Healthy urban development: a public policy gamechanger for challenging times

  • Election 24
  • Living standards and Levelling up

Professor Sarah Ayres, Intervention Area Lead: National Government and Dr Jack Newman, Senior Research Fellow, Tackling Root Causes Upstream of Unhealthy Urban Development (TRUUD) 

In this piece, Professor Sarah Ayres and Dr Jack Newman explore evidence-based ideas for improving urban development which can also help address health issues, inequalities and low productivity.   

When the inevitably exhausting furore of the 2024 General Election is over, a government of one colour or another will sit down to face one of the most challenging in-trays of modern times.

Public spending is being squeezed from all sides by inflation, deficit, debt, low growth, and the party politics of tax. Public services are in a dire state, with all sectors suffering from over a decade of underinvestment, and the health service in particular is struggling to cope. The economy is sluggish with low and unequal productivity, and the number of workers economically inactive due to ill health is at a 30-year high. People are struggling to access affordable and decent homes, with over 1 million on the waiting list for social housing, and the shocking revelation that 55 children have died in temporary accommodation since 2019. Moreover, all of these problems are exacerbated by growing spatial inequality across the country.

Against this backdrop, the winner of the next General Election will need to reach for public policy interventions that meet multiple objectives with minimal demands on the public purse. Our research seeks to build evidence for one such intervention: healthy urban development.

The research project,‘Tackling the root causes upstream of unhealthy urban development’ (TRUUD), seeks to improve urban development decision-making so that health outcomes are properly considered before it is too late. By taking a systems approach, we show how decisions made in areas like transport, housing, and city planning can have significant impacts on health outcomes. If these decisions begin to prioritise – or at least accommodate – public health considerations, there are potentially huge benefits for people’s healthy life expectancy and billions in savings for the public sector. Non-communicable diseases such as diabetes, heart disease or asthma account for 89 per cent of deaths in England, and ill-health among working-age people is estimated to cost £150 billion a year. The prevalence and severity of these diseases are significantly impacted by the urban environment in which most people live.

The challenge is that decisions about how our urban environment is built and used are incredibly complex. Decisions are the outcome of interactions between many different public agencies, political institutions, private businesses, community organisations, and of course, the millions of people using and inhabiting urban spaces. We recognise that it is not always feasible to prioritise public health. There are other important social outcomes that we must be sensitive to, like environmental sustainability, economic productivity, democratic legitimacy, social inequalities, and rich cultural life. However, we are confident that the application of cutting-edge social science can significantly improve the current situation.

Therefore, the aim is to encourage a range of decision-makers to think strategically about when and how it is possible for urban development to have a positive impact on public health. Our research points to numerous important and feasible interventions. Here we consider three of these. First, the project has developed the Health Appraisal for Urban Systems (HAUS) tool, which calculates the financial cost of unhealthy urban development decisions. Second, we call for a meaningful public health mission to overcome the policy siloes in which health is separated from other policy areas. Third, these changes must sit within wider reforms that address the UK’s over-centralised governance system.

First, TRUUD’s HAUS tool clearly shows the health outcomes related to urban design. It identifies who gets ill and with what disease as well as the economic cost of ill health. More specifically, it identifies where these costs are incurred across the system, which is often outside the health sector (e.g. education, welfare, crime and disorder, private sector). This type of innovative evidence can be used to show critical actors that they have a stake in pursuing public health. Our 132 in-depth interviews with UK urban development actors show that they are receptive to using this type of evidence to inform their decisions.

Second, to make use of the data provided by the HAUS tool and ensure urban development decisions actually benefit public health, it is necessary to reflect on the broader governance system in the UK. Deriving from the basic structure of the UK’s political system, a highly centralised system of policymaking has created a micromanagement burden on central government, which in turn reinforces its historic tendency towards departmental siloes. This is ultimately the biggest blocker for healthy urban development, and indeed any policy programme that seeks to tackle the major cross-cutting challenges of our time. We advocate a cross-government public health mission to embed the wider determinants of health into mainstream government policy.

In recent years, the government has made some positive steps, such as mayoral devolution in England and cross-government ‘levelling up missions’, including one on healthy life expectancy. But the scale of the rhetoric has not been matched by the delivery: centralisation and departmentalism have survived largely intact. To shift the dial, it is necessary to bolster the status of the ‘public health mission’ across government, ensuring that every department considers and reports against public health outcomes. This must be coordinated by a cross-government body responsible for strategy and monitoring, but ultimately, the delivery must be done at the local level.

Therefore, finally, we argue that the role of central government must shift from micromanagement to strategic oversight, passing funding and decision-making to lower tiers of government. To make this possible, it is necessary to focus attention on the many challenges faced by local government and mayoral combined authorities: fragmented and insufficient funding; underpowered local leaders; lack of research and policymaking capacity; incomplete and unaligned geography; ambiguous and opaque central-local relations. Solving these problems will provide the necessary foundations for healthy urban development.

After the General Election, if the incoming UK government can embrace cutting-edge social science, cross-government working and faith in devolution, there could well be solutions available to complex social problems that do not rely simply on finding lots more money. But the only way to make this happen is with bold long-term decisions. One such decision would be to put public health at the heart of urban development.

About the authors

Professor Sarah Ayres is Professor of Public Policy and Governance at the University of Bristol, and she is also the Intervention Area Lead: National Government at TRUUD. Sarah’s work has explored the complexities of devolution and city governance by exploring the inter-play between formal and informal structures, processes and outcomes. Her research has provided critical insights into how ‘informal’ decision making, i.e. what happens behind closed doors between political elites, has shaped devolution in the UK. Sarah has been an academic advisor to three successive UK Governments on English devolution and regularly provides written and oral evidence to both Government consultations and House of Commons Inquiries.

D Jack Newman joined TRUUD as a senior research fellow in January 2024, focusing on health inequalities in government decision-making. Over the past decade, Jack’s research has considered how the UK’s policymaking capacity and its policy priorities are affected by the structure of its political institutions and by the prevailing assumptions within them. In recent years, in roles at the Universities of Manchester, Cambridge, and Surrey, this has entailed research linking spatial inequality, English devolution, and the UK constitution. Jack has worked closely with think tanks and policymakers to link academic debates to current policy issues, including through partnerships with Demos and the Institute for Government. His research has been published in academic papers, policy reports, blog posts, written evidence to parliament, and the national press.

Image credit: Benjamin Elliott, Unsplash