Building public health

John Sorrell, CABE chair, discusses how good design in private and public spaces can bring about positive change in public health.

Introduction: the historical connections between the built environment, health and design

Good afternoon.

As you may know CABE's purpose is to champion the ability of architecture and urban design to transform people's lives for the better.

Buildings and the spaces between them impact on our lives in many ways. As the Prime Minister said in 2000:

 

\"We know that good design provides a host of benefits. The best designed schools encourage children to learn. The best designed hospitals help patients recover their spirits and their health. Well-designed parks and town centres help to bring communities together.\"

 

The health of the nation and the state of our towns and cities is also intimately linked.

Sanitation and other public health interventions have been shaping our cities for centuries.

At the beginning of the nineteenth century Britain was riding the crest of the industrial wave to become the world's first modern urban nation.

Social commentators from around the world converged on cities such as Manchester , Liverpool and Glasgow to witness the effect of this rapid and unchecked growth.

What they saw was truly awful.

The absence of any basic infrastructure left city authorities unable to cope with the filth, pollution, overcrowding and disease swamping the jerry-built slums that had sprung up to accommodate the rapidly expanding urban population.

The result of these sanitary and housing conditions was a total collapse in the life expectancy of the inhabitants.

In cities of over 100,000 people, life expectancy at birth dropped from 35 years in the 1820s to 29 years in the 1830s. For a slum dweller in early Victorian Glasgow or Liverpool chances of survival were the lowest since the Black Death.

A doctor named James Kay, who at the time was battling cholera amongst the great mills of Manchester 's Ancoats district, wrote in 1832:

 

\"He whose duty is to follow the steps of this messenger of death, must descend to the abodes of poverty, must frequent the close alleys, the crowded courts, the overpopulated habitations of wretchedness, where pauperism and disease congregate round the source of social discontent and political disorder in the centre of our large towns, and behold with alarm, in the hot-bed of pestilence, ills that fester in secret at the very heart of society.\"

 

In such an environment the effect of poor quality working and living conditions on people's health was all too apparent.

The response to this crisis by the emerging public health and town planning professions, as well as that of engineers and local politicians is well documented.

A little over 50 years after Dr Kay's work was first published the impact of these reforms was already being felt in Ancoats - Victoria Square, the first example of municipal housing in Manchester, was built in 1889 and was followed shortly by the development of model housing in adjacent Anita Street . Originally known as Sanitary Street , every house in this showcase development contained proper internal plumbing. An untold comfort for cotton mill labourers.

In many ways we are still enjoying that Victorian legacy of improved housing conditions, networks of sewers and public parks.

So I am delighted to have this opportunity to address you at a time when both the public health agenda and urban policy are once again being promoted with enthusiasm by government.

This afternoon I'd like to consider how, in the twenty first century, the design of the places and spaces where we live; where we work; where we play; where our children learn; where we treat and heal; can help to improve the nation's health

And I'd like to ask you to join my call for architects, designers, town planners and urban policy makers to once again work with public health professionals to create healthy communities within our towns and cities.

Defining good design

I'd like to begin by thinking about what 'design' actually means. As Norman Foster, an architect who I'm sure needs no introduction, once noted:

 

\"There is a tendency for a certain mystique to develop around such words as 'design', especially 'good design.' This is unfortunate because it tends to cloud the importance that design decisions have on our lives. Virtually everything that is man-made has been subject to a design process involving deliberate choices and decisions … As in all things this is something we can do well, badly or indifferently with corresponding end results. To this extent the very quality of our day to day living is profoundly influenced by the quality of our design.\"

 

Doing design well requires an understanding of much more than aesthetics. Of course looks are important, but much more important is the usefulness of the end product.

Good design is about ensuring that product - be it a piece of equipment, a building, a neighbourhood, a city, or even a service - makes life better for anyone who comes in to contact with it.

