Active Travel: The Miracle Cure?

1. Active Travel: The Miracle Cure? A guide for the NHS on raising physical activity levels through your local transport plan ‘The potential benefits of physical activity to health are huge. If a medication existed which had a similar effect, it would be regarded as a “wonder drug” or “miracle cure”.’ Sir Liam Donaldson – Chief Medical Officer (Annual Report of the Chief Medical Officer 2009, Department of Health, March 2010)

2. With your local transport plan currently in development, the NHS has a major the opportunity to ensure that local transport policies maximise the health benefits that walking and cycling can bring. Local Transport Plans (LTP): Your local authority is currently developing a new LTP starting from March 2011, setting out its investment priorities over the next five years. Contributing to better safety, security and health is one of the DfT’s five “goals” for transport, including to “improve the health of individuals by encouraging and enabling more physically active travel”. DfT expects local authorities to consider their contribution to these goals as over-arching priorities for their LTPs. Most LTPs will cover the next 3 – 5 years, as part of a 15-20 year strategy. Your authority must publish its plan by 31 March 2011. The NHS needs to be working now with local Highway Authorities to get walking and cycling prioritised in their areas. The Local Transport Plan Funding: Councils get an annual capital grant from DfT for small-scale infrastructure and road maintenance, but this is not ring-fenced for transport. They can bid for additional funding from DfT for “major schemes” costing over £5m. Revenuesupport is included in the wider “formula grant” from DCLG, but is not ring-fenced. Consultation and Engagement: Your authority is expected to consult on its LTP, although it is worthwhile engaging as early as possible in the process to shape thinking at the outset - start talking to your transport team now. In particular LTPs will need an Strategic Environmental Assessment, which includes a Health Impact Assessment. This is a major opportunity for the health sector to challenge local transport teams to do more on active travel.

3. Inactive lifestyles are contributing to an obesity epidemic, a major public health crisis that is already costing the economy and the NHS billions per year… The cost to each PCT of treating the effects of inactivity is significant: average £5m a year:1 Physical Activity is critical to good health: • Reduces risk of CHD, Stroke, Type 2 Diabetes by up to 50%, risk of premature death by 20-30%; • Improves well-being and mental health, particularly beneficial for maintaining independence and good health of older people.1 But inactivity is a major public health problem: • Only one in three adults meet minimum recommended level of physical activity; for older people it is less than one in five. Two in three adults are obese or overweight.2 • Total cost of absenteeism, premature death and treatment = £8bn - £10bn per year. £1bn - £1.8bn of this is direct treatment costs - a serious drain on NHS resources.1 • Major issue for NHS as an employer – healthy workforces make for lower sickness rates, better retention, improved patient satisfaction.3 The forecasts are for inactivity to get worse. If not addressed more than half of adults could be obese by 2050.4 Treatment costs alone will be unaffordable, regardless of the wider economic cost. • Be Active, Be Healthy – A Plan for Getting the Nation Moving, DoH 2009 • Health Survey for England 2008, DoH December 2009 • NHS Health and Wellbeing – Final Report (Dr Steve Boorman / DoH 2009 • Foresight (2007) Tackling Obesities: Future Choices – Project report, Govt Office for Science

4. But there is a solution: most people could meet recommended physical activity levels simply by including more walking or cycling in their daily lives. Chief Medical Officer’s recommendations for health enhancing physical activity (minimum): Children & young people: a total of 60mins of moderate intensity physical activity a day; Adults: a total of 30mins a day of moderate intensity physical activity five times a week. Moderate intensity physical activity includes cycling or brisk walking. Comparable European countries have higher levels of walking and, in particular, cycling. At Least Five A Week: evidence on the impact of physical activity and its relationship to health. DoH 2004 Levels of walking and cycling have, however, been in long term decline as car dependence has grown, contributing to our obesity problem. It does not have to be this way. There is a major opportunity to achieve public health goals alongside transport objectives through getting more people walking and cycling more often. Cycling levels in Britain are the lowest in Europe Estimated share of journeys (trips) made by bicycle European Best Practice 2006 Update – Atkins 2006

