondtothehealth

requirementsoflocalpopulations.

Providers of healthcare and of environmentsthat impact on health and well-being: acuteandprimaryhealthcaretrusts

andtheirestatedivisions projectmanagerswhodeliverbuildingor

refurbishmentprojectswithinthehealthcareestate localauthorityplannerswhoinuence

thequalityofthepublicrealm.

Suppliers of healthcare environments, andenvironments that impact on health and well-being:

designersandbuildingandestatesmanagers.

Why health and why now?

AsthelargestemployerintheEU,theNHShasconsiderablereachandimpact(seeAppendix2,iv,Thesize and inuence of the NHS).Ithasthepotentialtostrategicallyleadtheactionsnecessarytoco-ordinatepolicyanddevelopmentsforhealthcare,well-beingandsustainability:anapproachthatresonateswellwiththeNHSethosofpromotinghealthandwell-beinginthewholepopulation.Atthesametime,thereisgrowingrecognitionofthewayourenvironmentaffectsourhealthandwell-being,withthespatialplanningsystemnowacknowledgingthelong-termimpactsonqualityoflifeandlifestylefactors.Localauthoritiesandhealthcaretrustsareworkingtogethermorecloselytoachievethepositive,long-termoutcomesforhealththatresultfromactiontakentoday.

How to use this document

Chapter 1outlinesthechallengestoourhealthandwell-being,andtheroleplayedbythedesignofplannedenvironmentsandclimatechangemitigation.Italsoexploresthecommonalitiesbetweenwell-designed,therapeuticenvironments,improvinghealthoutcomesandthesustainabilityagenda.

Chapter 2looksattheaddedbenetsofgooddesignatthescaleofregion,city,neighbourhoodandindividualdevelopments,illustratedwithcasestudiesandpointersforaction.

Chapter 3looksatwhatneedstochange;itexaminestheassetsatourdisposalaswellastheconstraintstobeovercomeinordertoachievethemaximumeffectthroughinvestmentin,andmanagementof,buildingsandenvironments.

Appendix 1outlinesthemethodologyusedinbringingtogetherthismaterial.

Appendix 2providesbackgroundmaterialthatquantiessomeaspectsofthereport.

Aseparatedocument,Future health: furtherreading,listswidertoolkitsandkeydocumentsandisavailableonrequestfromCABE.

Appendix 3summarisesusefultoolkits.Italsodescribesorganisationsthataresourcesofinformationtohelppeoplemovefromtheoverviewinthisreporttomaterialthatcanhelpinspecicsituations.

Appendix 4listsabibliographyofreferenceworks.


6/53

6

Chapter 1Challenges and opportunities for ourhealth, well-being and environment

Our view of health is changing toencompass a social as well as a medicalmodel. The social model includes changesthat can be made in society and in thelifestyles of individuals to make thepopulation healthier. Illness is beginningto be dened from the point of view ofthe individuals functioning within societyin addition to monitoring biological orphysiological signs. In other words, good

health is determined not simply by accessto medical care, but by a range of factors,some of which are closely related to thequality of the physical environment.

6


7/53

7

A positive physical, socialand mental state

TheDepartmentforEnvironment,FoodandRuralAffairs(Defra)deneswell-beingas:apositivephysical,socialandmentalstate;itisnotjusttheabsenceofpain,discomfortandincapacity.12ThisillustratesthebreadthoftheconceptandrelatescloselytotheWHOdenitionofhealth.

Somehealthproblemsarelongerterm,forexample,oneinfourpeopleareaffectedbymentalhealthconditions.13Preventionofill-health,bothphysicalandmental,iscrucialindevelopingaholistic

approachtotacklinglong-termhealthissues.Thisholisticviewofhealthhasbeensteadilygainingrecognitionandisreectedacrossacademic,political,clinicalandhealth-relatedelds.Itisanapproachthatseeshealthandwell-beingasinterdependent;itholdspreventionasimportantascure,andlooksforlong-termsolutionsratherthanmoreimmediatelyattainabletreatments.Itis,however,verydifculttoquantify;rather,well-beingisaconceptimplicitlyunderstoodandappreciated.Acrosstheboard,thetermwell-beingisusedtogetherwithhealth

asameansofexpressingwhatmightformerlyhavebeenunderstoodaspublichealth,withincontextsrangingfromwork,toleisure,tohealthandsafety.Asapopulationshealthandwell-beingarevitalelementsworthyofinvestmentinanywell-functioningsociety,contributingfactorssuchasplannedenvironmentsmustbeunderstoodasfullyaspossible.

Dening health

8 ForthoseborninEnglandandWalesin1948,theaveragelife

expectancywas66yearsformenand70yearsforwomen.The2008

guresforthoseborninEnglandandWalesare78formenand82for

women,adifferenceof12years(OfceofHealthEconomics2009:

Sixty Years of the National Health Service.cabeurl.com/2s)9 OfceforNationalStatistics2008: UK residents are living

longer in good health,London,ONS.cabeurl.com/5nSeealsoSustainableDevelopmentCommission2008:Health, place andnature: How outdoor environments inuence health and well-being: a knowledge base,London,SDC.cabeurl.com/5o

10 ChiefMedicalOfcer2009:Thegreatsurvivor:another60years.

InNew Statesman/Pzersupplement,TheFutureDirectionoftheNHS.9February2009.cabeurl.com/8d

11 WorldHealthOrganisation2001:Fifty-fourth World HealthAssembly,np,WHO.cabeurl.com/5p

12 HMGovernment2009: Sustainable Development: Creating

sustainable communities and a fairer world[online].cabeurl.com/2t13WorldHealthOrganisation2001:Mental disorders affect

one in four people [online] .cabeurl.com/82

OveralllifeexpectancyfortheUKpopulationisimproving.Onaverage,peoplelive12yearslonger

thanwhentheNHSwasestablishedin1948.8

Disability-freelifeexpectancyhasincreasedformalesfrom60yearsin2000-02to78in2008andfrom63to82forfemalesinthesameperiod.9Medicaladvancesaccountformuchoftheincreaseinlifeexpectancy.However,theageingpopulation,risinglevelsofobesityandassociatedhealthconditions,burgeoningpoolsofchronicdisease,andgrowingconsumerexpectationsmeanthatthehealthservicefacesneedsanddemandsforhealthcarethatareever-increasingandever-changing. 10

Not just absence of disease

TheconstitutionoftheWorldHealthOrganisation(WHO)deneshealthnotonlyastheabsenceofdiseaseorinrmity,butalsoasastateofcompletephysical,mentalandsocialwell-being.Itemphasisesthatpeopleshouldenjoythehighestattainablestandardofhealth,sayingitisoneofthefundamentalrightsofeveryhumanbeingwithoutdistinctionofrace,religion,politicalbelief,economicorsocialcondition.11WHOsstatementgivesanegalitarian

impetustoinformourapproachtotacklinghealthissues,onethatisstandardpracticewithinclinicalandhealth-relatedprofessionsinthetreatmentofillnessorinrmity.Italsohighlightsthefactthathealthisaboutthewholeperson,mentallyandphysically,andtouchesonsocietalinuenceswhichweknowaffecthealthandhealthinequalities.
http://cabeurl.com/2shttp://cabeurl.com/5nhttp://cabeurl.com/8dhttp://cabeurl.com/5phttp://cabeurl.com/2thttp://cabeurl.com/82http://cabeurl.com/82http://cabeurl.com/2thttp://cabeurl.com/5phttp://cabeurl.com/8dhttp://cabeurl.com/5nhttp://cabeurl.com/2s


8/53

8

In tandem with these changing perceptions

of health and well-being, the provision

of modern healthcare is undergoing afundamental change as a result of more

integrated strategic planning on the part

of healthcare providers and professionals.

This is affecting the type of services

offered, how care is provided and the

settings in which it takes place.

Whilst predicting future trends comes with

great uncertainties, particularly in relation to

technological advances, it is likely that thepace of change will be faster than before.

This section looks at the changes that can

be detected in the health landscape, which

in turn will affect the delivery of care.

Improving health outcomes

Oneofthemainchallengesforthefutureisforcaretobeplannedstrategicallyacrossthewholesystem,andinfarcloserintegrationwithotherservices.Otherchallengestowhichthisnewstrategicdeliveryofserviceshastoriseinordertoimprovehealthoutcomesincludesocietalinuencesuponhealth,theexpectationsofpatients,andthechangingexpectationsofhealthprofessionals.

Social changes

Socialchangesaffectbothhowhealthservicesarebeginningtobedeliveredthatis,more

strategicallyandcollaborativelyandperceptionsabouthealthandstayinghealthy.Theyinclude:

1 Greater understanding of health impacts

Researchdemonstratestheneedtoaddressnegativeimpactsfromenvironmentalfactorssuchasfoodoflownutritionalvalue,poorairqualityandlackofopportunityforexercise.

2 Changing nature of disease

Theeffectsofunhealthyeatingandlackofexercise

placeagrowingburdenonhealth,asdosmokingandexcessivealcoholconsumption,whichareoftentheresultsofsocio-economicinequalitiesandpoorlifestylechoices.Preventativeapproachestothesefactorsneednotbelimitedtopublicitycampaigns;modifyingandimprovingthequalityofoursurroundingscanencourageandenablehealthierbehaviours.

3 Profound demographic changeOlderpeoplenowmakeupthefastest-growinggroupintheUKpopulation.In2007,9.8millionpeoplewereagedover65,andby2032thisgureisprojectedtoriseto16.1million,equivalenttoalmostoneinfourofthepopulation.Atthesametime,numbersoftheoldestold(peopleaged85andover)willmorethandouble,risingfrom1.3millionin2007to3.1millionin2032.14Longersurvivalratescomewithahigherlikelihoodofco-morbidities,coupledwiththehazardsoffrailty.Thesewillneedtobemetwithforward-lookingdesignsthatidentifyandmitigatehealthrisks.Onagenerallevel,however,theadvantagesassociatedwithmoreinclusiveandaccessibleenvironmentscanbelife-enhancingforall.

14 OfceforNationalStatistics2008: Benets and challengesof an ageing population,London,ONS.cabeurl.com/5q

1 Modern healthcare: more than hospitals
http://cabeurl.com/5qhttp://cabeurl.com/5q


9/53

9

Patient expectations and cultural changeAstheconsumer-anduser-focusedculture

gathersstrength,patientswillbemakingdemandsonthequality,contextandaccessibilitybothofservicesandoftheenvironmentalcomponentsthatencouragegoodhealth.Thiswillbeheightenedbythegenerallyolderdemographicoftheservice-userbase,andcanbesummarisedasfollows:

1 General user awarenessAsawarenessisraisedaboutpersonalresponsibilityforhealth,manypatientsnowexpecttoreceivemorepersonalisedcare,tailoredtreatmentandtoplayagreaterroleintakingdecisionsabouttheircare.

