Can places make us healthier?

A 19th century vision of ideal homes for the respectable working classes. Image: Wellcome Images.

All of us feel better when we’re surrounded by beauty and good design. It’s why we put so much effort into DIY, interior design or gardening. And it’s why for our holidays we seek out places that will make us both physically and mentally healthier than we can in our working life.

This might seem blindingly obvious. Yet public policy often points in the opposite direction. Developed societies rightly spend huge sums of money on health – hospitals, primary care, and new and old drugs account for at least 10 per cent of GDP and more in some countries.

But if you look at what we know about health there is an odd paradox. According to the Robert Wood Johnson Foundation, one of the world’s largest funders of health, summarising a huge amount of research, the causes of premature death are roughly as follows: 40 per cent behavioural patterns, 30 per cent genetics, 15 per cent social circumstance and 5 per cent environmental effects. The remaining 10 per cent is attributable to healthcare.

Given that medicine is an evidence-based field you would expect that this widely understood knowledge would be reflected in how funds are allocated. Instead, the opposite is the case. The vast majority of health spending goes to healthcare and within that to particular industries, notably pharmaceuticals.

We now take this for granted. But it wasn’t always like this. In the 19th century when rapid industrialisation and urbanisation left cities like Manchester, Birmingham and London wracked by ill-health, crime and misery, huge efforts went into dealing with the physical causes of ill-health. Vast public spending projects worked to deliver cleaner water and air; comprehensive sewers; better housing; and later such things as safe roads. These were all seen as just as important to a healthier population as better hospitals.

Indeed, there is a long history of using urban design to promote health. This thinking was integral to the great projects of Bournville and Peabody, the garden cities of the early 20th century and the new towns of the 1940s, and more recently it’s shaped the NHS Healthy New Towns initiative.

Yet health design has never had the same prestige or support as more narrowly clinical knowledge, and although much is known, little has been rigorously tested. So we can fairly safely say that hospitals are more likely to promote recovery if they make good use of nature, light and art, and if they offer privacy rather than long soulless wards. Similarly, health centres work better if they give people the scope for interaction rather than long lines of chairs or grim corridors.


But we don’t have strong evidence or detailed work on just how much impact these designs have, and even though much of this may appear fairly obvious, a moment’s reflection confirms that it’s at odds with how far too many hospitals and surgeries were designed.

The same imbalance is evident in the ways that towns and cities are planned. You can deliberately design transport and roads to make it easier to walk, cycle or run rather than always depending on cars. You can shape cities to make them full of nature, or even edible, with plenty of fruit trees for example. Planning can be used to reduce advertising of junk food near schools, to cut noise levels and to promote clean air. Much is known about how the presence of green and blue spaces – which means water, ideally in motion – can be good for mental health. Social norms can be influenced in a healthy direction, for example encouraging people to stop their cars from idling. And we’re beginning to see more systematic attention to what could be called MEEs – Mind Enhancing Environments – which can both calm and stimulate us in healthy ways.

But again there is surprisingly little rigorous evidence and surprisingly little use of systematic experiment so that when new initiatives like the Healthy New Towns one are started they have relatively little to draw on.

This under-development of health design reflects a broader mismatch in where we direct resources. Over the last few years, an ever-larger share of public funding has gone to biomedical research even as the results of that research have continued a remorseless long-term decline in terms of impact on health outcomes.

It’s not that we shouldn’t fund such vital research: it’s just that the imbalance with other fields that focus on behavioural, social and environmental influences on health has become huge, and indefensible.

Most new urban developments ignore what’s known about health design, and the situation is even worse in countries like China where cities are being built that are highly likely to be bad for physical and mental health.

We shape our buildings and our buildings shape us, as Churchill famously put it. For now, too many of them aren’t shaping us well. I hope that a new generation of doctors, architects and planners will put this right.

Geoff Mulgan is chief executive of the innovation charity Nesta.

 
 
 
 

The Tory manifesto promises to both increase AND decrease the rate of housebuilding

Housing secretary Robert Jenrick. Image: Getty.

In his 2014 Mansion House speech, the then-chancellor George Osborne expressed with uncharacteristic honesty the motives at the heart of how the Conservatives see British housing politics: “The British people want our homes to go up in value, but also remain affordable; and we want more homes built, just not next to us.”

Five years later these contradictions remain unreconciled and present in their manifesto, which contains two different and contradictory – but clearly extensively targeted and focus-grouped – sets of policies.

