1

Hampshire

Public Health Team

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Healthy Neighbourhoods

Transport

Healthy Homes Green Space

Spatial

Planning

JSNA

Spatial

Planning

JSNA

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CONTENTS

Item

Page Number

Summary

3

Introduction

4

Green Space Links with health 6 Hampshire data 7 What can be done?

9

Transport Links with health 12 Hampshire data 13 What can be done?

15

Healthy Homes Links with health 17 Hampshire data 17 What can be done?

18

Healthy Neighbourhoods Links with health 21 Hampshire data 22 What can be done?

25

Approaches to incorporating public health into planning

28

Recommendations

30

Appendix 1

31

Appendix 2

36

References

38

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SUMMARY

Our health is linked to our environment in many ways and recent guidance, such as the

Government’s planning policy framework1, recognises the important role that spatial planning can

have on health and wellbeing. This JSNA chapter aims to provide evidence of the links between, and

the opportunities from incorporating public health into planning.

This JSNA resource is structured around four themes; green space, transport, healthy homes and

healthy neighbourhoods. For each theme evidence is presented on the links with health and what

the planning system can do. This is informed by relevant literature, including a 2017 review by Public

Health England2, and illustrated with case studies. The table below provides a summary.

Theme Link to health What can planning do

Green space Increases physical activity Improves mental wellbeing Improves social connectedness Improves air quality

Open space standards Increase accessibility of green space Increase use of green space Urban planting

Transport Road traffic accidents Active travel promotes physical activity Impact on social isolation Active travel reduces air pollution

Promote walking and cycling Road safety Reduce car use Connectivity

Healthy homes Physical health (e.g. cold, damp) Mental health (e.g. overcrowding, noise) Social isolation

Housing design Housing mix Accessible design

Healthy neighbourhoods

Access to healthy/unhealthy food Access to education, healthcare, employment etc Fear of crime, social isolation etc.

Restricting unhealthy outlets Designing high quality public realm Provision of social infrastructure

Two other issues have been identified as particularly important for Hampshire – the ageing

population and social inequalities – so these cross-cut the four major themes throughout this

resource.

In addition to individual planning actions there are also more general approaches to incorporating

public health into planning which are detailed at the end of the resource and include protocols,

checklists and assessments.

Planners and public health specialist generally aspire to a common goal of making our environment

better so this resource concludes with recommendations for maximising the opportunities for

improving health and well being through spatial planning.

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INTRODUCTION

There are various definitions of spatial planning but for the purposes of this resource it is considered

as wider than traditional land use planning and encompasses urban, environment and transport

planning.

This geographic expression (i.e. the environment), both natural and built, has significant impacts on

physical and mental health. There is much evidence on just how important the environment in which

we live and work is for our health2 3; as Figure 1 shows, 10% of the impacts on health are

environmental.

Figure 1: Estimated relative contribution of different factors to health4

The promotion of good health is now explicitly stated in the UK Government’s planning framework1

with a requirement that local plans should “Take account of and support local strategies to improve

health, social and cultural wellbeing for all”.

UK Government Planning Practice Guidance5 defines a healthy community as “A good place to grow

up and grow old in … one which supports healthy behaviours and supports reductions in health

inequalities”.

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In 2016 Hampshire County Council published its Public Health Strategy6 which sets out a plan to

improve health in the county. Priority 5 of the Strategy is to ‘make local places healthy and safe’

which will be achieved by working in partnership with colleagues from county and district planning

teams.

Major Themes

This resource groups into four themes the ways spatial planning impacts on health and wellbeing:

1. Green space

2. Transport

3. Healthy homes

4. Health neighbourhood

For each theme the best available data and evidence is presented on

The links with health

The Hampshire situation

What planning can do - illustrated with case studies

Cross-cutting themes

The Hampshire JSNA7 looks at the current and future health and wellbeing needs of the local

population; it identifies the following cross-cutting themes as relevant to spatial planning:-

Ageing population

Figure A in Appendix 1 provides a summary of Hampshire’s population and the forecast

changes over the next few years. Overall the population is expected to increase by 6.5%

between 2015 and 2022 but the increase is much greater amongst the elderly (for instance a

30% increase in people aged 85+ is expected)8. The ageing population of the county is a

cross-cutting theme throughout this resource and includes considerations such as disability,

experienced by almost two thirds of people aged over 80, and dementia, which is estimated

to affect 1 in 14 people aged 65+9.

Inequalities

Hampshire is the tenth least deprived local authority but this masks localised pockets of

deprivation. Men from the most deprived areas have a life expectancy almost seven years

lower than those in the least deprived parts of the county6.

The Marmot review on inequalities concluded that one of six key policy objectives should be

to ‘create and develop healthy and sustainable places and communities’10.

More general approaches and processes that could aid closer working between public health and

planning are considered before conclusion by way of key recommendations.

7

GREEN SPACE

Link with health

There is a strong body of evidence linking contact with the natural environment and improved

health2. Green space supports physical and mental health and wellbeing through co-benefits of

physical activity and social interaction.

Access to the natural environment can help increase activity and reduce obesity, with research

suggesting that people with good perceived and/or actual access to green space are 24% more likely

to be active11. Green areas provide a pleasant environment in which to undertake physical activity;

for instance, linear woodland trails encourage walking and cycling12. Evidence shows that access to

recreational infrastructure (i.e. parks and playgrounds) is associated with reduced risk of obesity in

adolescents2.