2 Demands of an information societyWithincreasedaccesstoinformationthroughtheinternet,peopleexpectreliable,evidence-basedinformationabouttheirhealthandtheirtreatment.Newtechniquesforhealthcareprovisionwillbedevelopedtoexploitcommunicationstechnologies.Thiswillrequirechangesinbothprofessionaltrainingandinplaceswherehealthcareisaccessed.

3 Rising standards of environments for care

Patientsarelookingforgreaterprivacyanddignity,suchassinglebedrooms,welcomingambiencewitheaseofaccess,controllablelightingandtemperature,reducednoiseandviewsontoattractiveexternalspaces.Morehospitalityservices,suchascafsandshops,andaccommodationforrelativesandvisitors,arealsoexpected.Healthcarebuildingshavetobedesignedinresponsetosuchdemandsandsothatsuchchangescanbeaccommodatedovertime.

Staff expectationsTheimpactofservicestandardsreststoagreatextentonhowstaffworkandhowtheyarefacilitatedinwhattheydo.

1 A changing workplaceHealthcareprofessionalsexpecttheorganisationstheyworkfortoprovidehigh-qualitycare.Theywanthealthyandefcientworkplacesthatenhancethewell-beingofpatientsaswellasthemselves,allowingconvenientandrapidaccesstomedicalexpertise.15

2 Innovation in delivery

Whileacutehospitalsofferincreasinglysophisticatedandeffectivetreatments,thereisalsoapolicydrivetoshiftlessdemandingcareclosertothehome,andtointegrateitwithothercommunityservices.

3 Improving staff recruitment,retention and effectiveness

Researchtellsusthattheimpactofworkplacedesignissignicantenoughtoaffectproductivity,attachmenttotheworkplaceandlevelsofstaffretention(seebelow).

The user experience: how do therapeuticenvironments work?

Academicresearchintothetherapeuticeffectofenvironmentsshowshowtheirdesigncanaffecthealthoutcomesforpatientsandimprovetheperformanceofstaff.Aseriesofinvestigationsinto

theimpactoffactorsintegraltothedesignandplanningofahospitalandtheseprinciplesapplyintheirownwaytoprimarycarebuildingsare:

Views seen by a patient :Viewsvisiblefromahospitalbedcanhaveaneffectonthealreadyvulnerablestateofapatientshealth.Notableevidenceofnegativeeffectsofwindowlesshealthcareenvironmentsonoutcomeshasemergedfromstudiesofcritical-carepatients.Studieshavelinkedtheabsenceofwindows

incriticalorintensivecarewithhighratesofanxiety,depression,anddeliriumrelativetoratesforsimilarunitswithwindows. 16Comparisonsbetweenpatientswhohadaviewoutontoabrickwallwiththosewhooverlookednaturallandscapesshowedsignicantlylongerpost-operativestaysamongstthosewithpoorviews. 17

Noise levels and acoustics :Highnoiselevelshavebeenfoundtoincreaseperceivedstresslevelsinstaff,andbringaboutanxietyandsleeplessnessinpatients.18

15 Imison,C.2008:Future Healthcare Trends(PowerPointpresentation,TheKingsFund)

16 Ulrich,R.2000: Effects of healthcare environmental design on

medical outcomes, Design & Health: The Therapeutic Benets ofDesign.Proceedingsof2ndInternationalCongressonDesignandHealth,KarolinskaInstitute,Stockholm,Sweden,pp.51,52

17 CABE2002:The Value of Good Design, London,CABE.cabeurl.com/5r18 Ulrich,R.2000:Effects of healthcare environmental design on

http://cabeurl.com/5rhttp://cabeurl.com/5r


10/53

10

Exposure to natural light and its dailyrhythm:Naturallighthasbeenfoundtobe

immenselybenecialasapowerfulregulatorofthecircadiansystemand[stimulating]increasesproductivity,alertnessandhealthandsafetyofpatientsandcaregivers.19

Privacy and dignity:Thepresenceofotherpatientsinmultipleoccupancyroomsisseenasamajorsourceofperceivedstressorssuchaslossofprivacy. 20

Well-designedenvironmentshaveapositiveeffectonhealthcarestaff.Aspartofaresearchproject,

The role of hospital design in the recruitment,retention and performance of NHS nurses in England(2004),CABEsoughttodeterminewhethertheworkplaceenvironmentinuencednursingstaff.Althoughissuessuchaspayandresponsibilityweremoreimportant,theresultsshowedthattheworkplaceenvironmentdoesinuencenursingstaffandcaninuenceanindividualsdecisionaboutwheretowork.Commentsfromhealthstaffincluded:

A hospital that looks modern and clean will

attract staff. If you have a dingy looking concretestructure, that will turn you off working there.

When people come into one of the areas whichI manage, they comment that they dont thinkit looks like a clinical area. This is a bonus.

The environment can reduce violence and abuseagainst staff. The way hospitals are built shouldreduce noise. It is at night-time that most problemsoccur when patients are trying to sleep.21

The design of many hospitals and healthbuildings now recognises that the quality of thepatient and staf f environment is a main driverfor efciency in terms of health outcomes, staffperformance and integrated service delivery.

Appendix2,vigivesmoredetailsofresearchintotheeffectofenvironmentsonhealthandtable3summarisestherelationshipbetweendesignfactorsandhealthcareoutcomes.Thebenetsextendbeyondhospitals;section2inthischapter

illustrateshowthewiderenvironmentcanhavelong-termpositivebenets,suchastheeffectonphysicalactivity,andonstresslevelsoftheproximityofgreenspacesandcontactwithnature.

Where are services plannedwithin communities?

Someofthecaretraditionallyprovidedbyacutehospitalscannowbeprovidedinfacilitiesclosertohome,suchastreatmentandresourcecentresandcommunityhospitals.RoutinediagnosticproceduresandsimpletreatmentsareundertakenincommunitylocationsandmanychronicdiseasesarenowmanagedinGPsurgeriesandathome.

Thereareongoingeffortstoimprovethequalityandeffectivenessoftheprovisionofcare,andtotransformthewaycareisorganisedthroughpatient

pathwaysfromhometohospitalandback.Moreefcientcaredeliverymeansbringingcaretothepatientinoneplaceatonetime,forexample,theone-stopshopapproachtodiagnosisandtreatment.

Forprimaryhealthcareandcommunityservices,thetypeandsizeoffacilitiesareexpandingandthereisgreaterintegrationwithservicessuchassocialcare,leisure,sport,housingadvice,policeandcommunitydevelopment.Integrationisencouragingnewnetworksofcareacrossallhealthsectors

andwithotherpublicandvoluntaryservices.Thesebuildingshavegreatpotentialtobecomeafocusforpublicservicesforlocalcommunities.

Inthisnewlandscape,healthisnotplannedinisolation,butbythehealthsectorandlocalauthoritiestacklingdesiredoutcomestogether.Ittakesaccountofthewiderplanningenvironmentandimprovestheshapeofneighbourhoodstomeetlong-termhealthneeds.

19 Simenova,M.2004:HealthyLightingfortheVisual,Circadianand

PerceptualSystems: Business Brieng: Hospital Engineering & FacilitiesManagement,Report 3, Touch Briengs,London,pp.99-102

20Ulrich,R.2000: Effects of healthcare environmental design on


21CABE2004:The role of hospital design in the recruitment,retention and performance of NHS nurses in England,London,

CABE.cabeurl.com/5s.SeealsoAppendix2,vii,table4.
http://cabeurl.com/5shttp://cabeurl.com/5s


11/53

11

Location of facilitiesAccessibilityiscrucialforpeopletoreachservices,

yetthelocationofhealthcarefacilitiesisoftenabarrierinitself.AccordingtotheDepartmentofHealth,duringa12-monthperiod,1.4millionpeoplemiss,turndownorchoosenottoseekmedicalhelpbecauseoftransportproblems.22Thelayoutofurbanandsuburbanenvironmentsandpatternsofregionaldistributionofhealthcareservicesclearlyplayamajorpartintheeaseofaccesstoservices.Poorlyplannedenvironmentsandpoorlylocatedfacilitiescanaffecthealth.Theeffectsofpoordesignorlocationmaybedifculttorecogniseduringtheplanningphase,buttheycontinuelongafterdesignandcompletion.

Thechoiceofsitefornewservicesiskeytosatisfyingrisingpatientexpectationsofaccessibilityandqualityofcare.Issuessuchassiteownershipandavailabilityoftenimpactnegativelyonaccessandthereforeonhealthinequalities.CABEs2008samplesurveyofprimarycarebuildings,completedunderthelocalimprovementnancetrust(LIFT)programme,foundthatthesitesselectedwerefrequentlyownedbythehealthsectororthelocalauthorityandwereexpendableintermsof

theiruse,orwerenotwantedbyanyone,ornotalwaysappropriateforthedesignateduse. 23

The opportunities for locating care whereit is accessible depend on planning acrossthe whole system, from individual buildingsto whole geographical areas, and in closeintegration with other services. Crucial to theaccessibility and efciency of services are:

communicationbetweenagenciessothatservicesareco-locatedwhereverpossibleandnecessary

appropriatechoiceofsiteandappropriatesizeofdevelopmentforservicesenvisaged,withhealthintegratedwithintheurbanformalongsideotherlocalamenitieswhereverpossible

proximitytopedestrianandcyclingroutes,andpublictransport.

An ongoing investment

Anextensiveinvestmentprogrammehasresultedinnewhospitals,GPsurgeriesandotherhealthcarebuildings,manyofwhichhaveexcellentfeatures(asillustratedinthebestpracticeexamplesofthisreport) .

However,withcapitalinvestmentsslowingdown,evenmodernbuildingsneedmodicationtoreect

advancesinhealthcareandchangingcircumstances.Investmenttorefurbishexistingstockisbecomingincreasinglyimportanttobringfacilitiesuptodateanduptoexpectedsustainabilitystandards.

Frequently,withinbothnewandexistingfacilities,thelonger-termbenetsofpatientwell-beingandhigh-calibrehealthcareenvironmentsareregardedasoutsidethecoreprioritiesofmeetingtreatmenttargets.Unfortunately,thevalueofinvestinginlonger-termoutcomesisrelegatedduetoimmediatecostconcerns.

CommunityHealthPartnerships(CHP)addressesthisissueofvalueformoneyinits2008publicationsubtitledHow to Achieve Value for Money inHealth and Social Care Infrastructure.