5. Local transport plans are a major opportunity to promote more active travel locally, but transport teams cannot do this on their own… We know what is needed to encourage more walking and cycling: • A supportive built environment where people can walk and cycle safely and in confidence, and where key services and destinations are located and designed with pedestrians and cyclists in mind; and • Promotion and marketing measures to help people overcome their personal barriers to more walking and cycling. Successful active travel programmes do both: complementing better infrastructure with targeted promotional activities A number of English towns and cities that have managed to halt or reverse the decline in active travel: • 18% of trips in Cambridge are cycled, in York it is 10%. • Cycling in London has doubled in less than a decade; Darlington achieved a 113% increase in just three years. • Walking in the DfT’s sustainable travel towns increased by 10-13% over three years. Your local transport team have capital funding for infrastructure like cycle lanes & parking, traffic management and home zones… But do not have access to revenue funds needed for travel planning, marketing, training (pictured) etc to complement infrastructure..

6. Local transport teams have to balance a number of competing priorities. It is important to make the case that active travel can contribute to a broad range of local objectives. More walking and cycling can support a wide range of local and national objectives, including: • Improving public health • Reducing carbon emissions • Improving air quality & the local environment • Improving accessibility & reducing congestion • Improving quality of life & better neighbourhoods A relatively low-cost active travel programme can make a significant contribution to your local area agreement. Who you should talk to: Engagement at any level is worthwhile, but most can be achieved by engaging at all levels to embed Health priorities in the LTP. Local Strategic Partnerships are a good starting point, and Govt Offices can help make contacts. NHS Chief Exec’s should engage early in the process with their counterparts in the Highway Authority, making the case for putting walking and cycling at the heart of the LTP. You may find it useful point to the contribution active travel can make to Local Area Agreement indicators (see the Active Travel Strategy for examples) This should be followed by an ongoing dialogue between the Director of Public Health and Director of Transport to ensure that the benefits of walking and cycling are fully realised in implementation plans. Most authorities also have a cycling and walking officer who can advise on detailed plans and schemes. A starter for ten - what questions to ask your transport team in the first instance: • What percentage of trips made locally are less than 2 miles, and 5 miles? • What are current levels of walking and cycling? • What is the ambition for growing this? • How do they intend to deliver this? • How will they monitor / review?

7. And there is robust evidence of the effectiveness and value for money of active travel schemes to deliver a range of benefits. Evaluation of active travel schemes shows they can be very effective in delivering health benefits: • The health benefits alone of investing in cycling can be more than 2.5 times the cost. • The first 3 years of the DfT’s cycle towns programme saw cycling increase by 27%, and proportion of adults who took no exercise decreasing by 10%.1 • In DfT’s sustainable travel towns the proportion of people who never walked or cycled fell by 11%, cycling rose by 26-30% and walking by 10-13% in just 3 years. • Rate of return on sustainable travel towns’ investment was very high, with a benefit-cost ration of as much as 20:1.2 Benefit-cost analysis of training schemes suggests that returns are of the order of 7:1. The London Cycle Network has focussed on high density commuter routes and is likely to lead to health, congestion and air quality benefits. A recent benefit-cost analysis showed a return of approximately 4:1 for this type of infrastructure investment The health benefits of cycling outweigh safety risks by a factor of more than 20.3 1 Cycling Demonstration Towns – Development of Benefit-Cost Ratios; DfT February 2010 • The Effects of Smarter Choices Programmes in the Sustainable Travel Towns; DfT February 2010 • Valuing the benefits of cycling – SQW / Cycling England (2007)