Spending time in green spaces has been shown to produce levels and patterns of chemicals in the

brain associated with low stress13 and has positive impacts on blood pressure14. Research at Exeter

University found that moving to an area with more green space resulted in a sustained improvement

in mental health – watch this video to understand more:

http://vimeo.com/83228781

Research suggests that the presence of urban vegetation results in an overall reduction in air

pollution15 16. For example, schools surrounded by green space have been shown to experience

lower levels of traffic-related pollution in their classrooms17.

By improving physical fitness and reducing depression, the presence of urban green spaces can

enhance health and wellbeing and can indirectly impact on health by improving air quality and

limiting the impact of heatwaves by reducing urban temperatures18. For instance, an urban park has

been found to be 1°C cooler than a non-green site19.

Urban ‘blue’ spaces such as canals, rivers, lakes and estuaries are also important for mental

wellbeing20.

A review by Public Health England2 found no strong evidence of access to the natural environment

reducing health inequalities but studies do show that where green space is available, the

socioeconomic position of the local population does not affect how frequently it is used21 22 23.

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Contact with nature has a positive impact on obesity, physical activity, mental health and longevity

of older people24.

Hampshire data

Analysis of a Natural England Survey has been used to estimate the proportion of residents in each

area taking a visit to the natural environment for health or exercise purposes over the previous

seven days25; in Hampshire 23% of residents are estimated to make use of outdoor space for

health/exercise reasons compared to 18% nationally.

Across Hampshire 17% of the land and 81.4% of the population is defined as urban; Winchester is

the most rural district (only 41.7% of residents living in urban areas and just 4.6% of land defined as

urban) whereas in Fareham and Gosport nearly 100% of the land and population is urban (see Table

A in Appendix 1).

Figure 2 shows the areas of accessible natural green space in Hampshire (see Table B in Appendix 1

for definition and data).

Figure 2: Map showing accessible natural green space in Hampshire (see Table B in Appendix 1 for definition)

Although the New Forest has the greatest proportion of land area designated as accessible natural

green space, it is Hart which has the highest proportion of residents living within 300m of accessible

natural green space (50.7%) whereas Gosport has the lowest at just 10.3% (see Table B in Appendix

1).

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It is also important to consider the ‘man made’ green space available which includes play parks and

allotments; some districts in Hampshire have mapped this data. For instance, Figure 3 shows natural

and man-made green space in East Hampshire. For East Hampshire this increases the proportion of

the population living within 300m of green space from 28% to 75%. The increase in other districts

would vary.

Figure 3: Map of accessible natural and man-made green space in East Hampshire

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What can be done?

Proximity to an adequate quantity of high-quality green space has been found to have a protective

effect on health26 27, with its availability in areas of socioeconomic deprivation potentially reducing

health inequalities28 and increasing levels of physical activity29 30 31. The quality of the green space is

absolutely crucial: its use and enjoyment is dependent on it being safe and attractive32 33 34.

The NPPF states that “Planning policies should be based on robust and up-to-date assessments of

the needs for open space, sports and recreation facilities and opportunities for new provision”1. This

framework encourages local determination of open space standards; “Information gained from the

assessments should be used to determine what open space, sports and recreational provision are

required’.

Many areas have set standards for open space. For instance, the Winchester Open Space Strategy35

identifies specific needs or shortfalls of open space and then goes on to indicate what further open

space provision may be required in each area.

Case Study

Southampton Green Space Standards36

Southampton has developed local standards for green space which include accessibility standards,

measured in walking time, for various categories of green space.

Green space needs to be flexible enough to cater for different age groups and the varying needs of

the population. Commonly cited barriers to using green space include fear for personal safety,

antisocial behaviour, poor maintenance, being too busy at work or home, poor weather, poor

health, old age and lack of transport.24

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Public Health England (PHE)24 give three strategies for improving access to green spaces:-

1. Create new areas of green space and improve the quality of existing green spaces

2. Increase accessibility of green spaces and improve engagement with local people

3. Increasing the use of good quality green space for all social groups

Case Study: Creating new area of green space

Creating new: Natural Recreation Area at Bytheway in Dorset24

East Dorset District Council has created a ‘suitable alternative natural green space’ (SANG) for residents of a new development. SANG is intended to divert recreational pressure away from protected areas of nature conservation. The area offers a purpose-built outdoor recreation facility of 14 hectares of green space which lies close to existing protected areas. The plans include a new car park, footpaths, ponds, a boardwalk, benches and plants which will open up the green space. It is anticipated that this new area of green space will enable residents to engage in physical activities.

Accessibility means removing barriers that prevent people from accessing green space. These

barriers may be physical, economic, or social. For instance creating a safe and direct route to a local

playground may encourage families to walk or cycle to the park, and ‘step free’ flat routes and

pathways can open up facilities for those residents requiring wheelchair access79.

Much of Hampshire is rural but some districts (e.g. Rushmoor and Gosport) are defined almost

entirely as urban so it is important to learn how to increase outdoor activity from other urban areas.

In some urban areas with limited green space, experimental street closures (‘street play’) have been

implemented. These occur for set periods of time on a regular basis to encourage children to be able

to play actively, independently and safely near their own front door. This can help improve children’s

confidence, self-esteem and resilience as well as encouraging physical activity37.

There is evidence to suggest that planting trees in urban areas can bring multiple benefits from

reducing air pollution to providing shade38. Choice of species is important as some types of pollen

may produce adverse health effects.

