Marcus Grant: Radical transformation or bust

Welcome to a series of blogs on sustainable healthcare that will look at health, sustainability, and the interplay between the two. The blog will share ideas from experts across the healthcare field, some of whom are speaking at a major European conference looking at Pathways to Sustainable Healthcare in September 2013. More about the conference can be seen at

To an average UK citizen, an outsider to public health, “Health” (with a capital “H”) is viewed as a basic function of government: the government pours shed loads of money into the “system” and out pours better health for the population. Sometimes this might be delivered in an inefficient manner, but overall, better health pours out anyway: mainly from hospitals, but also from GPs. Everyday access to good quality air, water, and essential services, having parks and countryside on tap, and, for many in this generation, living in environmental conditions which are on the whole pretty habitable is taken for granted. But what about the influence of the everyday environment, our neighbourhoods, towns, and cities, on our health?   

I used to be an outsider. However, for the past 10 years I have been working close to colleagues, mainly in public health, on aspects of sustainable healthcare. Specifically, I have been involved with the complexities of the rise in non-communicable disease in urban populations—through healthy urban planning. My outsider naivety has been lost. I now distinguish a continuum in “Health” (still with a capital “H”); a continuum from tackling disease and caring for sick people at one end, to improving people’s health and supporting wellbeing at the other. Incredibly, we seem to have produced a system whereby these ends are now so far apart that they are no longer recognisable as both belonging to a single continuum. Even worse, they fight. Conflicts arising over prioritisation and resources obscure our overall understanding of what the “Health” project should be about at national level. The false dilemma: do we prioritise curing the sick, or supporting a population in being healthy—to stop them getting sick in the first place. Is there anyone looking strategically at how we can best support a healthy population across the whole life course, not just the intervention (or treatment) when people fall ill?

As a designer, I could use my skills to assist “Health” through the design of hospitals and health products, or I could turn my attention to the design of services and healthcare. But there is more to be gained, with less drain on resources, from the re-design of health itself. We need to provide incentives for health and not just curing illness. With projected rationing of care, rising demand and increasing economic burden of disease the current system is not fit for purpose now and certainly not for the predicted future.

There are proven and evidenced stalwarts of salutatory health, such as good food, green space, and community cohesion. How can we harness these as essential assets of sustainable healthcare?

The language of prevention includes primary, secondary, and tertiary prevention—none of them receiving the prioritisation needed to really reduce the economic burden of disease.

I suggest that there are three approaches that we all need to discuss and develop to extend our practice so that we can address all tiers of prevention. These approaches start to define a role for healthcare in influencing the social determinants of health. Firstly, we need to provide health evidence to other sectors where it supports changes in policy direction that have co-benefits. Examples can be found in the series of WHO policy briefings on the health co-benefits of climate change mitigation and expected health impacts. We need to harness a wider health workforce made up of the expertise of town planners, transport engineers, and urban designers. Secondly, we should not shy away from using health resources in non-health sectors where a health outcome can be evidenced.  For example public health may want to assist in supporting well maintained and accessible green spaces, especially in areas of deprivation.

Finally, we need to ensure that health facility investments themselves are designed not only to cure disease but also to improve people’s health. The design ethos of these investments should be that of an intervention. In addition to paying attention to the delivery of health in the interior of the facility, heed must be paid to the potential for delivery of increased health and wellbeing externally, to the surrounding communities using all the levers of the social determinants of health. Let’s allow health to flow out from future healthcare facilities, blending lessons from the Peckham Experiment with the brave new world of healthcare possibilities described by in Fit for the Future.

I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.

Marcus Grant is deputy director of the WHO Collaborating Centre for Healthy Urban Environments, University of the West of England (UWE), Bristol. The collaborating centre is based in a built environment faculty and supports the European Healthy Cities programme in all aspects of city transport, development, and urban design.