2000 years ago the Roman architect Vitruvius suggested three essential elements of a well designed building: Utilitas, Firmitas and Venustas. I'm sure your Latin is better than mine, but just in case, here is Sir Henry Wooton's 1832 translation, which has become the classic criteria by which building design is judged - Commodity, Firmness and Delight.

In other words a well designed building, or anything else for that matter, should be functional, well made and beautiful.

But true delight goes beyond the issue of beauty, it must also consider how the building contributes to the experience of those who use it, and whether it also makes a positive contribution to the community in which it is based.

Remaking the connections

This connection between design, aesthetics and quality of life was well understood by Dr Scott Williamson and Dr Innes Pearse, who in 1935 opened the pioneering Peckham Health Centre and began one of the great public health experiments of the twentieth century.

The Centre itself, designed by the engineer Sir Owen Williams, remains a modernist icon. It was described by Walter Gropius, the founding father of Bauhaus, as an 'oasis of glass in a desert of brick'.

Open plan, flooded with light and equipped with a swimming pool, gymnasium, theatre, dance hall and cafeteria as well as medical rooms, it epitomised Willamson and Pearse's ambition to promote good health and quality of life, rather than merely treating ill health. With this in mind the Peckham Health Centre was deliberately located in a relatively healthy community.

The Finsbury Health Centre, by contrast, was located in one of the London 's poorest boroughs. When the centre opened in 1938 conditions in Finsbury resembled those described by James Kay 100 years before. Poor housing and poor diets meant that tuberculosis, lice, rickets and diphtheria were common. As The Spectator observed at the time:

 

\"Finsbury is not a health centre in the same sense that Peckham is … Peckham is organised for health. Finsbury braces itself to fight disease with the best weapons and in the most efficient ways that man has yet devised, but insofar as its main operations begin after disease has taken hold, its whole existence is an acknowledgement of human failure to achieve or retain health.\"

 

Despite these contemporary observations Berthold Lubetkin, one of this country's great social architects, was keen to create a building that would persuade people to lead healthier lives as well as treat ailments. As a result the centre, with its Gordon Cullen murals and lecture theatre alongside its TB clinic, was one of the first integrated health centres in Britain .

However, the establishment of the National Health Service, with its emphasis on cure rather than prevention saw a shift away from such integrated services. Reflecting this the efforts of the architectural community during the 50s and 60s were focussed primarily on hospitals rather than local, community based health centres.

This coincided with a growing gap between public health and urban policy, exemplified by the publishing of the 1977 Urban White Paper, which made economic regeneration the principle aim of urban policy. A policy that was enthusiastically supported by Margaret Thatcher 's 1979 government.

During the 1990's a more comprehensive approach to socio-economic regeneration brought recognition of its potential health impacts, and programmes such as the Single Regeneration Budget and the New Deal for Communities included specific health objectives.

Labour's election in 1997 heralded both a long-overdue recognition of the centrality of cities in national economic, social and cultural life and a new agenda for public health, with the appointment of the first-ever Minister for Public Health and the introduction of community focussed initiatives, such as Health Improvement Programmes and Health Action Zones

However, there remains a divergence between physical regeneration efforts and the wider public health agenda.

An agenda which focuses on changing lifestyles and behaviour through taxes, subsidies, service provision, regulation and information.

While these are undoubtedly important tools, employing them will only ever win half the battle.

The other weapon in the arsenal - shaping and using the built environment for the promotion of health - is either barely mentioned, or viewed too narrowly, as merely a question of where to locate health facilities, rather than how to use the built environment as a tool for reducing demand on those facilities.

And yet, at the same time the built environment is undergoing a once a in a generation transformation:

Many of our towns and cities are enjoying an unprecedented renaissance, with populations growing for the first time in decades.

• Across the country we will see huge numbers of new houses built. The government forecasts that by 2016 up to 4 million new homes will be needed in the UK .
• The lottery is funding improvements to our historic public parks.
• And Britain is currently in the middle of the largest public sector construction programme for a generation, which is particularly benefiting the education and health sectors.

How then can we ensure these development programmes make a positive contribution to meeting public health objectives?