Sometimes, high expenditure can be good valueif it yields a higher benet per pound than, say,an alternative that requires lower spending.Understanding this issue does not necessarilymake matters any simpler. Calculating valuegained from health spending is, in any case,

notoriously difcult healthcare is an intermediategood its value is not intrinsic. Its real valuedepends on the impact that the healthcare hason the health and well-being of beneciaries.24

Attentionisrequiredateverystagetounderstandthevaluesbeingsoughtandtorecognisewhichoptionsprovidethosevaluestothehighestlevel.

Value for money makes most sense in healthterms when considered as the long-term valueto be gained from careful investment in the right

areas. The environmental levels across whichlong-term value operates can be dened as:

qualityoftheenvironmentwherecareisprovided

locationofservices performanceoffacilitiesinsupporting

effectiveness,safetyandefciencyofservices.

22DepartmentofHealth&NeighbourhoodRenewalUnit2005: Creating HealthierCommunities: a resource pack for local partnerships .cabeurl.com/2u

23CABE2008:LIFT Survey Report, London,CABE.cabeurl.com/5t24CommunityHealthPartnerships2008:Firm Foundations for World Class

Commiss ioning: How to Achieve Value for Money in Health and Social Care

Infrastructure,London,CommunityHealthPartnerships. cabeurl.com/5u
http://cabeurl.com/2uhttp://cabeurl.com/5uhttp://cabeurl.com/5uhttp://cabeurl.com/2u


12/53

12

25DepartmentofHealth2009: Tackling Health Inequalities: 10Years On,London,DepartmentofHealth. cabeurl.com/5v

26CommissionontheSocialDeterminantsofHealth,2009, Summary ofEvidence for the Review of Health Inequalities Annex2:Evidencefrom

theCommissiononSocialDeterminantsofHealth. cabeurl.com/5w

27Lopez,R.P.&Hynes,H.P.2006:Obesity,physicalactivity,andthe

urbanenvironment:publichealthresearchneeds, EnvironmentalHealth: A Global Access Science Source5(25).cabeurl.com/5x

28HouseofCommons2004:Third Report of the House of Commons

Select Committee on Health[online].cabeurl.com/5y

Well-planned environments can helpthe health service provide improved

care. In a similar way, the widerenvironment can help improvelong-term health and well-being.

The impact of unhealthy environments

Healthinequalitiesarepersistent,stubbornanddifculttochange.25ButevensomeoftheUKsmostpressinghealthchallengessuchaslifestyle-inducedobesity,childhoodasthmaandtheageingpopulationcanbemitigatedbythequalityofoureverydayenvironments.Inotherwords,theconsideratedesignofspacesandplacescanhelptoalleviate,andevenprevent,poorhealthorphysicalrestrictions.

TheCommissionontheSocialDeterminantsofHealth,initssummaryofevidencefortheReview of HealthInequalities in England post-2010,arguesthat:

The lived environment urban settings,neighbourhoods, communities are critical inthat they can both promote or inhibit access togoods and services, social cohesion, physicaland psychological well being and the naturalenvironment. Health related outcomes as diverseas obesity, depression and injury through violenceor accident can all be linked to the way we live.26

Forexample,becauseourenvironmentsdonotalways

offertheopportunitytoweavephysicalactivityintoourdailylives,itisnotsurprisingthatwalkingandphysicalactivitylevelsgenerallyaredecreasingamongchildrenandadults.USresearchspecicallylinksthistothequalityofthebuiltenvironment 27,andtherearetransferablelessonsfortheUK.Servicesarefrequentlytoofarawayorinaccessibleotherthanbycar,andthequalityofopenspaceinneighbourhoodsmaydiscourageresidentsfromenjoyingitforexercise.

Belowaresomeofthemostpressingchallengesintermsofhealthinequalities,andexamplesofwheretheplannedenvironmentcanplayarole.

Although 20 per cent of the population areobese, and two-thirds morbidly so, the NHScannot provide detailed clinical services orintensive clinical services for all of them.28

2 Well-being, positive lifestyles andthe planned environment
http://cabeurl.com/5vhttp://cabeurl.com/5whttp://cabeurl.com/5xhttp://cabeurl.com/5yhttp://cabeurl.com/5yhttp://cabeurl.com/5xhttp://cabeurl.com/5whttp://cabeurl.com/5v


13/53

13

TheUKnowhasthehighestobesitylevelsintheEU.29Nearlyathirdofourpopulationisobese,

andifcurrenttrendscontinuenearly60percentarepredictedtobeobeseby2050.ThiswouldmeanmorethanquadruplingcurrentUKspendingontreatingobesity-relatedillness(fromaround10billionto45.5billionattodaysprices). 30The means of getting to work, school, or tolocal services provide an important openingto weave everyday physical activity intoour lives and to combat obesity levels.

In terms of respiratory disease, the UK has thehighest rates of childhood asthma in the world,

withoneineightchildrencurrentlybeingtreatedforthecondition. 31Again,thecoststotheNHSarehigh;theestimatedannualdrugcostforasthmatotheNHSinEnglandandWalesinallagegroupsisapproximately115million,ofwhich8millionisonchildrenundertheageofve.32Researchhasshownaclearcorrelationbetweenasthmaandthelevelsofnitrogenoxide(NO2)inairpollutioncausedbytrafcnearthehome,whichresultsinrepeatedhospitalencounters.33Reliance on caruse and environments focused on car use

are driving up noxious emission levels, resultingin some of the worst rates of asthma worldwide.

In terms of an ageing demographic, the UKhas more people over 65 than under 16 for therst time ever, and the elderly population isset to grow.34Thisplacesincreasingimportanceontheaccessibilityofservicesandtheeasewithwhicholderpeoplecanmovearoundtheirneighbourhoods.Aswegrowolder,theneighbourhoodbecomesanincreasinglyimportantfactorinthequalityofeverydaylife.CommunitiesandLocalGovernmentnotesinits2008guidanceLifetime Homes, Lifetime Neighbourhoodsthatwhenlocalshops,localservicesorthelocalparkorleisurecentreareinaccessibleorevendangerous,olderpeoplecanliterallybetrappedintheirownhomeswithoutthecondenceoropportunitytogetout,makefriendsorgetthehelptheyneed.35Problemsinaccessinghealthservicesamongtheover-75sisofparticularconcern.36Health complications in terms ofboth physical and cognitive decline become

greater with age, and opportunities for both dailyexercise and interaction with the communitycome about with improved accessibility aroundneighbourhoods and to local services.

The design and quality of the built and openenvironment and the siting of buildings and

services have a fundamental impact on the healthand well-being of communities. So what stepscan be taken to use the planned environmentto work towards tackling health inequalities?

Physical exercise

Asdiscussedabove,lackofexerciseisakeyfactorintheepidemicofobesityapparentlydevelopingintheUK.Maintainingphysicalactivitylevelshelpstoavoidcognitivedeclineinlaterlife;astheWorldHealthOrganisationhighlights,physicalactivityis

likelytoreducemanyofthepsychologicalandsocialhazardsthatoftenarisewithage.Mentalillness,particularlydepression,Alzheimersdiseaseandfeelingsoflonelinessandsocialexclusion,[are]loweramongstpeoplewhoarephysicallyactive. 37

Active travelResearchoncommutingsuggeststhatthosewhowalkorcycletoworkaresignicantlynegativelyassociatedwithbeingoverweightandobese.38

Soactivetravelplaysakeyroleincombating

obesityandmakesiteasierforpeopletoundertaketherecommended30minutesaday,vedaysaweekofmoderatelyintensephysicalactivity.

29SustainableDevelopmentCommission2008:Health, place andnature: How outdoor environments inuence health and well-being: A knowledge base,London,SDC.cabeurl.com/5o

30Foresight2007:Tackling Obesities: Future ChoicesModelling FutureTrends in Obesity and Their Impact on Health .cabeurl.com/8g

31MedicalNewsToday2009:Trafc-Related Air Pollution Linked ToRepeated Hospital Encounters For Asthma.cabeurl.com/89

32NationalInstituteforHealthandClinicalExcellence,2008: NICE issuesguidance on inhaler systems for under 5s with asthma [online].cabeurl.com/8n

33Edwards,J.,Walters,S.&Grifths,R.K.1994:Hospitaladmissionsforasthma

inpreschoolchildren:RelationshiptomajorroadsinBirmingham,United

Kingdom,Archives of Environmental Health,49,223-27.cabeurl.com/7w34OfceofNationalStatistics2008: Ageing: the fastest

increase in the oldest old.cabeurl.com/6135CommunitiesandLocalGovernment2008: Lifetime Homes, Lifetime

Neighbourhoods: A National Strategy for Housing in an Ageing Society,London,CommunitiesandLocalGovernment. cabeurl.com/62

36 Ibid.37WorldHealthOrganisation,2002, World Health Day

Move for health[online].cabeurl.com/63

38Lidstrm,M,2007:Meansoftransportationtoworkandoverweightandobesity:

Apopulation-basedstudyinsouthernSweden, Preventative Medicine,46.
http://cabeurl.com/5ohttp://cabeurl.com/8ghttp://cabeurl.com/89http://cabeurl.com/8nhttp://cabeurl.com/7whttp://cabeurl.com/61http://cabeurl.com/62http://cabeurl.com/63http://cabeurl.com/63http://cabeurl.com/62http://cabeurl.com/61http://cabeurl.com/7whttp://cabeurl.com/8nhttp://cabeurl.com/89http://cabeurl.com/8ghttp://cabeurl.com/5o


14/53

14

SustranshighlightsthatalthoughtheUKhashistoricallyinvestedheavilyinfacilitatingsedentary

formsoftransport,thebalancemustnowchange,withinvestmentprioritybeinggiventoactive,healthymodessuchaswalkingorcycling. 39Almost100organisations,includingallsignicantUKpublichealthbodies,havesignedapolicystatementTakeactiononactivetravel40developedbytheAssociationofDirectorsofPublicHealth,whichrecommendshealthchecksoneveryland-useandtransportdecisionandthecreationofsafe,attractivewalkingandcyclingpaths.

Green infrastructure

Evenproximitytogreenspace 41canplayaroleinhowphysicallyactivepeoplearelikelytobe.Initsguidanceonhealthimpactassessmentsforgreenspaces,GreenspaceScotlandreferencesastudywhichfoundthatinresidentialareaswithhighlevelsofgreenery,thelikelihoodofresidentsbeingmorephysicallyactivewasmorethanthreetimeshigherandthechanceoftheirbeingoverweightandobesewasabout40percentlowerthanforareaswithlowlevelsofgreenery. 42

Urban fabric

Levelsofphysicalactivityarenotjustdictatedbytheproximityofresidentstogreenspaces;otherinuencesincludethequalityofthesurroundingenvironment,thedensityofresidences,themixoflandusesandthedegreetowhichstreetsareconnectedandtheabilitytowalkfromplacetoplace,andtheprovisionofandaccesstolocalpublicfacilitiesandspacesforrecreationandplay. 43

Opportunities for active travel, proximity to,and quality of, green spaces, and the qualityand mix of the urban fabric all play their role

in determining our levels of casual and activephysical activity and the associatedhealth benets.