The Conservatives have two housing targets. The first is to make significant progress to hitting “our target of 300,000 houses built a year by the mid-2020s”. The second is their aim to build “at least a million new homes” during the next parliament, which implies a target of 200,000 homes a year. This is not only 100,000 lower than their initial target but also lower than the current rate of housebuilding: 213,660 new homes a year. They have therefore implied at separate points in the same manifesto that they intend to simultaneously increase and decrease the rate of housebuilding.  

There are similar conflicts in their approach to planning. They intend to make the “planning system simpler” while simultaneously aiming to introduce community-led design standards for development and planning obligations to provide infrastructure for the local community.

None of this is unsurprising, The Tories don’t seem to know if they want to build more houses or not – so of course they don’t know whether they wish to make it easier or harder to do so.  

Politicians like obfuscation on housing policy to placate NIMBY voters. Take for example prospective Conservative MP and ‘environmentalist’ Zac Goldsmith’s crusade to save treasured local car parks. The manifesto can equally be accused of pandering to NIMBY instincts, protecting their shire voters from all housing, including ones they might actually need or want, by promising to protect the greenbelt.  

Instead, Conservatives intend to foist development on Labour-leaning inner-city communities and prioritising brownfield development and “urban regeneration”. This requires massive, infeasible increases in proposed density on brownfield sites – and research by Shelter has shown there are simply not enough brownfield sites in cities like London. Consequently, it is not clear how such a policy can co-exist with giving these inner-city communities rights on local design. Perhaps they intend to square that circle through wholesale adoption of YIMBY proposals to let residents on each street opt to pick a design code and the right to turn their two-storey semi-detached suburban houses into a more walkable, prettier street of five-storey terraces or mansion blocks. If so, they have not spelt that out. 

Many complain of NIMBYism at a local level and its toxic effects on housing affordability. But NIMBYism at the national level – central government desire to restrict housebuilding to make house prices rise – is the unspoken elephant in the room. After all, 63 per cent of UK voters are homeowners and price rises caused by a housing shortage are hardly unpopular with them. 


There is anecdotal evidence that protecting or inflating the value of homeowners’ assets is central to Conservative strategy. When George Osborne was criticised for the inflation his help to buy policy caused within the housing market, he allegedly told the Cabinet: “Hopefully we will get a little housing boom, and everyone will be happy as property values go up”. More recently Luke Barratt of Inside Housing noted that most Conservatives he spoke to at the 2018 party conference were scared “they’d be punished by their traditional voters if the values of their homes were to fall”. He was told by a Conservative activist at the conference that, “If you build too many houses, you get a Labour government”.

But the senior figures in the Conservative Party are painfully aware that the continuing housing shortage presents major long-term problems for the Party. As the manifesto itself acknowledges: “For the UK to unleash its potential, young people need the security of knowing that homeownership is within their reach.” Perpetual increases in house prices are incompatible with this goal. The problem has greatly contributed to the Conservatives’ severe unpopularity with a younger generation priced out of decent accommodation. 

Equally, there is increasing evidence that ‘gains’ from rising house prices are disproportionately concentrated in the south of England.  The differences in housing costs between regions greatly reduce labour mobility, suppressing wage growth in the north and midlands, which in turn leads to greater regional inequality. The policy of coddling southern homeowners at the expense of the economic well-being of other regions is a major long-term stumbling block to Conservative desires to make inroads into the ‘red wall’ of Leave-voting labour seats outside the south.

Before dealing with the issue of where housing should go, you must decide whether you want to build enough housing to reduce the housing crisis. On this issue, the Conservative response is, “Perhaps”. In contrast, even though they may not know where to put the necessary housing, the Labour Party at least has a desire in the abstract to deal with the crisis, even if the will to fix it, in reality, remains to be seen. 

Ultimately the Conservative Party seems to want to pay lip service to the housing crisis without stopping the ever-upward march of prices, underpinned by a needless shortage. Osborne’s dilemma – that the will of much of his party’s voter base clashes with the need to provide adequate housing – remains at the heart of Conservative housing policy. The Conservatives continue to hesitate, which is of little comfort to those who suffer because of a needless and immoral housing shortage.

Sam Watling is the director of Brighton Yimby, a group which aims to solve Brighton’s housing crisis while maintaining the character of the Sussex countryside.