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Case Studies: Urban Green space

Transport for London (TfL) Clean Air Fund39

Concern over high levels of particulate air pollution led to a green infrastructure strategy as part of

the TfL Clean Air Fund. In 2011–12, more than 600 large trees and a range of smaller trees and

shrubs were planted at hotspots along the TfL road network. A 200m2 green wall designed to

provide living cover in all seasons was installed on the south-east facing walls at Edgware Road

underground station in 2011 and a second 120m2 green wall was installed at the Mermaid Theatre

building the following year.

Research found that the shrubs and plants in the green wall at Edgware Road had the ability to trap

PM10, but that ability varied greatly across different plant species and their leaf characteristics.

Results suggested that green infrastructure is best used as a supplementary measure to support

emissions reduction, but should be viewed in the context of wider environmental benefits such as

reducing the urban heat island effect, biodiversity gains and aesthetic values.

Pocket Parks40

In London there has been a programme to develop small areas (less than 0.4 hectares) of public

space that are open and accessible to all. The programme aimed to deliver 100 new or improved

areas of greenery. The projects range from community orchards, green gyms and ‘edible bus

stops’.24

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TRANSPORT

Link with health

Developments in transport have revolutionised society, and benefitted health, by making a wide

range of services, educational facilities, workplaces, social contacts and leisure activities more easily

accessible. Motorised road transport is comfortable and convenient and is especially important for

older and less mobile members of society.

However, there are immediate and longer term hazards to health including41:

increased disease burden due to reduced levels of physical activity

road traffic collisions and injuries

air pollution

noise

Parents’ and children’s concern about road traffic injury is a major contributor to physical inactivity,

as parents can be reluctant to allow children out of the home without constant adult supervision.

The volume and speed of motorised traffic can also reduce opportunities for positive contacts with

other residents in a neighbourhood and, for many people, can contribute to increased social

isolation41. This was first observed in a US study42 in the 1970’s but similar results were found more

recently in a study of three streets in Bristol43.

In terms of mental wellbeing, studies have found walking and cycling journeys are frequently

relaxing41. Recent UK research finds that this ‘active commuting’ is positively associated with

wellbeing and is associated with reduced risk of feeling constantly under strain and being unable to

concentrate compared to car travel44.

Figure 4: The wider benefits to society of increased walking and cycling45

Figure 4 shows the positive impacts of active travel beyond the individual.

REDUCES

Traffic congestion

Carbon emissions

Road casualties

INCREASES

Local air quality

Social cohesion

Public realm

Quality of Life

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In terms of inequalities, disadvantaged areas tend to have a higher density of main roads, leading to

poorer air quality, higher noise levels and higher collision rates46.

With respect to our population ageing, safe routes to amenities are vital for keeping older people

physically and socially active. A recent systematic review found evidence of the link between the

physical environment and active travel in older people; aspects found to be important included a

safe footpath network and sufficient places to rest47.

Hampshire Data

In 2011 nearly 72% of Hampshire’s working residents travelled to work by car as either a driver or a

passenger48. At 21%, Gosport had the highest proportion of residents using active travel (that is

walking or cycling); this compares with 13.7% nationally. The proportion of residents using public

transport was highest in Basingstoke and Deane and Rushmoor; see Figure 5.

In terms of car ownership, households in Hart were the most likely to own one or more cars with

only 8% having no access to a car (compared with a national average of over 25%). Across Hampshire

car ownership was lowest in Gosport where around 22% of households had no access to a car.

Accessibility issues for rural Hampshire have been explored in the 2016 Socio-Economic Profile for

Rural Hampshire which finds only just over half (57%) of the rural population in the County are 20

minutes walk from a post office49.

Rates of road traffic deaths or serious injury are high in several Hampshire districts compared to the

national average (see Figure C in Appendix 1). This may be an artificial effect of the high density

traffic routes through these areas and the relatively low rural populations50.

Figure 5: Method of travel to work48

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The Sport England Active People Survey collects data on physical activity levels. Figure B in Appendix

1 shows the proportion of adults classified as inactive51 in Hampshire and its districts. Although

lower than the national average, there were still about a quarter of adults in Hampshire in 2015 who

were inactive. There is no comprehensive data available on children’s physical activity levels at local

authority level.

Nearly 81,000 Hampshire residents are estimated to be exposed to road, rail or air transport noise of

55 dB or more at night52. Exposure to noise can cause disturbance and interfere with activities,

leading to annoyance and stress. Furthermore, there is increasing evidence that long term exposure

to high levels of noise can cause direct health effects such as heart attacks53 and other health issues.

Local authorities monitor air quality and they must declare an Air Quality Management Area (AQMA)

if National Air Quality Objectives are not met54. In Hampshire there are 10 AQMAs; four in New

Forest, three in Eastleigh, two in Fareham and one in Winchester.

DEFRA have produced modelled estimates of the proportion of mortality attributable to particulate

air pollution55; Figure D in Appendix 1 shows these estimates for Hampshire and districts. No

estimate of the uncertainty of these figures has been produced and, therefore, it is inappropriate to

make comparisons between areas. The modelled estimate is that 4.5% of adult mortality in

Hampshire is estimated to be attributable to particulate air pollution.

What can be done?

Public Health England2 reviewed evidence from an international study of physical activity in relation

to urban environments; the study found residential density, number of public transport stops, street

connectivity and number of parks within walking distance were the characteristics most strongly

associated with increased activity56.

National Institute for Health and Care Excellence (NICE) recommends the following methods for

providing a physical environment that promotes active travel57:-

re-allocate road space to support physically active modes of transport (e.g. by widening

pavements and introducing cycle lanes)

restrict motor vehicle access (e.g. by closing or narrowing roads to reduce capacity)

introduce road-user charging schemes

introduce traffic-calming schemes to restrict vehicle speeds (using signage and changes to

highway design)

create safe routes to schools (e.g. by using traffic-calming measures near schools and by

creating or improving walking and cycle routes to schools).