Positive inuences on mental health

Mood,emotionandpsychologicalwell-beingarepositivelyaffectedbyparticipationinphysicalactivity,sportandexercise,accordingtoresearch.44Itfollowsthatthelocationinwhichactivitytakesplaceisalsogoingtohaveaneffect.Thereare

numerousexamplesofhowaccesstonaturecanworkasastressreliever.ADanishstudyfoundacorrelationbetweenthedistancefromhometogreenspaceandstresslevelsforallgroups.Foryoungerpeople,asimilarcorrelationwasobservedbetween

distancetogreenspaceandobesity. 45Accesstonaturecanalsohaveamarkedeffectonpeople

recoveringfromillness.Table1fromastudyinSanFranciscoshowsresponsesfrompeopleactivelyusinghospitalgardensintheirrecoveryprocess.

Table 1: Effect of use of hospitalgardens on recovery46

How do you feel after spending timein the garden?

Morerelaxed,calmer 79%

Refreshed,stronger 25%

Abletothink/cope 22%

Feelbetter,morepositive 19%

Religiousorspiritualconnection 6%

Nochangeofmood 5%

What is it about the garden that helpsyou feel better?

Trees,plants,nature 59%

Smells,sounds,freshair 58%

Placetobealoneorwithafr iend 50%

Views,sub-areas,textures 25%

Practicalfeatures,benches,etc. 17%

Dontknow 8%

143gardenusersatfourSanFranciscoBayAreahospitals

39Sustrans2009:Active travel and adult obesity.cabeurl.com/6540Sustrans2008:Take action on active travel - Why a shift from

car-dominated transport policy would benet public health .cabeurl.com/6541 GreenspaceScotland,2009:Health impact assessment

of greenspace a guide.cabeurl.com/30

42Ellaway,A.,Macintyre,S.&Bonnefoy,X.2005:Gratti,greeneryand

obesityinadults:secondaryanalysisofEuropeancrosssectional

survey,British Medical Journal331,611-12.cabeurl.com/6743Marmot,M.,2008: Closing the gap in a generation: Health equity through

action on the social determinants of health,np,WHO.cabeurl.com/68

44Cavill,N.(ed.),2007:Building Health: Creating enhancing places forhealthy, active lives. Blueprint for action,London,NationalHeartForum

inpartnershipwithLivingStreetsandCABE. cabeurl.com/6945Nielsen,T.S.&Hansen,K.B.,2007:Dogreenareasaffect

health?ResultsfromaDanishsurveyontheuseofgreenareas

andhealthindicators,Health and Place.cabeurl.com/8l46Cooper,M.C.&Barnes,M,2005:HealingGardensinHospitals,

The Interdisciplinary Design and Research e-Publication,1(1).cabeurl.com/8e
http://cabeurl.com/65http://cabeurl.com/65http://cabeurl.com/30http://cabeurl.com/67http://cabeurl.com/68http://cabeurl.com/69http://cabeurl.com/8lhttp://cabeurl.com/8ehttp://cabeurl.com/8ehttp://cabeurl.com/8lhttp://cabeurl.com/69http://cabeurl.com/68http://cabeurl.com/67http://cabeurl.com/30http://cabeurl.com/65http://cabeurl.com/65


15/53

15

Whilethereisnotnecessarilyacorrelationbetweenoneswell-beingandbeingcured,itis

plainthathowsomeonefeelsisimportanttohisorherrecovery.Interactingwithnatureandnaturalsurroundingsmakespeoplefeelbetter,accordingtothestudyabove.Thisisacrucialconsiderationforourincreasinglyageingpopulation.

The impact on health could be very greatif our planned environments do notallow for access to therapeutic forms ofrecovery for future, frailer generations.

Public health within the

planning process

Theurbanplanningprocessiscrucialtosuccessfulplacesthatenhancepeoplesqualityoflife.Theemphasisofplanningusedtobeonseparatinglanduses,suchasthoseforresidential,retail,workandleisurepurposes,withheavyrelianceonroadsandvehicularaccesstoconnectareas.Thathaschangedwiththemovetowardsspatialplanning,whichrecognisesthatthekeytosuccessfulplacesliesincommunication

betweenservicesandproximityofamenities,fromhealthcaretruststolocaltransportnetworks.

TheimportantroleofhealthwithintheplanningprocesshasbeenrecognisedbytheRoyalTownPlanningInstitute(RTPI)andisclearlydenedinitsgoodpracticenote5(2009). 47Itrecommendstoplanningauthoritiesthat:

neighbourhoodsshouldbedesignedtopromotewalkingandcycling

homesandneighbourhoodsshouldbedesignedtobeexibleandadaptabletomeettheneedsofthelocalcommunity,includingtheneedsoftheageingpopulation

thereshouldbeco-locationandintegrationofservicesincludingthoseforhealth,education,socialcare,theartsandleisure.

Inmanyplaces,healthcaretrustshavejoinedlocalstrategicpartnerships(LSPs)withlocalauthorities

inordertotackletogetherhealthinequalitiesatlocallevelandfromseveralperspectives,includinghavingasharedvisionwithintheirsustainablecommunitiesstrategyandlinkingthiswithintheirlocaldevelopmentframeworksandlocalareaagreements(seeexample1:Joiningupacrossadministrativeborderstotacklehealthinequalitiesthroughactivetravelandenvironmentalimprovementsonp.21).

Health needs to be a strategic planning goal withinnational, regional and local strategic planning.Active and sustainable movement is critical and

must be captured in policy. Essential communityfacilities such as healthcare centres need to belocated on key sites. The signicant contributionto public health and well-being of green space andhigh-quality public spaces has to be championed.

47RTPI2009:RTPI good practice note 5: Delivering healthy communities.cabeurl.com/33
http://cabeurl.com/33http://cabeurl.com/33


16/53


17/53

17

The potential of the NHS toinuence planning

Alongwithlocalauthorityplanners,theNHScanexertsubstantialinuenceovertheplanningofbuildingsandtheshapeofneighbourhoodstoachievelong-termhealthimprovements.AsthelargestemployerintheEU,itisnotsurprisingthattheNHShasoneofthelargestcarbonfootprintsat18milliontonnesofCO2peryear(3percentoftheUKstotalemissions).Thisiscomposedofenergy(22percent),travel(18percent)andprocurement(60percent).Despiteanincreaseinefciency,theNHShasincreaseditscarbonfootprintby40percentsince1990.Asit

recognisesinitsCarbonReductionStrategy(2009),thismeansthatmeetingtheClimateChangeActtargetsofa26percentreductionby2020and80percentreductionby2050willbeahugechallenge. 53

Building on mutual improvements for healthand for the environment resonates wellwith the NHS ethos of promoting healthand well-being to the whole population.

The economic incentive

Aswellasmitigatingdamagetoourenvironmentandhealth,thereareeconomicincentivestoacting.Inits2006report, The Economics of Climate Change,theSternReviewemphasisedtheadvantagesofwell-thought-throughprocessesinreducingtheriskofverydamagingandpotentiallyirreversibleimpactsonecosystems,societiesandeconomies.Withgoodpoliciesthecostsofactionneednotbeprohibitiveandwouldbemuchsmallerthanthedamageaverted.Itwarns,however,againstdelayineconomicterms:

Reversing the trend to higher globaltemperatures requires an urgent, world-wideshift towards a low-carbon economy. Delaymakes the problem much more difcult andaction to deal with it much more costly.54

reported a 4 per cent increase over baselinemortality (680 excess deaths) in England and

Wales between 16 July and 28 July 2006 whencompared with the average for the same period from2001 to 2005. This may be an underestimate. Thiscompares to an excess mortality of approximately2,000 people, representing 16 per cent of alldeaths in the August 2003 heatwave.51

Itisessentialtoconsidertheimplicationsofweatherandtemperatureuctuationswhendesigningfacilitiesandplacesmeanttoencouragehealingandgoodhealth.Forexample,theHeatwave Planrecommendsshadingwindowsandkeepingthemclosedwhen

theoutsidetemperatureishotterthaninside,andopeningwindowswhenitiscooleroutsidethaninside.Wherehospitalwardshavesealedwindowsthatdonotopen,respiratoryproblemsmaybeworsened.

Anotherconsiderationistheurbanheatislandeffect,wheretemperaturelevelsinurbanareasareincreasedbyalackofplantingandshading.TheDepartmentofHealthrecommendsstrategicplanningofthedesignoffacilitiesandplaces,forexample,coolroofs,greenroofsandcool

pavements.Creatinggreenspacesisanotheroption.Temperaturesinandaroundgreenspacescanbeseveraldegreeslowerthantheirsurroundings(seeUrban heat islandsinAppendix2,ii)becauseofevaporationandshadingfromtreesandvegetation.

Straightforward design measures can betaken to help mitigate the effects of climatechange on health, but they require strategicaction, long-term thinking and shared goals.

The role of buildings and places

Transportcontributes21percentoftotalCO2levelsintheUK,whileenergyfrombuildingscontributes65percent. 52Alongwithemissionsfromfuelandheating,thereisalsoembodiedenergy,ortheenergyusedinmanufacturing,suchasthematerialsusedforbuilding.

During the development of both local facilitiesand local spaces, there is a cumulative effectof decision-making around environmental

factors, which can either make for incrementalimprovements in the health and well-being of the people that use them, orexacerbate problems that already exist.

