Scottish Government

Joined Up Policy And Practice In Health And Transport

Steer Davies Gleave, Dr Tom Rye and Dr Dermot Gorman

Steer Davies Gleave together with Dr Tom Rye and Dr Dermot Gorman were commissioned by the Scottish Executive in late 2004 to carry out a review of joined up policy and practice in health and transport: the focus was on opportunities for healthcare professionals and transport planners to work together to create mutually beneficial outcomes, particularly in the achievement of sustainable transport and health improvement objectives through the promotion of physical activity. The research explored the growing links between transport and health at policy and practice levels, to learn from what has already been achieved in this field in Scotland and elsewhere. Recommendations on how joined up working can be promoted further in the future have been made. The work focused on transport's links with improvements to public health, and not on access to healthcare facilities.

Transport Research

Main Findings

• Joined up working in health and transport does exist, but it is by no means mainstreamed in Scotland.
• Increasing numbers of stakeholders are aware that it is in their interests to work with those in other policy areas to pursue common outcomes, even where their respective objectives may differ.
• The "actors" involved are much wider than just transport officers in local government and health promotion staff in the NHS - planning officers, community planning partnerships, outdoor access officers, amongst others, all have a role to play. These diverse but linked roles need to be recognised by all parties to enable progress to be made, although it presents a challenge for overall coordination of efforts.
• Many of the strongest initiatives which explicitly link transport and health are predominantly led by a desire to improve health as opposed to promoting sustainable transport. Exceptions include school and employee Travel Planning and specific action on developing cycleway infrastructure where health improvement is sometimes cited as a direct or incidental benefit.
• Significant progress needs to be made at a national level to convince policy makers across both health and transport sectors that there is merit in working together to achieve common outcomes, even where sectoral objectives may contrast. Moreover, there is effort needed to convince decision makers in the transport sector that there is a duty to consider the health impacts of transport policies and projects, as well as the need to actively seek to maximise health improvement opportunities.
• There is a lack of evidence of the cross-sector costs and benefits between the transport and health sectors, in part due to an inconsistent and non-prescribed approach to the monitoring of transport outcomes. Overall, there is potential for mutual benefits by complementary policy initiatives, which will require avoidance of conflicting priorities to be effective.

Purpose of the research

The Scottish Executive has been aware that there is currently some joined up working and thinking between the transport and health sectors across Scotland (e.g. promoting the health improvement aspects of cycling and walking in travel planning).

This study was commissioned with the aims of exploring the growing links between transport and health at both policy and practice levels, to learn from what is already present in Scotland and elsewhere, and to recommend ways in which joined up working can be promoted further in the future.

Methodology

The research began in late 2004, and was completed in autumn 2005. The study has consisted of the following tasks:

• Review of policy, research and information to scope the links between transport and health, and establish baseline evidence.
• Interviews with selected individuals to inform the review stage.
• Wide-ranging email questionnaire of relevant organisations and posts across Scotland.
• Review of good practice from elsewhere (outside of Scotland).
• Selection and investigation of eight case studies across Scotland to examine in more detail the links being made between transport and health, challenges faced and opportunities for improving these links.
• A seminar on overcoming the challenges in joined up working on health and transport identified during the study, held in Glasgow on 8th June 2005, with an audience of experts and professionals in the fields of health, transport and cross-sector working.

Scoping the problem

Linking transport and health does not always refer to access to healthcare. There are strong links between transport and health improvement, such as encouraging individuals to walk or cycle to work, school or other key destinations in their average day. The World Health Organisation advocates that "walking and cycling as part of daily activities should become a major pillar of the strategy to increase levels of physical activity as part of reducing the risk of coronary heart disease, diabetes, hypertension, obesity and some forms of cancer" (as well as reducing air and noise pollution and improving the quality of urban life). The Scottish Executive's Physical Activity Strategy: Lets Make Scotland More Active has the goal of increasing and maintaining the proportion of physically active people in Scotland, including through active travel. At the same time, promoting travel by sustainable modes also meets transport and planning policy objectives - car ownership and traffic congestion are growing in Scotland, with people driving further and more often.

Examples of joined up working

Joined up working in transport and health is happening in Scotland, although it is by no means mainstreamed. Examples of joined up working include:

• Policy links at the national level, such as Scotland's 2004 Transport White Paper objective to protect the environment and improve health.
• Local policy links, through community plans and joint health improvement plans.
• Promotion of health benefits in outdoor access schemes, local walking and cycling initiatives, school and employee travel planning.
• Promotion of walking and cycling to patients by frontline medical staff in medical referral schemes.