An example of traffic-calming is to use 20mph speed limits for which there is a growing evidence

base on the benefits58 and repeated national surveys show strong public support for 20mph in

residential streets59 60.

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Case Study

Cambridgeshire Guided Busway

This is a new bus network with a high-quality off-road path for walking and cycling. It was opened in

2011 and is the longest of its kind in the world. Research found the provision of a new bus network

and high-quality traffic-free path for pedestrians and cyclists resulted in a shift away from using the

car and an increase in time spent in physical activity on the journey to and from work. The

intervention was not associated with a change in the number or distance of commute trips, which

suggests that the modal shift in commuting patterns may be translated into an increase in time

spent in physical activity on the journey to and from work. These findings support the assumption

that changing the built environment can bring about changes in travel behaviour and contribute to

consequent population health gain61. Public Health England use this study as evidence that

reconfiguring transport systems to improve population health and reduce health inequalities2.

People walk more in places with mixed land use (such as retail and housing), higher population

densities and highly connected street layouts. These urban forms are associated with between 25%

and 100% greater likelihood of walking62. The likelihood of someone walking for non-work purposes

rose by 14% for each 25% increase in the level of street connectivity where they lived63.

Both walking and cycling are encouraged by effective use of direction and distance signs. According

to NICE64, signage should give details of the distance and/or walking time, in both directions,

between public transport facilities and key destinations.

Spatial factors positively associated with cycling include the presence of dedicated cycle routes or

paths, separation of cycling from other traffic, high population density, short trip distance, proximity

of a cycle path or green space and (for children) projects promoting ‘safe routes to school’65. Rural

areas, like much of Hampshire, have particular barriers to active travel such as fast roads and lack of

pavements.

In terms of the economics of active travel, NICE state that it can be assumed that the long-term

health and economic benefits associated with increases in cycling and walking would ‘neutralise any

initial (infrastructure) costs’66. In urban areas, encouraging active travel can also create more

economically thriving spaces:

Retailers report an increase in trade of up to 40% when places are made more attractive for

walking.

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Places that are easier and more attractive to walk around (designed for so-called

‘walkability’) do better commercially (with an 80% increase in retail sales) and have higher

housing values.

The ageing of Hampshire’s population needs to be taken into account when planning for more

walking opportunities. Factors that can affect older people’s physical activity include pedestrian

infrastructure, safety, access to amenities and services, aesthetics and environmental conditions67.

Having frequent pedestrian crossings with increased crossing times and audible/visual cues are

necessary to help people with dementia safely cross the street68. Small-scale improvements such as

good street lighting or improved road crossings can also encourage movement69.

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HEALTHY HOMES

Links with health

The relationship between housing and health is complex. Research suggests that poor housing is

associated with increased risk of cardiovascular diseases, respiratory diseases and depression and

anxiety. Housing-related hazards that increase the risk of illness include damp, mould, excess cold

and structural defects that increase the risk of an accident (such as poor lighting, or lack of stair

handrails). The strength of the evidence linking such factors to ill health varies but is strongest for70

Accidents - 45% of accidents occur in the home and accidents are in the top 10 causes of

death for all ages

Cold - cold homes are linked to increased risk of cardio-vascular, respiratory and rheumatoid

diseases, as well as hypothermia and poorer mental health.

Housing also impacts on mental wellbeing although the evidence base is less well developed than for

physical health71. Poor housing can cause stress and lack of control and overcrowding can cause

relationship problems.

The Building Research Establishment estimates that 20% of UK housing does not meet decent homes

standard72. Poor housing is estimated to cost the NHS at least £2.5 billion a year in treating people

with illnesses directly linked to living in cold, damp and dangerous homes73.

Location of homes is also very important; poor locations can contribute to crime and fear of crime.

Good locations can have indirect benefits for health through access to services, green space and

employment71.

Hampshire data

There were 577,700 dwellings in Hampshire in 2015 and this is set to increase by 8.5% by 2022 (see

Figure A in Appendix 1). Data from the 2011 Census shows that 18% of households in Hampshire

were living in flats (see Figure 6), 67% were owner-occupiers and over half (54%) were under-

occupying their accommodation74.

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Figure 6: Hampshire households by accommodation type 201174

There were 932 statutory homeless households in Hampshire in 2015/16, with rates highest in

Gosport, and over 39,500 households were defined as in fuel poverty (see Figures E and F in

Appendix 1).

What can be done?

Understanding housing needs is fundamental to improving health through provision of adequate and

appropriate housing. Housing needs surveys are a statutory requirement for district planning

authorities but they vary in what they cover and, therefore, in their usefulness.

Case Study

Suffolk Housing Need Survey73

In 2014 Suffolk County Council worked with its seven districts to conduct a Housing Needs Survey

that went beyond the minimum requirements to include aspects such as health and the economy.

Suffolk County Council’s planning strategy manager James Cutting explains: “The traditional way of

doing these surveys is pretty comprehensive, but perhaps rather one-dimensional. They do not

really cover the wider determinants – health, care and economic prospects.”

This survey informed the development of a Housing and Health Charter75 for Suffolk. This sets out a

whole system approach to integrate housing and health policies, with focus on areas such as building

age-friendly homes.

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Homes can contribute positively to health and wellbeing if they incorporate the elements summarised in Figure 7.