51 DepartmentofHealth2009: Heatwave Plan for England 2009.cabeurl.com/6c52DirectGov2009:The Causes of Climate Change[online].cabeurl.com/6d53NHS2009:Saving Carbon, Improving Health: NHS Carbon Reduction

Strategy for England,London,NHSSDU.cabeurl.com/6e54SirNicholasStern,2006:Stern Review on the Economics of Climate

Change, Cambridge,CambridgeUniversityPress.cabeurl.com/8a
http://cabeurl.com/6chttp://cabeurl.com/6dhttp://cabeurl.com/6ehttp://cabeurl.com/8ahttp://cabeurl.com/8ahttp://cabeurl.com/6ehttp://cabeurl.com/6dhttp://cabeurl.com/6c


18/53

18

TheimportanceofeconomicsustainabilityisalsomadeexplicitintheZagrebDeclarationfor

HealthyCities,whichwassignedbypoliticiansfromthemajorcitiesofEuropeataconferenceorganisedbyWHOinOctober2008.Oneoftheveprinciplesandvaluesofactionsays:

Sustainable development: the necessity of workingto ensure that economic development and allits supportive infrastructural needs includingtransport systems is environmentally and sociallysustainable: meeting the needs of the presentin ways that do not compromise the ability offuture generations to meet their own needs.55

Making an impact

Anycommitmenttoreducecarbonlevelsmustembracethemanagementanddesignofbuildings,procurementandchoiceoftransport,astheNHSCarbonReductionStrategy(2009)acknowledges.Itoutlinesthehealthbenetsforpatientsandpopulations,andforthehealthcaresystemitself.Forexample,increasedlevelsofactivetravelleadtoareducedriskofobesity,diabetes,heartdisease,and

mildmentalillness,aswellasreducingroadtrafcinjuriesanddeaths,andimprovingairquality.56

Thedatabaseofguidanceandcasestudiesofsustainablehealthbuildingscontinuestoexpand.Amongstthemostsignicant,theSustainableDevelopmentCommission(SDC)workswiththeNHStoclarifythenatureof,andthebenetsgainedfrom,sustainablehealthcarebuildings.Thesequalitiesinclude:

accessibilitybypublictransport,walkingandcycling

siteanddesignthatpreserveandenhancebiodiversity

adaptabilitytochange,forexample,climate,newwaysofworkingandnewtechnologyusingresourcessuchasenergyandwaterefcientlyinitsconstructionandthroughoutitslifetime. 57

SomeofthetoolkitsdescribedinAppendix3,suchasthechecklistfromSHINE,dealwith

howtomeasuretheimpactofdesignideasonsustainableperformance.Theseneedtobeusedthroughoutthelifeofabuildingorpublicplace.

55WorldHealthOrganisationEurope2008: Zagreb Declarationfor Healthy Cities: Health and health equity in all local policies,Policydeclaration,np,WHO.cabeurl.com/6f

56NHS2009:Saving Carbon, Improving Health: NHS Carbon Reduction

Strategy for England,London,NHSSDU.cabeurl.com/6e57SustainableDevelopmentCommission2005:Healthy Futures: Buildings

and Sustainable Development,London,SDC.cabeurl.com/6g

Best practice in environmental managementgenerally involves using simple, well-

understood ideas and executing them reallywell, ensuring that buildings are easy tomanage to their optimum performance,with robust systems that can, as far aspossible, be handled by non-specialist users.Simpler approaches tend to be more robust,easier to manage and more predictable.
http://cabeurl.com/6fhttp://cabeurl.com/6ehttp://cabeurl.com/6ghttp://cabeurl.com/6ghttp://cabeurl.com/6ehttp://cabeurl.com/6f


19/53

19

Chapter 2Best practice

Revisiting the design of places, spacesand buildings and how they work canbe a catalyst for change.

Design can synthesise complexrequirements and make sustainableplaces for health and well-being.Many current developments are drivenby a single agenda and satisfy a narrowset of goals. When policy, planning

processes, needs assessments anddesign projects are better co-ordinated,they can succeed in multiple ways.The following scenarios at city,neighbourhood and building scalesdemonstrate how to resolve complexdemands for sustainable environmentsthat also better serve the long-termhealth needs of populations and enhance

physical and mental well-being.

19


20/53

20

Inuencing the future oftowns and cities

Planning at town and city scale is acomplex activity shaped by many hands.

Change is often the result of incrementaldevelopment on which the health ofcity populations so depends. In itsHealthy Cities initiative, the World HealthOrganisation denes a healthy city as onethat is continually creating and improvingthe physical and social environments, andexpanding the community resources thatenable people to support each other inperforming all the functions of life and in

developing their potential.58Those who inuence development atthis scale need to be supported in thinkingcarefully about how networks of differentfacilities, including green infrastructureand healthcare buildings, can be deployedover time in optimum locations, wherethey are accessible through sustainablemodes of travel. To do this means bringing

people concerned with well-being,illness prevention and healthcare into thediscussion of policy development andinterpretation at the vital early stages.Communication and common incentive-building between local authoritiesand health authorities is an essentialfoundation for this.

Some principles conducive to health, well-beingand sustainability that can run though local

authority policies at city scale are as follows:

Createurbanformthatiscompatiblewiththecharacteristicsofahealthycity,asdenedbyWHO.59

Developahierarchyofacuteprimaryandcommunityhealthcarefacilitiesthatjoinupdeliveryofservicesfromhospitaltohome.

Developajoining-uppolicybetweenhealthcareandlocalauthorities(seeexample1:Joining

upacrossadministrativeborderstotacklehealthinequalitiesthroughactivetravelandenvironmentalimprovementsonp.21).

Co-ordinatehealthprojectswithexistingandproposedtransportandpedestriannetworks,withlargerfacilitieslocatedatmajorhubsandmorelocaldeliverywithinwalkingdistanceofthecommunitiestheyserve.

Establishnetworksofgreeninfrastructureto

manageairquality,overcomeurbanheatislandeffectsandreducenoiseandstress(seebestpracticeexample4:Tacklingtheurbanheatislandeffectatcitylevelonp.21).

Integratecity-ordistrict-wideheatingforhousingandlocalcommunityhealthfacilitiessothattheycanbesharedacrossareas(seeexample3:Creatingdistrictheating,includingahospitalwithitsowncombinedheatandpowerplantonp.21).

Useapproachestodevelopmentthatreducespeedandvolumeofmotortrafcandencouragewalkingandcyclingsothatairquality,accessibilityofservicesandopportunitiesforphysicalactivityareimproved(seeexample2:Locatingnetworksoffacilitiesaccordingtopedestrianaccessibilityonp.21).

Trytoanticipatefuturedevelopmentsinhealthcaredelivery,includingtechnologytoimprovetreatmentandprevention,andtheimpactonurbanformandlocationoffacilities

(seeexample5:Projectingfuturescenariosforcity-integratedhealthcarenetworksonp.22).

58WorldHealthOrganisation2005: Healthy Cities andUrban Governance[online].cabeurl.com/6h

59 Ibid.seealsoAppendix2.i,g.1.
http://cabeurl.com/6hhttp://cabeurl.com/6h


21/53

21

Best practice examples

1: Joining up across administrative bordersto tackle health inequalities through activetravel and environmental improvementsBuckinghamshirePrimaryCareTrust(PCT)playsastrongroleinBucksStrategicPartnership,thelocalstrategicpartnership(LSP)forBuckinghamshire.AmajorpriorityoftheLSPistheHealthyCommunitiesStrategy,whichisaboutthewiderdeterminantsofhealthandwell-beingratherthanthedeliveryofhealthcareitself.Itpromotesphysicalactivitythroughwalkingandreducingcarbonemissionsforallpublicsectororganisations.The

strategyrecognisesthatimprovingthephysicalandsocialenvironmentisessentialifhealthandwell-beingaretobeimproved.www.buckspartnership.co.uk

2: Locating networks of facilitiesaccording to pedestrian accessibilityLiverpoolPCTandLiverpool&SeftonLIFTcohave

joineduptheirthinkingfortheequitableprovisionofhealthcarefacilitiesacrossthecity.Aftersurveyingresidentsandpinpointinganoptimum15-minutemaximumwalkingtimetoanyhealth

centre,anewnetworksitescentresacrossthecitywithin15minuteswalkofeveryresidentialaddress.Thepartnershipalsoprovidesservicesintheeveningsandatweekends.www.lshp.co.uk

3: Creating district heating, including a hospitalwith its own combined heat and power plantSouthamptonhasdevelopedtherstgeothermalenergyandcombinedheatandpower(CHP)districtheatingandchillingschemeintheUK.ThecitycouncilpersisteddespiteinitialsetbacksandnowhasaCHPgeneratorandabsorptionheatpumps.RoyalSouthHampshireHospitalhasalsoopeneditsownCHPplant.PaulineQuanArrow,ChairmanofSouthamptonCityPCT,says:Wearepleasedtobeleadingtheway...carbondioxideandotheremissionsareaseriousthreattoourhealthandwell-being,

andthereforetheNHShasamajorparttoplayinensuringthatthisistackled.IwouldencourageotherNHStruststogetinvolvedwithsimilarinitiatives.cabeurl.com/3i

4: Tackling the urban heat island effect at city levelThecityofChicagohasenactedlegislationthatrequireslandscapingaroundparkinglotsandmoreenergy-efcientbuildingpractices.Thecouncilencouragesresidentstouselight-coloured,reectivematerialsforroofs,toplanttreesonpropertiesto

increasetheshadingofbuildingsandparkinglots,andtoincreasetheamountofvegetationoverall.ProjectsincludearooftopgardenonCityHallwhichhassettheprecedentforgreenroofsinthecity,apermeableandreectivealleyontheNorthSide,milesofmedianplantersandmanycampusparksthattransformasphaltparkinglotsaroundpublicschoolsintoparks.Chicagoalsousesgreenbuildingtechnologiesandpracticesinallofitspublicbuildingprojects.www.cityofchicago.org

Con

serv

ationD

esignF

orumAndiCooper,ConservationDesignFor

um

PictonHealthCentre,MBLAarchitectsDanielHopkinson
http://www.buckspartnership.co.uk/http://www.buckspartnership.co.uk/http://www.lshp.co.uk/http://cabeurl.com/3ihttp://www.cityofchicago.org/http://www.cityofchicago.org/http://cabeurl.com/3ihttp://www.lshp.co.uk/http://www.buckspartnership.co.uk/


22/53

22

5: Projecting future scenarios for city-

integrated healthcare networksTheHygiopoliscityplanningproject,conceivedbyMedicalArchitectureandArtProjects(MAAP),hypothesisesacityinthefuturewherehealthylifestylesandaccesstohealthcarearepriorities.Itemphasisesactiveandpublictransportsystems,accessiblegreenandbluespaces,adaptablehomessuitableforcareathome,andintegratedservices.Aneighbourhoodcentreisproposed,withaprimaryschool,facilitiesforolderpeople,communitymentalhealthnurses,socialworkersandGPsallononesite.cabeurl.com/8b

Hygiopolis,MAAParchitectsVIEWpictures
http://cabeurl.com/8bhttp://cabeurl.com/8b


23/53

23

Development at a neighbourhood scalecan range from small-scale interventions

in established communities, throughto the wholesale redevelopment orregeneration of failing urban areas. Thoseinvolved include local planning authorities,health authorities, housing associationsand private developers.