As the Wanless Report noted, people need to be given the opportunities to take responsibility for their own well being. How can we best use the design of our buildings, places and spaces to provide that opportunity? To encourage behavioural change and tackle the physical inactivity that leads to obesity and related chronic diseases.

Housing

Since the earliest sanitary and planning reforms, efforts have been made to address the link between poor housing and poor health.

While these reforms contributed to the decline in tuberculosis and other infectious diseases, there remains a significant number of damp, cold, and badly designed and maintained properties that leave their often vulnerable residents at risk of respiratory illnesses, hypothermia, rheumatic disorders, falls, and stress.

The government's efforts to address these issues through the Decent Homes Standard and measures to tackle fuel poverty are welcome.

But to see the full potential for where we live to promote public health, we must look beyond the home to the neighbourhood.

Streets and neighbourhoods

Most sustained exercise is taken during the course of everyday, necessary activities, such as travelling to work or going to the shops, rather than specifically for health purposes. We must therefore ensure that our built environment provides a network of routes and destinations that maximise the potential of this everyday activity.

We have long been a nation of suburbanites, and while we are still fortunately a long way from American levels of suburban sprawl, there can be little doubt that the low density housing development that continues to be built across the country has increased reliance on the car.

If we want to encourage people to walk and cycle around their neighbourhoods, rather than use their cars, we have to make our streets safe and attractive, ensuring the design of street layout meets the needs of all users, not just drivers.

Too many recent housing developments are built effectively as compounds. With one way in and out, usually marked by a roundabout and limited, if any, footpaths.

Retail parks are even more forbidding. Even the most determined pedestrian has to battle with a hostile environment, which appears to be designed precisely to discourage their presence, supposedly in the name of road safety.

Such street layouts force pedestrians to take lengthy diversions from the logical, direct route, creating further encouragement to take the car instead.

These features seriously undermine the potential connectivity between areas which is essential if we are to encourage people to use alternatives to the car for local journeys. Some work has, however, been done to calm traffic and improve the usability of neighbourhoods, not least the excellent Home Zones initiative .

But such 'safe areas' have to be linked if we are to create safe routes to school, work or the shops. This does not mean more soulless walk ways and underpasses to separate pedestrians and others from cars; rather we need to find ways to produce the kind of shared streetscape that exists in some of our more established urban areas.

There are good examples in the Netherlands and Denmark of radical redesigning of road layout and changes in priority which appear successful.

By blurring the boundaries between 'traffic' and 'people', by removing road signs and markings, levelling pavements with road surfaces and making other physical changes to the street scene, driver behaviour has been modified.

Drivers have to rely on eye contact to negotiate rights of way, as a result lower speeds are achieved and accidents reduced - drivers know they are sharing space with pedestrians and so take more care.

In the UK , good examples can be seen in housing developments such as Poundbury on the outskirts of Dorchester , where the road layout has been designed to level the playing field between traffic and pedestrians, and in the Royal Borough of Kensington and Chelsea 's improvements to the layout of High Street Kensington and also in their proposals for Exhibition Road .

Of course, traffic is only one factor that discourages people from using their streets and public places.

The hardening of our urban environments, and the increased use of remote surveillance that occurs as a result of vandalism, crime and the fear of crime are combining to produce insecure and unattractive places.

But we are now developing a much better understanding of how urban design can reduce crime and limit vandalism by creating places that the community will want to use and enjoy.

Parks

Victorian municipal leaders recognised the importance of public parks and public spaces in encouraging healthy behaviour amongst their citizens.

Good quality air, water and public spaces formed the backbone of Victorian efforts to improve public health. While access to clean air and water became enshrined in law, the same is unfortunately not true for our parks.

In recent years our public spaces have suffered from a loss of vision about the benefits they can deliver when designed and maintained to the highest quality.

But parks and green space can be seen as the 'gyms' of lifestyle activity. They provide open space where people can be active, from walking the dog to throwing a Frisbee, from flying a kite to kicking a ball.