Figure 7: What is a healthy home?76

In order to achieve healthy homes, new developments should adhere to the Building for Life 12

standards77 which are summarised in Figure 8.

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Figure 8: Building for Life Criteria77

The location of homes is important as to lead a healthier lifestyle people need access to green space,

opportunities for safe, active travel and access to services and appropriate facilities (see other

themes within this resource).

In terms of inequalities, for many the choice of home is shaped by adverse financial circumstances

rather than by preference. There is some evidence that targeting home improvements at low-

income households significantly improves social functioning as well as physical and emotional

wellbeing78. Whilst the evidence is unclear around the impact of affordable housing on reducing

health inequalities, provision for population groups with specific needs has been shown to improve

outcomes2.

To be ‘accessible, adaptable dwellings’ for older and less mobile people, homes should be built to

the 2015 Building Regulations Part M79 which incorporates the majority of the Lifetime Homes

Standard80. The Royal Town Planning Institute (RTPI) list five principles of good housing design

including visual clues, noise reduction and interior design81. In Hampshire County Council the Access

Team82 are a source of expertise and advice on accessible design.

22

HEALTHY NEIGHBOURHOOD

Links with health

‘Neighbourhoods’ can be defined as ‘places where people live, work and play and have a sense of

belonging’2 whilst ‘public realm’ is used to describe the streets and the spaces between buildings.

Neighbourhoods and the public realm can affect health through encouraging healthy lifestyles such

as increasing active travel and visiting green space.

The quality of our neighbourhood and of the public realm also influences health, for instance

“Crowding, graffiti, abandoned buildings, vandalism, street litter, poor maintenance of buildings,

traffic, parking, dampness, lack of places to stop and chat, poor personal safety, lack of recreation

facilities and green spaces, and noise” are all associated with distress and depression.83

People who perceive their neighbourhoods to be hostile, dirty, poorly maintained and lacking in safe

places to play are more likely to experience lower levels of mental wellbeing84. Well-lit

environments, safe and sociable play areas and street patterns that allow for informal contact

amongst residents can all act to reduce social isolation and have positive benefits on health. Fewer

and weaker social networks have been associated with a number of adverse health outcomes

including cardiovascular disease, mental health problems and higher rates of mortality85.

The range of facilities and services will vary between areas with some being health-promoting (such

as health centres, leisure centres, cultural facilities and food shops that sell fresh produce) and some

may be health-damaging (for instance, bars, fast food outlets, off-licences and betting shops).

Evidence of the impact of access to healthier foods on health is still under-developed2 69 but

research shows residents of communities with ready access to healthy foods also tend to have more

healthy diets86. Also, recent UK based research has found an association between the density of fast

food outlets and childhood obesity87. Another large-scale UK study looking at fast food in three

locations (neighbourhoods, commuting and near work) found that the density of outlets correlated

with increased fast food consumption and exposure to multiple outlets during the day was strongly

associated with higher BMI and risk of obesity88.

In terms of inequalities Table 1 shows which issues are more predominant in areas of social

disadvantage84. For instance, there are a higher proportion of fast food outlets per head of

population in more deprived areas69.

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Table 1: Features of the built environment/neighbourhood issues that are more likely to be experienced in areas of socioeconomic disadvantage

84

Built environment feature Potential health and wellbeing risk

High levels of traffic Factors associated with mental wellbeing such as stress, anxiety and depression. Increased risk of injury or death. Lower levels of walking and other forms of active travel

Vacant and derelict land Reduced social capital and feelings of safety within community. Poor mental wellbeing and reduced incidence of exercise in outdoor spaces

Poor quality housing Poor mental wellbeing and increased likelihood of health damaging behaviours (e.g. smoking, alcohol consumption, inactivity)

Lack of quality green space/public spaces

Lower mental wellbeing, increased stress, inactivity and less social activity.

Poor quality streetscape, shops and employment opportunities

Lower mental wellbeing, reduction in levels of walking and cycling, reduced social activity and higher unemployment or in work poverty.

Limited access to travel (including infrastructure for active travel)

Low levels of walking and cycling, isolated and poorly connected communities, loss of social activity.

Limited availability of amenities/facilities

Loss of social activity, increased rates of crime, loss of community identity.

Amenities/facilities which promote unhealthy behaviour (e.g. betting shops, fast food outlets)

Increased likelihood of making unhealthy choices such as poor diet and alcohol consumption, increased risk of financial hardship.

Antisocial behaviour and problems with neighbours

Reduced feelings of safety and increased stress related mental health problems (e.g. anxiety and depression). Reduced levels of social activity particularly from vulnerable population groups.

Hampshire data

In Hampshire over 1 in 5 children aged 4-5 years are overweight or obese and this rises to nearly 1 in

3 of our 10-11 year olds89. Over the period 2013-15 an estimated 65.8% of adults in Hampshire were

defined as overweight or obese which was significantly higher than the national average89.

Table 2 shows data from the Department of Transport on the proportion of residents living within 5

minutes (by public transport or on foot) of a food store. Although this data comes with a number of

caveats90, for instance it represents theoretical journeys rather than real journeys, it is nevertheless

a useful indication of access to healthy food with the more urban areas clearly having better access

than the more rural districts.