Health benets at this scale ofdevelopment involve locating appropriatecommunity facilities in the right place and

structuring the environment to encouragepeople to use sustainable forms of traveland take physical activity.

Compact mixed-use developmentsProvideanappropriatelevelofneighbourhood

healthcarefacilitieswithinwalkingdistanceofthecommunitiesserved(seeexample1:Locatinghealthcareservicesaccessiblyandalongsideotherpublicamenitiesonp.24).

Employapproachesthatdesignoutcrime,suchasbuildingsoverlookingpublicroutesandspaces(naturalsurveillance),andgoodstreetlighting.

Useurbandesigntohelpwaynding,andsupportthiswithclearinformationonwalking,cyclingandpublictransportoptions.

Sustainable transport solutions

Providesafe,legible,convenientandattractiveroutesthatencouragepeopletowalkandcycle.

Ensurepedestrianandcyclingroutesconnecthealthcarebuildingstoresidentialneighbourhoodsaswellasotherkeyareasofactivitysuchasshops,schools,leisurefacilitiesandworkplaces.

Considertheuseofhomezonesinresidentialareas,whichlowertrafcspeeds,prioritisepedestrianmovement,andemphasiseplaceovermovementasthemainfunctionofresidentialareas.

Implementmeasurestoreducethespeed

andvolumeoftrafcandtherebylowerthefrequencyandseverityoftrafcaccidents.

The potential of green spaces Usetreesandotherplantinginlocalparksto

createcarbonsinks,improveairquality,reducesoilerosion,andprovideshadeinsummer.

Encourageoutdoorexercise,includingactiveplayforchildrenandteenagers(seeexample2:Usinggreenspacetoencourageactivelifestylesandreducepollutiononp.24).

Promotebio-diversityandprovideaccesstothenaturalworldbecausethiscanreducestressandrelievethesenseofovercrowdinginurbanenvironments(seeexample3:Improvingmentalwell-beingthroughcontactwithnatureonp.24).

Championthecreationandupkeepofallotmentsandcontactwithnaturetoencouragephysicalexercise,healthyeating,mentalwell-beingandreductionincarbonemissionsfromfoodmiles.

Wider servicing strategies Makedistrict-wideheatingforhousingandlocal

communityhealthcarefacilitiesapossibilitysothattheycanbesharedacrossareas.

Influencing the shape and healthof neighbourhoods


24/53

24


1: Locating healthcare services accessiblyand alongside other public amenitiesLutonWalk-inCentreisafour-storey,patient-focusedfacilityincentralLutonnexttoabusyshoppingstreet.Thereareminortreatmentareasandexiblespacesfordrop-inclinics.Thevolumeofpatientsishighandthroughputisfast.ThePCTcarriedoutathoroughsitesearchandappraisal,andmadecreativeuseofanexistingbuilding.

2: Using green space to encourage activelifestyles and reduce pollutionBeforeitsrefurbishment,MileEndParkwasableak,fragmented,under-usedopenspaceinthecentreofTowerHamlets,anauthoritywithalargepopulationandlittlegood-qualityopenspace.Theparknowhousesaleisurecentreandgym,andprovidessafeandattractivepedestrianandcycleroutes,signicantlycontributingtopollutionreductionwhereneighbouringroadsareheavilyusedandcongested.IthasbecomeaninvaluablegreenchainofopenspaceandtranquillitythroughLondonsEastEnd.cabeurl.com/6i

3: Improving mental well-being throughcontact with natureWiththeNationalCareFarminginitiative,partnershipsareformedbetweenfarmersandhealthandsocialcareagencies,todevelopthepotentialofindividualsratherthanfocusingontheirlimitations.Commercialfarms,woodlandsandmarketgardensareusedasabaseforpromotingmentalandphysicalhealththroughnormalfarmingactivity.www.nc.org.uk

4: Encouraging greater self-responsibilityfor health and well-beingTheWell-beingWagonissetupunderActivateLondon,agroupofprojectsaimedatpromotinghealthyeating,andphysicalandmentalhealth,supportedbytheBigLotteryfund.Cookerydemonstrationsandnutritionaladvicearegiventoresidents.Staffhelppeopletousetheinternetforhealthylivingwebsitesandinformationonrecipes,exerciseandwaysofalleviatingstress.cabeurl.com/5o

Da

vidMorleyarchitectsMorleyvonSternberg

TheFoldCareFarm,Worcestershire

MicheleTurriani
http://cabeurl.com/6ihttp://www.ncfi.org.uk/http://cabeurl.com/5ohttp://cabeurl.com/5ohttp://www.ncfi.org.uk/http://cabeurl.com/6i


25/53

25

Key issues to address in the designstage include the following.

Making healthcare facilities accessible Selectsitesforhealthcarefacilitiesthatare

well-servedbypublictransportandpedestrianroutesandplanprimarycare,suchasGPsurgeries,tobewithincyclingorwalkingdistanceofthecommunitiestheyserve.

Planhealth-andsocialcarestrategically,todeliverservicesinthemostappropriateenvironment,fromthehospitalthroughtothehome.

Considerbringingotherservicesandactivitiesintohealthcarebuildingstocreateacommunityfocus,

allowingawiderrangeofpatientcareandadvicetobeprovidedbyco-ordinatedteamsofprofessionals.

UseICTtoimproveservices.Provideappropriateinfrastructuresforincreasedaccesstohealthcareprovision,inthehome,inhealthcarefacilitiesandothercommunitybuildings.Thiswillincreaseoperationalefciency,makingservicesmoreconvenientandreducingtheneedtotravel(seeexample2:Adoptingsmarttechnologysystemsonp.26).

Creating therapeutic environments Designinteriorsthatusenaturallightandexploitviewstoreducestress,aidhealing,helpwayndingandprovideinspiringlivingandworkingconditions(seeexample5:Atherapeuticcareenvironmentformentalwell-beingonp.27).

Specifymaterialsfromsustainablesourcesthatarerobustanddurable,butensurethesecreateanon-institutionalfeelingcapableofupliftingthespirits(seeexample4:ThemostsustainableGPpractice?onp.27).

Makegooduseofcolour,butbesensitivetotheeffectsofsensorystimulionpeopleinmentaldistress.

Providepersonalisedcareinplaceswithstrongidentityandlocalcharacter(seeexample1:Personalisedcareandcommunityresourcesinaplacewithstrongidentityonp.26).

Providing adaptable accommodation Planthesiteandbuildingformtoallowfor

exibility,sothatfacilitiescanbeextendedorreconguredtorespondtofuturechanges

inthedeliveryofhealthservices.

Regardless of their size or function,whether newly constructed or a

refurbishment, all building projectscan be structured to create a positiveimpact on peoples health and well-being.The collective decisions of health-serviceusers, design teams, planning authoritiesand those responsible for the day-to-day provision of services will determinewhether projects merely deliver onnarrow goals, or whether they contributein a more holistic way, providing wider

health and well-being benets.

Running and delivering healthcare buildings


26/53

26

Ensureallbuildingsareadaptableover

timetoaccommodatenewclimatechangetechnologiesastheybecomeavailable. Designspacesincommunityhealthbuildings

formulti-functionalusetoallowdeliveryofarangeoftreatmentsandservices(seeexample3:Long-termexibilityandtheabilitytorespondtoservicechangeonp.26).

Encouraging physical activity Usesitecharacteristics,pathnetworks

andgreeninfrastructuretocreateeasilyaccessibleexercisetrails.

Locateattractivestaircasesinconvenientplacestoencouragewalkingandreducetheuseoflifts.


1: Personalised care and communityresources in a place with strong identityMaggiesCancerCareCentresofferacommunityofadviceandsupportforcancerpatientswithincarefullydesignedandwelcomingbuildingsthathaveadomesticfeel.EachcentreissituatedbesideanNHScancerhospitalandhasbeendesignedtobeasuninstitutionalaspossible,withlight,spaceandwarmth.Theheartofthecentreisalwaystheinformalkitchenarea(suchashereatMaggiesInverness).

2: Adopting smart technology systems

AtAkershusHospital,Oslo,amotorisedsystemdistributesmedicationfromapharmacystoreinthehospitaldirecttowardsusingrobots.Clean,sterilisedstaffuniformsaredistributeddailyfromvendingmachinestokeephygienelevelsashighaspossiblebyremovingthenecessityforstafftobringtheiruniformsinandsohelpingtokeepinfectionlevelsdown.

3: Long-term exibility and the abilityto respond to service changeAttheHeartofHounslowLIFTbuilding,twowingscontaininghealthandsocialservicesandofcespacesaresuitableforbusiness,health,socialandcommunityuseandaredesignedtobeexiblyusedforwhicheverservicemayneedtooperateinthearea.Acoveredcommunalstreetcreatesamall-likeinformalmeetingspaceforthecommunity,andapublicplazasitsatthefrontforthesurroundingneighbourhood.

Pen

oyre

&Pra

sadarchite

ctsAnthonyWellerArchimage

Maggies

Highlands,Inverness.Page&Parkarchitects

CFM

ller

archite

ctsTorbenEkserod


27/53

27

4: The most sustainable GP practice?

Theaward-winningSwaffhamSurgeryisoneofthebest-performingnewbuildingsintheNHSestate.Thecostimplicationsweredealtwithpragmaticallybythearchitect,thecontractorandNorlifeLIFTco,withthecarbonfootprintreducedthroughsustainablebuildingmaterials,cleverorientationandpassivetemperaturecontrol.

5: A therapeutic care environment

for mental well-beingAttheBamburghClinic,StNicholasHospital,Newcastle,amentalhealthunitwasdesignedtoprovideasecurebuttherapeuticenvironmentforpatients,manyofwhomrequirelong-termcare.Thevisionwastoprovideanon-stigmatisingenvironmentbyenablingthenecessaryobservationthroughdesign,providinggooddaylight,viewsandaccesstooutdoorspace.

C

haplinFarrantArchitects,RichardLeeney

MAAP

archite

ctsVIEWpictures


28/53

28

Chapter 3What needs to change

By using the planned environmentto help nurture a healthier population,we can reduce the burden on thehealthcare service. But, in order toachieve this, there are fundamentalissues to address in how we plan,procure and approach the narrowingof health inequalities.

28


29/53

29

Planning

Althoughvariouspublichealthobjectiveshavebeendesignedtoaddresswideninghealthinequalities,thelong-termhealthandwell-beingimplicationsfortheusersofbothnewandimproveddevelopmentsarenotyetfullyintegratedwithinplanningpolicyandlocalauthoritydevelopmentplans.

Localauthoritiesarestillinsufcientlysupportedintheirconsiderationofthelong-termeffectsonhealthcaredevelopments,forexample,intermsofthevolumeoftrafcduetothesitingofservicesorthequalityofopenspacesforsafephysicalactivity.