8. The National Institute for Health and Clinical Excellence offers the first evidence-based recommendations on improving the physical environment to encourage physical activity. NICE PH8 (2008) “Promoting and creating built or natural environments that encourage and support physical activity” includes a number of recommendations you can use when as a checklist when reviewing LTP or development proposals. The Recommendations can be summarised as: • Strategies, Policies & Plans: New developments always prioritise the need for people (including those whose mobility is impaired) to be physically active as a routine part of their daily life, local facilities and services are easily accessible on foot, by bicycle. • Transport: Pedestrians & cyclists given highest priority when developing or maintaining streets and roads. • Transport: Plan and provide a comprehensive network of routes for walking and cycling, offering convenient, safe and attractive access to workplaces, homes, schools and other public facilities. • Public Open Spaces: and public paths can be reached on foot, by bicycle and accessible by public transport. They are maintained to a high standard, safe, attractive and welcoming to everyone. • Buildings: Different parts of Campus sites (hospitals, universities) are linked by appropriate walking and cycling routes; new workplaces are linked to walking and cycling networks, where possible, improving the existing walking and cycling infrastructure by creating new, through routes. • Buildings: Staircases are designed and positioned to encourage people to use them, and are clearly signposted and attractive to use (e.g. well-lit and well-decorated). • Schools: School playgrounds are designed to encourage varied, physically active play. Primary schools should create areas to promote individual and group physical activities. www.nice.org.uk/Guidance/PH8

9. There are many ways that the NHS can contribute to local walking and cycling plans… PCTs can directly support LTP objectives to get more walking and cycling in a number of ways: • 78% of people consult their GP at least once during the year: many will not be active enough. It’s an opportunity to directly engage with people to encourage more active travel in their daily lives. • NHS staff, contractors and patients generate a lot of local trips. Making NHS sites easy for cyclists and pedestrians to access can help people rely less on their cars and get more active. • PCTs can help Identify neighbourhoods or groups with high levels of physical inactivity where intervention would bring most health benefits. • PCTs can complement capital investment in active-travel infrastructure, such as a new cycle route, with revenue-based measures to promote take-up and maximise benefits. Useful sources of information: The Active Travel Strategywas published by DH and DfT setting out the Govt’s plans to increase walking and cycling. Be Active, Be Healthysets out the estimated health-care costs of physical inactivity. At Least Five A Week established the Chief Medical Officer’s recommendations for health-enhancing Physical Activity. NICE PH8provides evidence-based guidance on how to improve the physical environment to encourage active travel. Cycling England have published evidence on the health benefits of cyclingand an evaluation of cycling towns. DfT have published evaluation of the impacts of the sustainable travel townprogramme. The NHS Operating Framework 2010/11encourages PCTs to work with councils to promote better health and more physical activity.

10. And places around the country where health and transport sectors are realising the benefits of working together London NHS Camden and Walk Englandhave produced easy to follow walking maps to explore their local area and get fit at the same time. The Active Stepsprogramme in Sutton is a groundbreaking initiative to increase physical activity and reduce car trips. It is linked to local NHS checks to identify those at greater risk of cardio-vascular disease. 97% of users said they became more active, 85% felt healthier, 46% lost weight. Liverpool Liverpool City Council and PCThave signed an agreement to make it a “Cycling City” to improve quality of life and create a healthy low-carbon city. The agreement sets out to generate a 10% increase in cycling trips by March 2011. And to make access to health services easier on foot, a network of new treatment centres are being sited across the city within 15 minutes walk of every residential address. A number of PCTs are already funding “Bike It” Officers to promote cycling in schools: “We aim to encourage Active Travel as an essential component of a healthy lifestyle for all ages, and Bike It is a proven intervention to help children develop that habit of healthy travel.” Adrian Dawson, Director of Public Health at Bournemouth and Poole PCT.

11. But don’t just take our word for it… “For most people, the easiest and most acceptable forms of physical activity are those that can be incorporated into everyday life. Examples include walking or cycling instead of travelling by car…..” At Least Five A Week: the Chief Medical Officer’s report on physical activity, 2004 “The top five policy responses assessed as having the greatest average impact on levels of obesity [include] increasing walkability / cyclability of the built environment…..” Foresight Tackling Obesities report, Government Office for Science 2007