24

Table 2: Percentage of population living within 5 minutes by public transport or on foot from a food store91

District Percentage of population living within 5 minutes (by public transport or on foot) of a food store

Basingstoke and Deane 11.7

East Hampshire 12.0

Eastleigh 14.3

Fareham 12.4

Gosport 37.9

Hart 14.0

Havant 31.1

New Forest 12.3

Rushmoor 29.3

Test Valley 16.1

Winchester 16.6 Note: Data based on LSOAs classified as being within 5 minutes of a food store. The percentage of the district’s population living in these

LSOAs was calculated using Hampshire County Council’s 2015-based Small Area Population Forecasts.

PHE have published data showing the density of fast food outlets in each ward. In this context ‘fast

food’ refers to food that is available quickly including, but not limited to, burger bars, kebab and chip

shops92.

Figure 9 shows this data mapped for Hampshire wards and Table C in Appendix 1 gives the data at

district level. The England average is 88 outlets per 100,000 population. East Hampshire and Gosport

have the highest rate of fast food outlets (111.5 and 111.2 per 100,000 respectively) whereas

Winchester (46.0) and Test Valley (59.7) have the lowest rates. The wards with the highest rates are

Eastrop in Basingstoke (501.7) and Totton East in the New Forest (404.5).

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Figure 9: Map showing number of fast food outlets per 100,000 population (by ward)92

26

What can be done?

Boyce and Patel (2009) found only anecdotal evidence that local access to healthy food may improve

diets but recent evidence relating proliferation of fast-food outlets to poor dietary behaviour and

obesity levels in young people87 does suggest that addressing the food environment though planning

could be beneficial.

Action on the food environment is supported by the NICE public health guidance ‘Prevention of

Cardiovascular Disease’93. NICE recommends encouraging planning authorities “to restrict planning

permission for takeaways and other food retail outlets in specific areas (for example, within walking

distance of schools)”.

PHE explain that the lack of evidence on the use of planning policy to restrict fast food restaurants is

because local authorities have only started to use such mechanisms in recent years69. There is, thus,

a lack of evidence demonstrating a causal link between actions and outcomes, although there is

some limited evidence of associations between obesity and fast food94, and around interventions to

encourage children to stay in school for lunch95. There are, however, strong theoretical arguments

for the value of restricting growth in fast food outlets, and the complex nature of obesity is such that

it is unlikely any single intervention would make a measurable difference to outcomes on its own.

In terms of using the planning system to restrict unhealthy food outlets, Townshend96 lists the

following potential policies:

Allowing outlets only in certain locations

Restricting clustering

Restricting proximity to other uses e.g. schools

Clamping down on ‘back door’ applications (e.g. A3 restaurant applications which are

actually A5 takeaways)

Townshend warns that the ‘Use Classes Order’ is too blunt an instrument to distinguish between

healthy and unhealthy outlets. However, recent Planning Guidance suggests this as a way of

supporting a healthy food environment97 and there are some recent examples of success in

restricting hot food takeaways (see case studies).

Townshend also suggests that restrictive policies could be used to address clustering; that is the

concentration of different uses (such as betting shops and sub-prime financial services) that together

provide unhealthy environments96.

In terms of health inequalities, evidence suggests that new supermarkets in areas with previously

limited access may have uneven effects, increasing fruit and vegetable consumption for some, and

increasing the consumption of unhealthy food for others98.

27

Case Studies: Restricting unhealthy outlets

A number of local authorities have produced planning documents relating to hot food takeaways99, these include the following: - To prevent an undue concentration of units within retail frontages - To avoid units clustering together (usually no more than two adjoining each other) - To limit proximity to schools and, in a few cases, leisure and recreation facilities. Birmingham Planning Policy100

In 2012, Birmingham City Council imposed a cap on the number of fast food outlets, requiring that

no more than 10% of a shopping area or high street are takeaways, and has refused 26 out of 42

proposed outlets since this time.

Medway Council99

Medway has introduced a condition to be applied to planning permissions for new hot-food takeaways (use class A5) controlling the hours of operation where proposals fall within 400m of the boundary of a primary or secondary school and are situated outside an established core retail area or local centre. Gateshead101 In response to concerns about obesity levels in Gateshead, the council developed a hot food takeaway Supplementary Planning Document (SPD). In addition to the usual considerations such as litter and anti-social behaviour, this SPD also has criteria around the childhood obesity levels of the ward in which the planning application sits. These criteria are linked to the Gateshead Borough’s ambition to reduce Year 6 obesity below 10% by 2025. The SPD also deals with clustering by stating that the number of approved A5 establishments should not exceed the UK national average per 1000 population and there should be no more than 2 consecutive A5 uses. Applications for A5 uses are also required to include a Health Impact Assessment. To date 100% of applicants have been refused on the basis of the SPD. Haringey102 Following evidence of the negative impact of access to gambling venues on health, supplied by the Haringey Public Health Team, planners were able to justify a policy in their Local Plan to restrict betting shops. Haringey Council has set a maximum threshold of 5% of units within the town centre which it considers reasonable to support economic development whilst protecting against adverse impacts.

28

Food growing can help to create and maintain healthy communities. There is emerging evidence of a

positive association between urban agriculture and improved attitudes to healthy food, social

connectivity and increased fruit and vegetable consumption2. Allotments can and do improve

community wellbeing, providing a source of fresh food and opportunities for healthy outdoor

exercise and social interaction, as well as being a positive resource for people with physical and

mental health disabilities103. Schemes to share land with others for growing fruit and vegetables plus

the use of vertical gardening or green walls offer a means of local food production to householders

who may not have access to their own garden or an allotment.

PHE have summarised the evidence around building healthy neighbourhoods2; important aspects

include compact, mixed communities which maximise opportunities for social engagement and

active travel.

