How do you grow a healthier city?

Urban economies face the challenge of growing gaps between the health of the rich and poor.

One hundred years ago, in what was then Essex, London County Council built the largest housing estate in Europe. The Becontree estate, built on 3,000 acres of former market gardens and country lanes, was to provide council-owned “cottages” for workers, complete with a garden of their own. The initiative was part of an effort to build new, healthier communities for workingclass families who were moving out of an overcrowded and unhealthy London. Many of its residents had returned from the trenches of the First World War. The project, which took 14 years to complete, would grow to 26,000 houses, providing homes for 100,000 people.

At the time, the estate was a solution to the class inequalities of London. A century later and British cities are still deeply unequal. The Covid-19 pandemic hit poorer parts of towns and cities much harder, with areas such as Barnsley, Wolverhampton and Newham recording higher rates of deaths, according to the charity The Health Foundation. Covid aside, there are disparities in life expectancy across the UK. In London, a woman in the borough of Barking and Dagenham will live to an average age of 82, and a man to 78. Not many miles away in Westminster, a woman will, on average, live to 87 and a man to 85. Even within those localities there are huge gaps between different neighbourhoods. In 2011, life expectancy in Westbourne in Westminster was 75, while in wealthier Knightsbridge and Belgravia it was 89. In Glasgow, male life expectancy in 2011 was just under 74 years, the lowest of any UK city.

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In 2014, the World Health Organisation estimated that these health inequalities cost European countries just over 9 per cent of their gross domestic product, highlighting the role that investing in the prevention of disease through urban development can make to the broader economy. Some cities are trying to grow their way out of health inequalities, marrying economic development with efforts to improve the quality of housing, jobs, public space and transport.

There are “particular risks and opportunities for public health when you’re looking at urban environments”, says Chris Naylor from The King’s Fund think tank. “When cities go wrong, they can be really bad for public health,” he adds, but the concentration of people, resources, jobs and industries in a small area generates opportunities to create a healthier place. In London, for example, there is an abundance of large and small businesses, philanthropic institutions, and significant public and voluntary sectors. When harnessed these can have a significant impact on health.

This can happen at a more individual level through economic growth and improving the quality of employment, which is linked to better physical and mental health. It can also happen at a larger scale through the planning system and by “social innovation”, Naylor says. He gives the example of New York, where “innovation labs” help public agencies and the voluntary sector to develop new solutions to poverty and other social determinants of health.

Local governments can use their planning powers to channel development and cultivate neighbourhoods that support walking and cycling, access to green spaces, and healthy and affordable food. “Probably the most important thing to do from a health perspective is to do things that encourage small increases in physical activity among those who are currently least active,” says Naylor. These interventions can be hyper-local, down to the street level, and can start to chip away at the inequalities that exist within cities and towns. The risk is that local governments choose easy options that encourage the “wealthiest and healthiest” to be more active. While this delivers results, it also widens the gap between rich and the poor.

NHS England’s 2015 Healthy New Towns programme sought to tackle this problem in ten new neighbourhoods being built across England, ranging in size from just under 1,000 homes to over 13,000. “The idea was the NHS funded some work there on how we can, by getting the health sector involved from the start in planning these places, create places where it’s easier to live a healthy life”, says Naylor.

“What we didn’t want to do was create this wonderful enclave in this new development,” says councillor Maureen Worby, the cabinet member for health and social care integration in Barking and Dagenham and chair of the local Health and Wellbeing Board. The London borough is the site of the Becontree estate. It is also the location of the new 10,000-home Barking Riverside development, which is testing how to incorporate health inequality reduction into new builds.

Barking and Dagenham was one of the Healthy New Town sites chosen by the NHS. Unlike most of the other projects in the scheme, Barking Riverside was a “brownfield site” that had historically been mostly industrial. The aim was to see how health inequalities could be reduced, in part through green space, access to the river, health services, and decent housing introduced to the new development.

Their project “was about how do you design in the concepts of a Healthy New Town and how do you make that relate to an existing population”, Worby says.

This meant ensuring the benefits went beyond the immediate area and into the surrounding communities. A locality board, made up of representatives from the council, the developer, residents and the local NHS, is ensuring the development meets that goal. One of their big projects is creating a “well-being hub” that will bring together health and council services such as employment and money advice, and leisure facilities. When people go into the hub, they might be there for a GP appointment but could be referred for help with money, or to exercise classes in the same building.

“It is a different model and I’m really lucky that our health partners here want to try out something a bit different,” says Worby.

She is now working to incorporate the Healthy New Towns principles into the planning and development policies for the whole of Barking and Dagenham. For example, developers are encouraged through the planning policy to provide food-growing spaces such as community orchards and allotments. It is something she believes builds on the legacy of the Becontree estate and the desire to build healthier places.

“You’ve got to view good health as an asset to society,” says Jo Bibby, director of health at The Health Foundation. “Our interest is in improving population health and reducing inequalities,” she says. The Health Foundation has been working on the links between health and the economy, including how to robustly quantify the value of “good health”. For example, poorer people tend to have poorer health, which has an impact on their ability to work and get good employment, which has a knock-on effect on health, which in turn costs money in terms of healthcare.

“We think if you could quantify that, it would make it easier to make the case for investment in preventative action that helps people stay in good health in the first place,” says Bibby. At the moment, poor health is seen as an “inevitability” for some groups of people that has to be managed by the healthcare system.

The foundation looked around the world for examples of places that were using economic development to drive improvements in health and reduce inequalities. One example that stood out was Auckland in New Zealand, which has developed a “place-based model” for social and economic development in the south of the city, where there are greater health needs and a larger proportion of people from Polynesian and Maori communities. Called the Southern Initiative programme, it works with community groups, and creates interventions that improve health, well-being and employment.

The foundation came to the conclusion that an “inclusive economy” was one of the best ways to do this. In Burlington, in the US, for instance, the city picked up a 25-year economic development strategy from 1984 that emphasised self-sufficiency, a strong voluntary sector, protection of the environment, and participation of marginalised groups. For The Health Foundation, an “inclusive economy” means investing in infrastructure such as housing and digital communications, interventions to support lifelong learning and reskilling to adapt to employment, as well as targeted programmes to support people into the labour market. It announced a funding round at the end of 2020 to develop this approach in the UK.

“We don’t yet treat health as if it’s part of our infrastructure,” says Bibby. “One of the things that needs to happen is having that right…incentives in place.”

As cities continue to develop, they will face choices over what to invest in if they want to reduce health inequalities. They can use their planning powers and streetlevel changes to direct some of that change and channel investment from developers, and they can put money into services that help tackle the wider determinants of health in an area, such as the well-being hub in Barking Riverside. But inequalities are stubborn. New places can be built to better standards, but the challenge is what to do in those places where inequality seems to be locked into the geography.

This article originally appeared in the Spotlight supplement on regional development. You can download the full edition here.