Barriers and challenges

Whilst there is some joined up working ongoing between transport and health, a number of key barriers and challenges have been identified in this research:

• Guidance and definition issues over what links between transport and health mean, perhaps inevitable given the early stage of development of these links, but something that needs to be improved upon to develop a consistent approach across Scotland.
• Staffing and management issues, with a dependency at present on motivated staff due to a lack of mainstreaming of joined up transport and health at a strategic level.
• Funding issues, related to the nature of funding available (often short term), and the relatively low levels of funding dedicated to the areas of transport which can have a key role in health improvement (e.g. walking, cycling and local community projects to promote physical activity).
• Political will and priorities allocated at the local level, often driven by central funding and selective performance monitoring, as well as the desire to have high-profile "photo opportunity" projects. This can be at odds with the need identified in this work for more consistent application of low profile initiatives which lead to outcomes not so amenable to "photo opportunities".

Key recommendations

Overall, there needs to be some fundamental features in place for joined up working to happen, which include:

• A strong policy framework.
• A requirement to monitor.
• Secured and long-term resources.

The research suggests there may not be the desire from professional staff across sectors for another single-issue initiative or campaign to emerge from the Scottish Executive (in this case, a health and transport initiative). However, there is clearly a need to mainstream the links between transport and health through existing frameworks.

Specific recommendations have been developed in response to the barriers and challenges to joined up working identified in this research.

• Develop Good Practice Guidance, and fund dissemination of existing good practice tools to professionals in the field.
• Ensure the National Transport Strategy provides strategic direction on how transport can contribute to health improvement.
• Improve the evidence base and enable monitoring of progress by developing a wider range of transport indicators and targets at a national level; providing better guidance on how to monitor cross-sector initiatives; and building meaningful monitoring into statutory Regional Transport Strategies.
• Produce a final Walking Strategy for Scotland with targets (given the contribution that walking can make to health improvement objectives).
• Provide national guidance on school travel plans and the development of school travel packs to strengthen links to health improvement objectives and avoid each local authority "re-inventing the wheel".
• Continue and monitor efforts to implement the national physical activity strategy at the local level, including raising awareness of the national initiative (and thus help establish the links to transport outcomes).
• Provide updated national design guidance on how to better incorporate walking and cycling into new development, urban design, travel planning and thus contribute to healthcare outcomes.
• Showcase a medical/active referral scheme that has widened the scope of referral to include walking and cycling schemes, thereby demonstrating the potential to directly link healthcare initiatives with sustainable transport objectives.
• Incorporate a consideration of health improvement into the assessment/appraisal of transport policies and schemes, including Scottish Transport Appraisal Guidance, to help mainstream this approach by demonstrating the wider societal benefits.
• Provide more guidance and funding for pilot Health Impact Assessments related to transport to help embed joined up working.
• Research the effectiveness of levels of funding for cycling and walking at a local level available from non-ringfenced funding sources.
• Build on work carried out by Paths to Health, Sustrans and Living Streets Scotland which promote both healthy and sustainable transport opportunities at a local level.
• Improve coordination of overlapping initiatives such as those dealing with schools to help mainstream joined up working in this sector.
• Re-visit short term funding cycles for many initiatives and posts covered by this research to provide a more stable, long term environment for improved joined up working.
• Require public bodies to implement travel plans, leading by example in an area of behaviour change that has potential to link transport and health improvement effectively.

Opportunities for the future

There are a number of key opportunities for improving the links between transport and health in the future, which can assist in mainstreaming this relationship and reinforce the mutual benefits of joined up working.

• The community planning process, a strong opportunity to encourage joined up working across sectors.
• The second round of Local Transport Strategies (although these are not statutory documents with a formal link between monitoring and funding).
• Statutory Regional Transport Strategies, providing a strong framework for regional transport planning with a duty to work with health sector partners.
• Core Path Planning and outdoor access duties on local authorities from the Land Reform (Scotland) Act 2003.
• Local projects from the Paths for All Partnership and Paths to Health Project.
• Utilising existing transport funding opportunities innovatively.
• Increased use of non-transport funding opportunities.
• Greater involvement of frontline health care staff in the promotion of physical activity through broader referral schemes.
• Programmes for travel behaviour change and travel planning which promote health benefits alongside sustainable travel.
• Further implementation of the national physical activity strategy at a local level, through development of local strategies and forums which bring partners together across sectors, and provide an excellent opportunity for coordination of efforts.

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