Procurement

Thepressurewithinpublicserviceprocurementtodeliverontimeandonbudgetmeansthatholisticthinkingonhealthandwell-beingcanfallbythewayside,evenonprojectsthataresupposedtobepromotinghealth.Forexample,thecreationoftherapeutichealthcareenvironmentsthatusenaturaldaylightandventilationcanbringtheaddedbenetsofshorterpatientrecoverytimes,andinthelonger

termareworththeinitialhighercapitaloutlay.

However,projectteamsarenotalwaysresourcedwiththespreadofskillsneededtoensurethatthisisconsidered.Asaresult,theremaybenoorlimitedcheckstoensurethatthehealth-relateddesignaspirationsofabriefhavebeenembeddedintheschemes.

Overcoming silo thinking

Deliveringwiderpublichealthbenetsthroughthedesignofthebuiltenvironmentisdependentupongoodstrategicdecision-making.Thisisnothappeningaseffectivelyasitcouldbecausetheagendastodeliveronhealthcare,well-beingandasustainableapproachtoourbuiltenvironmenthavenotyetfullymovedawayfromthesilosinwhichtheytendtoreside.

Toovercomethis,afullerunderstandingofthewidercontextofadeliveryarenaneedstobeencouraged.Agenciescansuccessfullycometogetherearlyinthedevelopmentprocesstocreateasharedpublichealth

agendaexample1(onp.21)andexample3(onp.26)showwherethisisalreadyhappening.

Using assets effectively

Acoremessagethathealth,well-beingandsustainabilitymustallbeconsideredtogetherisemphasisedinavarietyofwaysinmuchoftheexistingguidanceandgeneralinformationavailabletotrustsandthoseresponsibleforenvironmentsthatimpactonourhealth.Manyoftheseexplainhowthedesignprocessprovidesatimewhentheseideascanbeintegrated,andgiveexamplesofhowthiscanbedone.

Guidance,however,canbehardtoacton.Therightinformationmaynotbeavailableatthetimeitisneeded.Itcanbehardtoconvinceabudget-holder

tospendmoretimeandmoremoneyinitiallyinordertogetthebestsolutionforthelongterm.Appendix3describessomeofthekeyguidanceandlistssourcesoffurtherhelpandinformation.AmoreextensivelistoffurtherreadingisavailableonrequestfromCABE.


30/53

30

Recommendations

Thebenetsofaholisticapproachtohealthcare,

well-beingandsustainabilit yareclearandtheskillsandknowledgeexisttoimplementit.Buthowcanwemakeithappen?

Interrogatinghowdevelopmentdecisionsaremadeisarststep.Betteroutcomesmaycostmore,buttheywilldeliveradditionalvalue.Joined-upthinkingisneededtoensurethatmaximumhealth,well-beingandsustainabilit ybenetsaccruefromeverydevelopmentinterventionormanagementprocess.

For the policy-makerswhosetnational,

regionalandlocalvisionsforhealth,well-beingandsustainableenvironmentsthismeans:

Join up the policy initiatives in health,environment and planning, from national tocommunity level.Morecollaborativeworkingbetweengovernmentdepartments,suchasregular,informeddiscussionsandjointinitiativesbetweenthedepartmentsforHealth;CommunitiesandLocalGovernment;Environment,FoodandRuralAffairs;andEnergyandClimateChange

wouldhelpdelivermoreefcientlyonsustainablepublichealthpolicy.Theexistingministerialdesignchampionnetworkwouldbeideallyplacedtoleadonthiscollaborativeworkingbetweenofcials.

Encourage joint goals within communities bysupporting the available vehicles for strategicservice delivery. Jointstrategicneedsassessments(JSNAs)andlocalstrategicpartnerships(LSPs)goaconsiderablewaytowardsinter-agencyworking.Buttheycanonlyworkwelliftheyareproperlyresourcedandefcientlyrun;ifsustainabilityisembedded;ifinformationissystematicallysharedbetweenagenciesandifrolesareclearlydened.Again,top-levelsupportisessentialif

jointinitiativesaretohappenontheground.

Make collaborative work easy by streamliningthe impact assessments and best practicestandards that protect health, well-being andsustainability. Whereverseparateassessments

arerequired,aseparatesetofpeopleisneededtocarrythemout.Drawingonthecommonnet

benetsforcommunitiesbycombiningtoolssuchashealthimpactassessments,environmentalimpactassessmentsandsustainabilityimpactassessmentswillenablehealthy,sustainableenvironmentstobecomeareality.

Set minimum design standards. The2009

CommunitiesandLocalGovernmentpublicationWorld Class Places(cabeurl.com/8c)saysthatallpublicbuildingprogrammesshouldhaveminimumdesignstandards.Designpolicyandminimumstandardsshouldbedenedforallrelevantgovernmentdepartments.

Explain the market advantages, identifying themutual benets that a joined up approachcan bring.Theprestigeassociatedwithradical,innovativeinterventionscanbringattractivelong-termbenetstoprovidersaswellascommunities.

For commissionerssettingoutthehealthandwell-beingrequirementsforlocalpopulations,thismeans:

aimingforchangeandthinkingafreshaboutlong-terminvestment

developingstrategicplansforpublicservicesthatencompasshealthandsocialcare

overcomingsiloworking:engageagenciesfor

changeatalocallevelincludinghealthtrusts,localauthoritiesandtheindependentsector

ensuringthatalldevelopmentishelpingtodeliverhigh-qualityenvironmentsforhealthandwell-beinginaresponsibleandsustainablemanner

beingunafraidtoaskforfreshthinkingthatisrigorouslytestedthroughpropositionsanddifferentscenarios.

For providers ofhealthcareandenvironmentsthataffecthealthandwell-being,thismeans:

valuingdesignasacatalystforchange:realisethepotentialfordesigntosynthesisecomplexissuestobestadvantage

gettingtheDNAoftheprojectrightattheoutset:realisethebenetsofprovidingeffectivecare,improvinghealthoutcomesandrespondingtothechangingclimatethroughdesign

60CommunitiesandLocalGovernment,2009, World Class Places:The Governments strategy for improving quality of place,London,CommunitiesandLocalGovernment. cabeurl.com/8c
http://cabeurl.com/8chttp://cabeurl.com/8chttp://cabeurl.com/8chttp://cabeurl.com/8c


31/53

31

makingthequalityofexperienceapriority:

createtherapeuticplacestoengagepeopleandsupportwell-being

respondingtothedynamicandchangingnatureofhealthcaredelivery,andcreatingenvironmentsthatarelonglife,looset(exiblydesignedtorespondtoevolvingpatternsofcare)andlowcarbon.

Wherever we may be within the processes thathave long-term impacts on peoples health andwell-being, we can think beyond our traditionalremits by committing to more integrated

working methods and collaboration with usefulagencies where necessary to achieve commongoals. To meet those priorities of environmentalquality that can have a lasting effect on ourown health, we can make an impact on healthinequalities and enable stronger health andmental well-being for future generations.


32/53

32

Appendices

32


33/53

33

This report is informed by the following resources:

A literature review of evidence and connectionsbetween health and/or well-being, andthe design of buildings and places.

Fromnationalandinternationalsources.ThisisavailablefromCABEonrequest.

Detailed consultations Specialistswerebroughttogetherina

seriesofworkshopstodebatethecontextforhealthcare,well-beingandsustainabilityacrossthepublicandprivatesectors,and

whereplannedenvironments,includinghealthpremises,canbringtheseagendastogether.

Theseworkshopsweremadeupofspecialistsfrom:

healthcareservicedeliveryandresearch

well-being,inparticularwithrespecttohealthyneighbourhoodsandmasterplanningforhealth

healthcarebuildingdesign

sustainabledesign.

Toolkits and advice on how to carryout projects for healthcare buildings,neighbourhood planning and

successful design and planning projects.Keytoolkits,checklistsandguidancearedescribedinAppendix3.

Appendix 1Methodology


34/53

34

i. Well-being

TheUKSustainableDevelopmentStrategydeneswell-beingas:

A positive physical, social and mental state; itis not just the absence of pain, discomfort andincapacity. It requires that basic needs are met,that individuals have a sense of purpose, thatthey feel able to achieve important personalgoals and participate positively in society.It is enhanced by conditions that includesupportive personal relationships, strong andinclusive communities, good health, nancial

and personal security, rewarding employmentand a healthy and attractive environment.61

Theabovedenitionofwell-beingisverymuchinthespiritoftheWHOdenitionofhealth,whichstatesthatahealthyandattractiveenvironmentinitselfcontributestowell-being.

We include as an indicator of emotional wellbeingthe incidence of low-level mental health problemssuch as depression, anxiety, stress, panic

attacks, phobias and obsessive-compulsivedisorders. But emotional wellbeing is broaderthan just the presence (or absence) of commonmental health problems and so we also includelife satisfaction and levels of happiness.

Lifeexpectancyhasreacheditshighestonrecordandthe2008guresforthoseborninEnglandandWalesare78formenand82forwomen.

In rich countries, (e.g. UK) low socioeconomicposition means poor education, lack of amenities,unemployment and job insecurity, poor workingconditions and unsafe neighbourhoods.62

Appendix 2Further research and detail to supplement the report

61Defra,2008:SustainableDevelopmentIndicatorsinyourPocket.

cabeurl.com/6o

62Marmot,M.2008:Closing the gap in a generation: Health equity throughaction on the social determinants of health ,WHOCommissiononSocial

DeterminantsofHealth:nalreport,np,WHO. cabeurl.com/68

A city should strive to provide:

1Aclean,safephysicalenvironmentofhighquality(includinghousingquality)

2Anecosystemthatisstablenowandsustainableinthelongterm

3Astrong,mutuallysupportiveandnon-exploitativecommunity

4

Ahighdegreeofparticipationandcontrol

bythepublicoverthedecisionsaffectingtheirlives,healthandwellbeing

5Themeetingofbasicneeds(forfood,water,shelter,income,safetyandwork)forallthecityspeople;

6

Accesstoawidevarietyofexperiencesandresources,withthechanceforawidevarietyofcontact,interactionsandcommunications

7Adiverse,vitalandinnovativecityeconomy

8

Theencouragementofconnectednesswiththepast,withtheculturalandbiologicalheritageofcitydwellersandwithothergroupsandindividuals

9Urbanformthatiscompatiblewithandenhancestheprecedingcharacteristics

10Anoptimumlevelofappropriatepublichealthandsickcareservicesaccessibletoall,and

11Highhealthstatus(highlevelsofpositivehealthandlowlevelsofdisease).

