Health and sustainable development

Anna Coote, head of Engaging Patients and the Public at the Healthcare Commission, explores ways to strengthen the relationship between the sustainable environment and health.

I have been asked to talk about the connections between health and sustainable development and to explore the implications for architecture and building. I'll be looking at public health and at the corporate activities of the National Health Service.

What is sustainable development?

First, a word about sustainable development. This has four main components. It brings together social, economic and environmental sustainability and puts them in the context of democratic engagement and accountability.

What makes people healthy or ill?

The evidence tells us that social isolation, poor education, fear of crime, disrupted family life and unhappiness are bad for health (happy people live on average 7 years longer than unhappy people). Likewise, poverty, joblessness, powerlessness and economic insecurity are bad for human health. These are the social and economic dimensions of sustainable development.

And the evidence also tells us that environmental damage is bad for health - air pollution, contaminated water, poor food supplies, heavy road traffic, dislocated neighbourhoods, poorly designed buildings. Climate change brings extremes of heat and cold, flooding, storms, drought and threatens the very essentials of human life.

What's more, health risks tend to pile up in the lives of the poor and dispossessed in ways that are vividly reflected in health statistics. Poor people get ill more often and die much younger than people who are well off.

Government policy

The government's health white paper, Choosing health, acknowledged in 2004 that, 'the environment we live in, our social networks, our sense of security, socio-economic circumstances, facilities and resources in our local neighbourhood can affect individual health.'

It also called for a 'strong role for Government in promoting social justice and tackling the wider causes of ill-health and inequality in health'.

The new sustainable development strategy for the UK, published last year, includes indicators that measure progress towards sustainable development in health terms: inequalities in infant mortality and adult life expectancy; healthy life expectancy; premature death rates from cancer and heart disease; and trends in smoking, diet, and childhood obesity,

So there are compelling arguments, backed up by major public policy initiatives, that the pursuit of sustainable development can profoundly influence population health, and the pursuit of preventative health measures can help attain the goals of sustainable development and vice versa. Unsustainable behaviour harms health. Unhealthy behaviour is unsustainable.

Unsustainable behaviour is bad for business

But failing to focus on keeping people healthy is not just bad for our quality of life. It makes bad business. Derek Wanless reported to the Treasury in 2002 on how much he estimated the NHS would cost in future. He said that failure to pursue policies that prevented illness and encouraged people to adopt healthy lifestyles would cost the tax payer some £30 billion extra a year by 2020 - that's money that will be needed in future for the treatment and care of illnesses that are in fact avoidable.

What can the NHS do?

Now let's look more closely at the NHS. Think of all the things it does routinely to enable it to provide health services - employment, procurement, management of energy, waste transport - and last but not least - capital development, landholding and building.

This is the largest single organisation in the UK and one of the largest and most powerful in the world. Its annual budget is nearing £90 billion a year. It employs more than a million people. It spends more than £11 billion a year on goods and services. And it's in the middle of massive building boom.

Seen from this angle, the NHS itself has huge potential to do good - or harm - to the health of the nation and to the cause of sustainable development. Not by providing health services, but by how it uses its resources to do everything else; how it operates as a powerful participant in planning decisions in the city, in the town, in the village, in the neighbourhood and community.

Investing in employment

For example, in spite of what we hear about hospitals needing to cut back, the NHS has a perpetual staffing crisis. It cannot find enough workers, so poaches doctors and nurses from the developing world where their skills cannot easily be spared.

Yet many NHS trusts are located in neighbourhoods where there is high unemployment, and where conditions are such that people get ill because they are poor and jobless. If the NHS invests some of its billions in basic training for local people, to prepare them to take the first steps into employment, they'll start coming into the hospitals as workers rather than as patients.

Getting jobs make them less vulnerable to illness; the fact that they live locally provides the NHS with a reliable, committed workforce. It doesn't work straight away, it doesn't work for everyone. But in the longer term it can create a virtuous circle - helping to improve health in the community, reducing preventable disease, lessening the burden on the NHS and freeing it up to provide better for those with unavoidable illness.

Food: another 'virtuous circle''

Another example: one of the scandals of the NHS is that some patients leave hospital suffering from malnutrition. The food's poor, they don't like it, or can't eat it and even if they do eat, it doesn't do their health any good. This slows down patient recovery rates and makes them vulnerable to further ill health. This is the same point that Jamie Oliver and others have been making about school food - kids do better at school if they eat well; patients do better in hospital if they eat well.

If the NHS uses its resources more carefully - arranging its purchasing and catering policies so that it provides nutritious food in ways that encourage patients to eat and enjoy - it could do marvels not only for patients' health, but for staff and visitors too. It could also use its power as one of the largest food purchasers in the country, to encourage local and sustainable food production, strengthening local economies, to reduce the environmental damage caused by shipping foods across vast distances, and to promote organic and other environmentally sound agricultural practices. Another virtuous circle - advantages all round.

Buildings: do we need them?

Now let's look at buildings. The NHS is currently engaged in the largest capital development programme in its history. Hospitals and primary care premises are being built or refurbished on a vast scale, right across the country, involving huge sums of public and private money. By 2010, over £11 billion is expected to have been spent on 100 new hospitals and over £1 billion on new primary care buildings.

Most of the new hospitals are being planned with only a passing nod to the principles of sustainable development. Many of them are partly or entirely unnecessary - they've been commissioned to satisfy the clamour of the medics for prestigious monuments to the heroic-rescue model of healthcare. More often than not, plans are being executed with more thought for the financiers' bottom line than for the future needs of patients. And for ten, twenty, even thirty years'time they will gobble up huge helpings of taxpayers' money without any guarantee that they will make anything like a proportionate contribution to the nation's health.