In encouraging these activities the importance of good design and maintenance is critical. A park can quickly become a no-go zone if neglected, but even a well maintained park that does not provide spaces for different uses and users will not play its full part.

A well designed park can however establish a virtuous cycle, when more people are attracted to a space it becomes more interesting, which in turn attracts more people, who are encouraged to stay longer and under take more activity.

The built environment has health impacts beyond physical inactivity, of course, and this is particularly true of parks and green space.

There is for example a great deal of evidence that well designed and accessible green space can contribute to better mental health outcomes; proximity to nature and greenery can relieve some of the stress of city living, and good public space can foster beneficial social interaction, which adds to well-being.

Work places

Winston Churchill's quote 'We shape our buildings, and there after they shape us' takes on a whole new meaning when we consider how building design could contribute to tackling physical inactivity and how such opportunities are often missed.

At the most basic level, the provision of showers and other facilities in offices can encourage people to cycle to work, or to take exercise before or during the working day.

But there are more intrinsic aspects of building design that can modify and shape our behaviour. The increasing invisibility of stairs in many commercial, public or even residential buildings is a case in point.

If you think about the lobbies of recently built offices, hotels and other public and semi-public buildings, one of the consistent elements is the absence of stairways.

They exist, and fire regulations demand them, but they are more often than not invisible, hidden away, while banks of lifts or escalators signal that the way to move around the building is by standing still.

Compare this with buildings of previous generations, where not only were stairs visible, they were celebrated as a central and grand aesthetic element of the building.

Of course, the technological changes - including lift technology itself - that have allowed for much taller buildings, coupled with the entirely legitimate demands of equal access, mean that stairs cannot be the only or even primary means of moving between floors. But it is hardly surprising that some people without mobility difficulties will still use lifts to move just a couple of floors if stairs are hidden, unattractive and made inconvenient to use.

The design of our work places can also have a fundamental impact on occupational health. 14 million days are lost each year in the UK through absenteeism from work, at least 70 per cent of which is related to health issues.

One of the keys to addressing this is to ensure that basic human needs for daylight, fresh air and comfortable temperatures are met - quite simply people cannot work at their best if they can't breathe, hear and see properly.

And the same applies to children in schools.

Schools

In our schools classrooms with good daylight, natural ventilation and good acoustics have been shown to have a significant impact on educational achievement.

The Building Schools for the Future initiative will see every secondary school in the country rebuilt or refurbished over the next 10-15 years. It's vital that this investment, along with a significant investment in primary education, ensures that children are taught in environments that have been designed with these and other benefits in mind.

A healthy mind and a healthy body go together. We have the opportunity, right now, to design our new schools, internally and externally, with health as well as education in mind.

Not just the classrooms, social spaces, dinner halls and lavatories, but also the playing fields and playgrounds, which have an obvious role to play, both in allowing a range of activities to take place during the school day, and as a potential community resource out of school hours. Sports of all kinds need to be considered as part of the equation so that facilities are planned at an early stage in the Building Schools for the Future programme.

And beyond the school grounds, there should be safe walking and cycling routes, encouraging physical activity on the journey to and from school.

Health buildings - Hospitals and primary care

Meeting basic human needs can also have a significant impact on health outcomes. Research has shown that something as fundamental as being able to enjoy a view from your hospital bed can radically reduce recovery times. So, why don't we design this early on in the process?

Good design on both large and small scales can deliver a wide range of benefits, from reducing intake and dependency on pain relieving drugs, to aiding the recruitment and retention of staff.

For example, the humble bedside cabinet, if re-thought and redesigned, could help address a number of issues such as independence on the ward, competition for space at the bedside, drug dispensation, secure personal storage and problems of dehydration and water dispensation.

A redesigned bedside cabinet could contain a chilled water dispenser that can be activated by the patient pushing the glass against a lever. The cabinet could provide secure storage for the patient's personal belongings, along with lockable drug storage.