Planning can impact on other aspects of a healthy neighbourhood through supporting social

infrastructure such as healthcare, education and leisure facilities. The mechanism for doing this is

through developer contributions obtained via Section 106 or through the Community Infrastructure

Levy (CIL)104. The CIL is a development tariff that can be charged on new developments (that result in

a net increase in floor space or residential units) to contribute funds towards a list of local

infrastructure projects (known as a Regulation 123 list). Section 106 planning obligations require

developers to make a financial or in-kind contribution to mitigate on-site impacts from new

development but since 2015 Section 106 policies have been scaled back to on-site contributions.

Case Study

Winchester City Council’s CIL

Winchester City Council (WCC) adopted its CIL in 2014. The levy will be charged per square metre of

new development (a new building or an extension) over 100 square metres of gross internal

floorspace, or if it involves the creation of additional dwellings.

The Council has produced a CIL Regulation 123 list which sets out the infrastructure which will be, or

may be, funded fully or partly by CIL contributions (and will not be funded through Section 106

contributions). This includes a number of infrastructure types of direct relevance to health outcomes

and health inequalities, such as open space provision, leisure facilities, community and cultural

facilities.

In order to be included in a CIL, Public Health teams and the local NHS need to provide costed

evidence of needs and gaps when planners are preparing the Regulation 123 list.

Finally, in terms of Hampshire’s ageing population, there are some simple measures that can be

made to make public spaces more dementia-friendly such as providing benches at cross-roads to

give people time to think and keeping street furniture simple to prevent it being mistaken for

another object105.

29

APPROACHES TO INCORPORATING PUBLIC HEALTH INTO PLANNING

With the clear links between spatial planning and health, there are some important ways that

professionals from these two disciplines can work more closely in Hampshire. Public Health England

concludes that good ‘communication between built environment and health professionals is

essential’2. The TCPA work stream on ‘reuniting planning and health’ has many useful resources to

add this process including good practice guidance and checklists106.

Through engagement with district planning authorities, Hampshire County Council has produced a

‘Public Health and Planning Position Statement’. Work is now underway to operationalise this

through training, engagement and setting up of processes for consulting with public health on

planning applications.

The Bristol case study below highlights the value that public health can add to the planning process.

Case Study

Bristol Protocol for bringing health expertise into decision-making on planning107

Public Health comments on planning applications resulted in:

- encouraging measures or change in design to promote active travel and the importance of

sustainable transport planning.

- emphasise on the link between transport planning and physical health (active travel, walking,

cycling) and safe environments (secured cycle parking).

- demonstration of the co-benefits between tackling global warming and promoting healthy urban

principles (reduction in car emissions, enhanced public transport, reduction in car parking spaces, in

particular in inner city locations, to encourage take up of alternative modes of transport).

Many local authorities have now incorporated health policies within their Local Plan or produced

health-specific Supplementary Planning Documents (SPDs); some examples are given as case studies

below.

30

Case Studies

Worcestershire Health SPD108

The SPD is being produced by the three local authorities of Malvern Hills District Council, Worcester

City Council and Wychavon District Council in conjunction with the Strategic Planning team and the

Directorate of Public Health at Worcestershire County Council.

Its purpose is to provide guidance when planning for and creating healthier developments, whilst

providing communities and organisations with greater support to take positive action to improve

their health and wellbeing and encourage more positive forms of participation in healthier

environments.

Greenwich Health-Specific Policy in Local Plan109

This policy states that ‘all development must allow and enable residents to lead more healthy and

active lifestyles’. Measures that will help to build healthier communities and address health

inequalities must be incorporated into development where possible, and developments are

expected to promote healthy and active living for all age groups, including older people.

Health Impact Assessment (HIA) is one tool for ensuring health is considered in planning

applications. See Appendix 2 for further details on HIA and how it can be incorporated with other

statutory assessments.

31

RECOMMENDATIONS

Local Plans and policies

1. Ensure policies to promote good health and mitigate against adverse health impacts

are integral to the development of new, and the review of existing, Local Plans

2. Consider the development of general health SPDs or SPDs to tackle specific issues,

such as clustering of unhealthy outlets

3. Consider developing specific open space standards, based on Natural England

criteria, that incorporate quantity, access and quality.

Evidence base and monitoring

1. Incorporate local public health indicators into the monitoring of plans.

Responding to plans and planning application

1. Ensure a public health response is sought for local plans and major planning

applications (i.e. those of more than 100 residential units or with major retail or

recreational development)

2. Consider, and provide evidence of needs and gaps for Community Infrastructure

Levy/Section 106 contributions from developers to fund health promoting

infrastructure.

32

APPENDIX 1

Figure A: Demography in Hampshire8

33

Table A: Urban Areas - Percentage of population living in urban areas110 and Percentage of Land

Area defined as Urban111

District Population living in urban areas (%) Land defined as urban (%)

Basingstoke & Deane 73.9 10.3

East Hampshire 64.9 15.8

Eastleigh 89.9 76.7

Fareham 99.5 82.5

Gosport 99.6 99.8

Hart 69.5 21.7

Havant 98.5 87.0

New Forest 71.9 14.8

Rushmoor 99.9 96.8

Test Valley 64.3 8.9

Winchester 41.7 4.6

Table B: Population living within 300m of natural green space

Natural green space includes the following:

Ancient Woodland – Forestry Commission

Open Access Land – Natural England

National Nature Reserve – NE

Local Nature Reserve – NE

Hampshire and IoW Trust Sites – accessible sites only

Common Land – Omitted Extinguished or Exempt – Hampshire County Council (Countryside)