WHO1997:Twenty Steps for Developing a Healthy Cities Project,3rdedn,Copenhagen,WHORegionalOfceforEurope.

Figure 1: WHO qualities of a healthy city
http://cabeurl.com/6ohttp://cabeurl.com/68http://cabeurl.com/68http://cabeurl.com/6o


35/53

35

ii. Climate change Table 1: Health effects associated with climate change

Heatwaves Heatwavesareprojectedtobecomemorefrequent.Theveryold,chronicallyillandpooraremostsusceptibletoheat-relatedillnesses.Theadditionaldeathsinsummerwillbeoffsetbyadeclineofapproximately20,000cold-relateddeathseachyearduetowarmerwinters.Intheperiod19712003meanannualheat-relateddeathsdidnotriseassummerswarmed.This

impliesanincreaseinthepopulationstolerancetoheat.Inthesameperiodannualcold-relatedmortalityfellbymorethan33percent(DH,2008a).

Improvedtolerancetoheatinthefuturewillreduceimpactofhottersummers,butincreasedfrequencyandintensityofheatwavesarestillamajorconcerntohumanhealth.

By2012,therewillbea1in40chancethattheSouthEastofEnglandwillexperienceaseriousheatwave(averaging27CinSouth-EastEngland)causingover3,000immediateheat-relateddeathsand6,350furtherheat-relateddeathssoonafterwards(DH,2008a).

Air pollution TheairpollutionoftheUKwillcontinuetochange.Whileconcentrationsofanumberofimportantpollutantsarelikelytodeclineoverthenexthalf-century,theconcentrationofground-levelozoneislikelytoincreaseduetotheprojectedincreasesindry,sunnyweatherinsummerwhichfavourozoneproduction.Thiswillincreaseattributabledeathsandhospitaladmissions.Theincreasesarelikelytobesignificantwithasmanyas1,500additionaldeathsandhospitaladmissionseachyear.

Cold-related illnessand deaths

Cold-relatedillness,fallsanddeathsarelikelytodeclineduetowarmer,wetterwinters.

River, coastal floodingand flash floods

Floodsareassociateswithfewdirectdeaths,butthefulleffectonhealth,intermsofindirectmortalityandmorbidityduetoinfectiousdisease,mentalhealth,andinjuries,isnotknown(DH,2008a).

Theriskofmajorfloodingdisasterscausedbyseverewintergales,heavyrainfallandcoastalerosionislikelytoincreasecontaminationofdrinkingwater,increasewaterborneinfectionsandexposuretotoxicpollutants,accompaniedbypsychologicalconsequences,destructioninjuriesanddeaths.Latereffectsoffloodingincludestressandmentalhealthproblems(Tapsell,2002).Riverfloodsorstormsurges,whichcanbeforecastseveraldaysinadvance,havefewercasualtiescomparedtoflashfloodswherethereisnopriorwarning.

Infectious diseases Casesoffoodpoisoning(Salmonellosis)andwaterbornediseases(Cryptosporidiosis)linkedtowarmweatherarelikelytoincrease.A1Cincreaseintemperaturemightresultinabouta4.5percentincreaseinfoodpoisoning.Theeffectofwarmersummersonfoodbornediseaseincidentswilldependonfuturefoodhygienebehaviourandtherelativecontributionofdifferentpathogens,aswellaschangesintemperature(DH,2008a).

Vector-bornediseases

OutbreaksofmalariaintheUKarelikelytoremainrare,thoughhealthauthoritiesneedtoremainalerttothepossibleoutbreaksofmalariainotherEuropeancountriesandtothepossibilitythatmoreeffectivevectors(differentspeciesofmosquito)mayarriveintheUK.RapidresponsetooutbreaksofmalariawillreducethechancesofthediseasebecomingendemicintheUK.

Tick-bornediseases(e.g.Lymedisease)arelikelytobecomemorecommonintheUK,butthisismorelikelytobeduetochangeoflanduseandleisureactivitiesthattoclimatechange.Thelikelihoodthattick-borneencephalitiswillbecomeestablishedintheUKisverylow.


36/53


37/53

37

Figure 8.3: Direction and magnitude of change of selected health impacts ofclimate change (condence levels are assigned based on the IPCC guidelines onuncertainty, see www.ipcc.ch/activity/uncertaintyguidancenote.pdf)

Negative impact Positive impact

Very high confidenceMalaria:contractionandexpansion,changesintransmissionseason

High confidenceIncreaseinmalnutrition

Increaseinthenumberofpeoplesufferingfromdeaths,diseaseandinjuriesfromextremeweatherevents

Increaseinthefrequencyofcardio-respiratorydiseasesfromchangesinairquality

Changeintherangeofinfectiousdiseasevectors

Reductionofcold-relateddeaths

Medium confidenceIncreaseintheburdenofdiarrhoealdiseases

Urban heat islandsDuringaheatwaveitislikelytobehotterincitiesthaninsurroundingruralareas,especiallyatnight.Temperaturestypicallyrisefromtheouteredgesofthecityandpeakinthecentre.Thisphenomenonisreferredtoastheurbanheatisland(UHI)anditsimpactcanbesignicant.InLondonduringtheheatwaveofAugust2003,thedifferenceintemperaturebetweenurbanandrurallocationsreached9Conoccasions.ArangeoffactorsvariesbetweenruralandurbanareasandcontributestotheUHI.

Thermalpropertiesofbuildingandroadmaterialsandtheheightandspacingofbuildingsandairpollutionlevelsresultinmoreofthesunsenergybeingcaptured,absorbedandstoredinurbansurfacescomparedwithruralsurfacesduring

thedayandaslowerlossofthisenergyatnight,resultingincomparativelyhigherairtemperatures.

Lessevaporationandshading,withaconsequentreductioninassociatedcooling,takesplaceinthetypicallydrierurbanareasasthereislessvegetation.

Greaterinputsofheatasaresultofthehighdensityofenergyuseincities,forexamplefrombuildingsandtransport,ultimatelyendsupasheat.

Strategicplanningisthereforerequiredtotakeaccountoftheabovefactors,particularlyinthecontextofclimatechange.Atalocallevel,thisincludesthemodicationofsurfaceproperties,forexamplecoolroofs,greenroofsandcoolpavements.Plantingtreesandvegetationandthecreationofgreenspacestoenhanceevaporationandshadingareotheroptions,astemperaturesinandaroundgreenspacescanbeseveraldegreeslowerthantheirsurroundings.63

Themagnitudeofhealthimpactsascurrentlyunderstoodaresummarisedingure2fromtheIntergovernmentalPanelonClimateChange.Whiletheseareglobalimpacts,theyallhavesomerelevancetothehealthstatusoftheUKpopulation.

Figure 2: Health impacts associatedwith climate change

Source:IntergovernmentalPanelonClimateChange,2007,IPCC

FourthAssessmentReport(AR4),Climate Change 2007: Impacts,Adaptation and Vulnerability,chapter8.cabeurl.com/8p

63DepartmentofHealth,2009: Heatwave Plan for England 2009:Protecting health and reducing harm from extreme heat and heatwaves,

London,DepartmentofHealth cabeurl.com/6c
http://cabeurl.com/8phttp://cabeurl.com/6chttp://cabeurl.com/6chttp://cabeurl.com/8p


38/53

iii. The NHS carbon footprint

Figure3showsthenecessaryreductioninNHScarbonemissionsby2020inordertomeettargetssetoutintheClimateChangeAct2008.Itdemonstratesthehighproportionincomparisonwithemissionsfromothersources.

Figure 3: Carbon dioxide emissions (MtCO2)by source, 1990-2000 and predicted to 2020

38

Total emissions

ThetotalNHSEnglandCO2emissionsfor2004wereestimatedtobe18.61MtCO2.ThiscompareswithoverallUKandEnglandconsumptionemissionscalculatedasfollows:

2.7% oftotalUKemissions(699MtCO2)

3.2% oftotalEnglandemissions(584MtCO2)

88% ofthewholeofNorthernIrelands

emissions(21.3MtCO2),whichhas1.7millioninhabitants

58% ofthewholeofWalessemissions(32.0MtCO2),whichhas2.9millioninhabitants

32% ofthewholeofScotlandsemissions(58.8MtCO2),whichhas5.1millioninhabitants.64

64SustainableDevelopmentCommission2008:NHS England CarbonEmissions Carbon Footprinting Report,London,SDC.cabeurl.com/6s

CO2emissionsbysource,1990to2020,MtC

MtC

1990 2000 2010 2020

180

160

140

120

100

80

60

40

20

0

TransportIndustryServicesResidentialRefineriesPowerstations

Source:SustainableDevelopmentCommission2008: NHS England Carbon

Emissions Carbon Footprinting Report,London,SDC.cabeurl.com/6s
http://cabeurl.com/6shttp://cabeurl.com/6shttp://cabeurl.com/6shttp://cabeurl.com/6s


39/53


40/53

40

OnatypicaldayintheNHS:

almost1millionpeoplevisittheirfamilydoctor 130,000gotothedentistforacheck-up/treatment 33,000peoplegetthecaretheyneed

inaccidentandemergency 8,000peoplearecarriedbyNHSambulance 1.5millionprescriptionsaredispensed 2,000babiesaredelivered 25,000operationsarecarriedoutincluding320

heartoperationsand125kidneyoperations 30,000peoplereceiveafreeeyetest districtnursesmake100,000visits.67

v. NHS building stock

Thereisstillademandforinvestmentincommunityhealthcarefacilities,andforimprovedenergyperformance.ButunlikerecentPFIprojectsforlargenewhospitals,theseprojectswillbemainlyrefurbishmentsofexistingbuildings.Implementingthemwillrequireimaginativeuseofdesignandmanagementideasinexistingcontexts.

By2010,justafthoftheNHSstockofhospitalswillpre-datethebirthofthehealthservicein1948.Beforethecurrentgovernmentsbuildingprogramme,itstoodat50percent.

SinceMay1997,89majorhospitalschemes(68PFIand21publiccapital)openedand26areunderconstructionandareworthover10.5billion.

49capitalLIFTschemesworthover1billionhavedelivered125newprimarycarebuildingsand74areunderconstruction.

189ProCure21schemesworth854millionhavebeencompletedand133areindevelopment

withaprogrammevalueofover2.3billion.68

67SustainableDevelopmentCommission2008:NHS England CarbonEmissions Carbon Footprinting Report,London,SDC.cabeurl.com/6s

68Ibid.
http://cabeurl.com/6shttp://cabeurl.com/6s


41/53

41

vi. Research into therapeutic design

NoiseStudieshavefoundthathospitalnoisel

future health full report 0

Documents