Simple design interventions have been used to great effect in the proposals for Lewisham Primary Care Trust's Children and Young People's Centre.

When it opens in 2006 the centre will be a great example of a patient centred healthcare facility that puts the person before the system.

Four previously separate services for children and young people, Child Health, Child and Adolescent Mental Health, Special Educational Needs and Social Care services, will be co-located in a therapeutic, environmentally sound building, that should become a nationally recognised model for the delivery of primary care.

The reception has been designed so that staff can point out exactly where patients need to go to, as all departments are visible across the courtyard. Colour coding makes orientation instinctively easy, with each department identifiable by a particular colour.

Across the health service design can have a direct clinical and psychological impact - drip stands, bedside cabinets, views from windows, the right lighting and good communication, ensuring patients are kept informed at all times all make a difference to the patient experience.

And yet when, in 2004, CABE asked members of the public to comment on their experience of hospital environments, 83 per cent of the comments were negative.

Cold, depressing, dehumanising, Kafka-esque, dirty, smelly, frightening, impersonal, confusing, dull, shabby, windowless, grim, over-crowded, Gormenghast, no personality, stressful, unpleasant, little natural light or air, harsh, disorientating, designed to confuse, no privacy - were just some of the expressions used to describe that experience.

The current levels of investment in both acute and primary care buildings provide a once in a lifetime opportunity to use architecture and design to address these issues and improve the experience for staff and patients alike.

Projects such as the Bromley by Bow Centre, which was awarded the The John Edward Worth Silver Medal by the Royal Society for the Promotion of Health in 2004. Or the recently completed 'super surgery' in Newham, provide us with examples of how the vision that 70 years ago gave us the Peckham and Finsbury Health Centres is replicable today.

Hospitals and doctors' surgeries are community buildings; they serve local residents and should make a positive contribution to their surroundings. I discussed earlier how the design of streets and buildings can contribute to public health.

The design of health buildings must reflect this thinking. Just as the NHS is leading on issues such as smoking at work so they should take the lead on encouraging physical activity through the design and layout of health facilities.

A call for action

There is much talk at the moment about creating sustainable communities. The Office of the Deputy Prime Minister defines these as: "places where people want to live and work, now and in the future. They meet the diverse needs of existing and future residents, are sensitive to their environment, and contribute to a high quality of life. They are safe and inclusive, well planned, built and run, and offer equality of opportunity and good services for all."

And of course in order to be sustainable communities they must also be healthy communities. The built environment provides the backdrop to everything we do - and well designed buildings, streets and neighbourhoods will be essential if we are to achieve this vision.

In the past the design and planning professions have found it difficult to have an effective dialogue with health professionals. Specialist languages on both sides have created a gap between the professions that we must bridge if we are to make the most of the current opportunities.

NHS London's Healthy Urban Development Unit, established in 2004 to create sustainable and healthy communities across the capital, could provide one model for craeating this dialogue.

We need to ensure that not only are health facilities integrated into the planning of new developments, but also that regional and local planning policy documents address the aim of enhancing healthier development and promoting more sustainable communities.

Planners and designers should in turn engage with Primary Care Trusts, encouraging them to see the built environment as a means of meeting their public health targets.

This is an important and exciting time. As I said earlier, we are living during a once in a generation change to the built fabric of our towns and cities. This is an historic opportunity that we all must grasp.

Each year almost 700,000 children are born in the UK . Most of them will be born in a hospital. They will go on to live in the houses we are building today; learn in the schools we are building today; work in the offices we are building today; and they will play, both as children and then with their own children and grandchildren in public parks, both old and new.

Our opportunity and, I believe, our duty, is to design and build an environment which for each child, over their whole life, gives them the best possible quality of life.

150 years ago our forefathers worked together to understand the implications of urban growth on public health, and to promote the benefits of well designed neighbourhoods.

Let us work together again to understand today's challenges, make the most of the opportunities given by the unprecedented public and private building programme, and create a healthy urban policy that has people, communities and quality of life at its heart.