District Percentage of land area that is natural

green space

Population living within 300m of

natural green space

Total population

Percentage of population

within 300m of natural green

space

Basingstoke and Deane 2.8 33,982 171,779 19.8

East Hampshire 11.0 33,017 119,361 27.7

Eastleigh 8.2 37,963 128,729 29.5

Fareham 7.2 34,171 114,079 30.0

Gosport 5.1 8,584 83,659 10.3

Hart 9.4 48,157 95,011 50.7

Havant 8.4 48,080 123836 38.8

New Forest 41.8 58,472 177,819 32.9

Rushmoor 9.0 19,720 96003 20.5

Test Valley 3.6 27,653 123,402 22.4

Winchester 4.3 27,464 120,599 22.8

Hampshire Total 12.9 377,263 1,354,277 27.9

Note: This definition is based on Level 1 of ANGSt which was developed in the early 1990s and following

research into minimum distances people would travel to the natural environment. ANGSt is a powerful tool in

assessing current levels of accessible natural green space, and planning for better provision. It identifies those

sites that might be considered natural sites, and areas within other green spaces that have a value for nature,

and more importantly it identifies areas of nature deficiency where the standard is not met and where actions

may be put in place to address this http://www.ukmaburbanforum.co.uk/docunents/other/nature_nearby.pdf

34

Table C: Fast Food Outlets per 100,000 population92

District Number of fast food outlets

Total Population in 2015 No. of outlets per 100,000

Basingstoke and Deane 76 122,314 62.1

East Hampshire 61 54,685 111.5

Eastleigh 88 114,113 77.1

Fareham 61 99,194 61.5

Gosport 83 74,614 111.2

Hart 51 66,068 77.2

Havant 99 122,695 80.7

New Forest 120 125,277 95.8

Rushmoor 96 95,742 100.3

Test Valley 51 85,450 59.7

Winchester 55 119,583 46.0

Hampshire Total 841 1,079,735 77.9

35

Figure B: Physically inactive adults89

Figure C: Killed and seriously injured road casualties89

Figure D: Fraction of mortality attributable to particulate air pollution89

36

Figure E: Homeless households in temporary accommodation89

Figure F: Percentage of households experiencing fuel poverty89

37

APPENDIX 2

Health Impact Assessment (HIA) is a means of assessing the health impacts of policies, plans and

projects using quantitative, qualitative and participatory techniques. HIA helps decision-makers

make choices about alternatives and improvements to prevent ill health and to actively promote

wellbeing. It is intended to help make decisions by predicting the health consequences of

implementing proposals112.

Case Study

Central Lincolnshire Integrated Impact Assessment (IIA)113 Central Lincolnshire moved to an IIA approach in 2010 to incorporate the following into one assessment: Sustainability Appraisal (SA) Strategic Environmental Assessment (SEA) Equalities Analysis (EqA) Health Impact Assessment (HIA)

“The HIA was a desktop exercise which used existing knowledge and evidence; it involved a broad assessment of the potential impacts against the wider determinants of health. This approach is commensurate with the level of detail required for the SA so that no objective was assessed in any more detail than the other objectives. The main benefits have been the ability to influence the policies in the plan through identifying potential negative or positive impacts and making recommendations as to how the Plan can mitigate these.” Charlotte Robinson MRTPI, Planning Policy Officer Central Lincolnshire Local Plan Team

38

The benefit of doing HIA is that health consequences of a plan, policy or development may not be

anticipated without it. Decision makers have to try to achieve best economical and political

outcomes with health and frequently have to trade off gain in one area against gain in another. HIA

helps them to appreciate the health gains and losses with different options.

However, conducting an HIA takes a huge amount of time and resource and spatial planning already

has its own statutory assessments: a Sustainability Appraisal (SA) is a systematic process that must

be carried out during the preparation of a local plan and some planning applications will also require

an Environmental Impact Assessment (EIA). The revised EIA Directive requires consideration of the

direct and indirect effects on ‘population and human health’114.

An approach used by some planning authorities is to incorporate HIA into these other assessments

as an Integrated Impact Assessment (IIA) (see Central Lincolnshire case study). Alternatively in some

areas an initial HIA screen is included within the SA with a full HIA only needed if the screening

identifies major issues.

39

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Haringey Council (2016) Development Management DPD: pre-submission version http://www.haringey.gov.uk/sites/haringeygovuk/files/06_haringey_dmp_dtp_221215.pdf 103

Local Government Association (2009) Growing in the Community 104

http://healthsustainabilityplanning.co.uk/joint-working/healthcare-infrastructure-implications-of-development/ 105

South Worcestershire Council (2016) Planning for Health Supplementary Planning Document http://www.swdevelopmentplan.org/wp-content/uploads/2016/12/S-Worcs-Draft-Planning-for-Health-SPD-2016-v1.3.pdf 106

TCPA Reuniting planning and health https://www.tcpa.org.uk/Pages/Category/health 107

Bristol Method (2015) ‘How to reduce traffic and its impacts’ www.bristol2015.co.uk/method 108

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Greenwich Local Plan Core Strategy Adopted 2014 http://www.royalgreenwich.gov.uk/info/1004/planning_policy/869/local_development_framework/2 110

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Office for National Statistics Rural Urban Classification https://www.gov.uk/government/collections/rural-urban-classification 112

PHE HIA Gateway www.apho.org.uk/hiagateway 113

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Dunwoody, J. and Johnson, P. (2016) How to consider health in EIA. Journal of the TCPA vol. 85 no. 11.