In other words, they are locking the NHS into long-term spending commitments that we are not at all sure we will need as patterns of illness and treatment change over time.

Dangers of poor planning and design

If great care is not taken, these buildings will have large car parks, lots of lifts, energy intensive air conditioning, heating and lighting. They will use materials from unrenewable sources and equipment that needs to be transported over long distances to get to the site.

They will often involve costly demolitions of existing buildings that might be adapted at far less cost in financial and environmental terms. They may well encroach on greenfield sites beyond cities and towns where access depends heavily on the use of private cars. They will produce almost unimaginable amounts of waste. Between 80 and 150 million tonnes of construction waste goes into landfill every year, costing £1 billion in landfill tax.

Doing things differently

Is there an alternative? Yes there is.

For a start, there could be a much smaller number of high quality specialist centres, combined with a larger number of small (possibly mobile) community-based clinics and care centres. This would be a lot more effective and give far better value for money.

And every building that does go ahead could meet high standards of sustainable development. And here, again, is the chance to create a virtuous circle.

A sustainable building can provide a healthy environment to work in, reducing absenteeism and improving staff performance. It can provide a good environment to receive treatment and care in - improving patient recovery rates. Building design can affect the ease with which infections such as MRSA can be isolated, or spread. A building can be constructed using sustainable materials and local labour. It can make maximum use of natural heating and ventilation, reducing the amount of energy it consumes.

It can be located and designed to facilitate water conservation, minimise waste and encourage walking, cycling and public transport rather than private car use. It can be situated on a brownfield site, helping to preserve green spaces. It can be part of the local community.

By managing energy, waste and water sustainably, by creating environments that reduce staff sickness and hasten patient recovery, this approach can make very substantial financial savings over time.

Examples of good practice

There are, of course, examples of good practice in the NHS. Sue Atkinson has worked hard to make a lot of them happen, especially in London. Here are just three illustrations:

• Whipps Cross University Hospital NHS Trust is a £340 million PFI redevelopment in north-east London. It's working with local colleges and Jobcentre Plus to provide training and support to help local people get jobs associated with the development. And a predemolition audit has aimed to reduce waste going into landfill by up to 30 per cent.
• The Rutland Lodge Medical Centre in Leeds is designed so that air from the natural ventilation of rooms can be drawn along central corridors and vented through solar chimneys. It's got photovoltaic panels on the roof that power the building.
• A redevelopment in Burnley combines GP and dental practices, a leisure centre, a community café, a crèche and a training suite on a site that will be accessible by public transport, walking and cycling. It aims to play a key role in local regeneration and health promotion, involving the community in its planning, providing education and job opportunities, and encouraging physical activity.

Good Corporate Citizenship

Examples like these have been brought together in an initiative to promote what has come to be known as Good Corporate Citizenship. This is about using corporate resources in things like employment, procurement and buildings, to promote health and sustainable development - minimising risks to health and helping to safeguard the long-term viability of the NHS.

The NHS self-assessment model

As part of this initiative, the Department of Health has been working with the Sustainable Development Commission to develop the capacity of NHS organisations use their resources more wisely. This partnership has produced a web-based self-assessment model for NHS staff and trust boards. In six areas, including buildings, the website explains what sustainable development means and how it can be put into practice. It gives people a chance to judge their own performance, provides examples of good practice and slide shows to help people spread the word.

The model was launched in March this year and it has proved remarkably popular. You can find it on the website. It's not a solution, but it's a start.

Barriers to change

I do not have much time to explore the barriers to change, but let me just mention some of them briefly.

The first is that health policy has to be produced by the Department of Health and yet most things that seriously affect health come under the auspices of other departments - work and pensions, education, trade and industry and environment. It can be difficult to drive through change, when every department, every ministerial team, has its own priorities on which it wants to be judged.

Another inhibiting factor is that most health professionals derive their income, status and job satisfaction from making people better after they have become ill. They tend to be rather more supportive of policies that improve the health services they provide, than of policies that aim to prevent people needing their services in the first place.

A third problem is that health policies that focus on choice tend to favour the better off. Choice may be highly desirable in theory. But individual choice as a policy driver, unless firmly rooted in policies to promote shared responsibility and equal capacity to choose, is likely to widen health inequalities and so undermine the purpose of sustainable development.

Another inhibiting factor is the Government's drive for 'efficiency', which implicitly encourages purchasing decisions that go for economies of scale rather than longer-term value. There is still important work to be done to redefine 'efficiency' in sustainable terms. The need to develop whole life costing and accounting is acknowledged in the UK sustainable development strategy, but the message has yet to get through to those who spend public money out in the field.

A final problem relates to priorities and incentives. The prevention of illness and the pursuit of good corporate citizenship are endorsed in policy, but they are not the sort of thing that ambitious health professionals and managers build their careers upon.

In conclusion

As the saying goes 'vision without action is hallucination'. What counts in the end is whether there is sufficient energy, enthusiasm, political will, leadership and power to drive through the actions that must be taken and to keep the action going over very considerable periods of time. It's about making, managing and sustaining change, not just drafting policies or legislation.

It is possible to achieve better health outcomes by pursuing sustainable development. It is possible to achieve more sustainable outcomes by preventing illness, reducing health inequalities and using NHS corporate resources strategically. The price of failure is vast - in terms of wasted resources and wasted lives. The prize of success - better health, better quality of life and substantial long-term savings - is worth every effort we can make.