Putting Health in its Place: Linking Evidence on Regeneration, Housing and Health Giving urban policy its ‘medical’: The place of health in area-based regeneration initiatives Rowland Atkinson, Hilary Thomson, Ade Kearns and Mark Petticrew

Background The growth of an evidence-based policy movement: –‘Policy-makers should have available to them the widest and latest information on research and best practice, and all decisions should be demonstrably rooted in this knowledge’ (Policy Hub website) Can evidence be accumulated and utilised by policy-makers on key urban policies? The role of systematic reviews - establishing the evidence base and recipes for effective policy

Health and ABIs Health as a wider justification for urban policy programmes/area selection ABIs a major means of urban regeneration to alleviate socio-economic deprivation –Significant investment, tackling determinants of health –Over £11bn (€16bn) 20 years Intuitive links of health to investment targeted at deprived areas - overlapping geographies of health and ‘urban’ problems

Regeneration and health ‘The benefits of including health in the strategy of regeneration are twofold. First there are the direct benefits of improving peoples physical and mental health and well being. Second, are the indirect benefits for employment, quality of life, levels of stress, and the cost of hospital admissions or medicines.’ Health & Regeneration. Dept Environment, Transport and the Regions 1996

Regeneration and health ‘Area regeneration has a key contribution to make to improving health. It tackles the social, economic and environmental problems of multiple deprivation. And it embodies the concerted approach the Government seeks to foster.’ Working together for a healthier Scotland Scottish Office 1998

Regeneration and health ‘Local neighbourhood renewal and other regeneration initiatives are in a particularly good position to address health inequalities because they have responsibility for dealing with the wider determinants that have impact on people’s physical and mental health.’ Health and neighbourhood renewal. Dept of Health & Neighbourhood Renewal Unit, 2002.

Aim & rationale of the review To examine national evaluations of government funded regeneration/ABI programmes at national level To assess the place of health in evaluation documentation To examine the measures used of health impacts How can we find out if ABIs have had health impacts and outcomes?

Method of review Urban programmes included 1980 to date (9 programmes, all UK): Urban Programme, Urban Development Corporations, Estate Action, City Challenge, Small Urban Renewal Initiatives, Single Regeneration Budget, New Deal for Communities, Social Inclusion Partnerships, New Life for Urban Scotland Included evaluations which reported on achievements or impacts: –Excluded strategy or process-only documents –Qualitative or quantitative methodologies National evaluations only - not single evaluations of local health projects

Results 856 references identified 780 not obviously relevant or duplicate 76 full documents examined by 2 researchers 29 documents reporting national evaluations included in review

Programmes and health impacts Urban Programme - Daycare facilities, advice/counselling on alcoholism, Improving primary and community care and services for priority groups. Health and ethnic min’s, Number of health projects 357, clients per week 22,561 City challenge - SMRs and Limiting long term illness in certain case studies, Health centres, Health of CC residents was on average poorer than elsewhere, Integrated health and voluntary social services Estate action - Reduction of social stress (homelessness and crime) linked to health, Family health/fear and worry about crime i.e. stress

Programmes and health impacts Single regeneration budget - Changes to residents self-reported health (negative), Access to a doctor and services, Mortality for Hull and Nottingham case studies only, No. of new health facilities. No. of new sports facilities, Satisfaction with health centre – quality and accessibility, Drug prevention SIPs - Limiting long term illness, low birth weight babies, coronary heart disease, cancer, stroke, smokers, Access to health services (problems!) UDCs - none, SURIs - none

The contrasting place of health over time 1960s-1980s: Urban Programme: implicit links between social deprivation and poor health, health a funding theme 1980s: Urban Development Corporations: dominated by economic regeneration and property development - health/social impacts absent Mid 1990s: Single Regeneration Budget: multi-agency, partnership approach (including health authorities), links between social exclusion and quality of life, health implicit, health a funding theme

Place of health over time 2000: New Deal for Communities Explicit, aim to improve peoples health, identify what works specific impacts i.e. morbidity rates Programme vision ‘to have lower worklessness: less crime; better health; better skills and better housing’

Health impacts of urban programmes Partnerships with health authorities and raising agenda of health inequalities in deprived areas Health related output e.g. health and social facilities built or improved User satisfaction: quality and accessibility Access to health services e.g. registered with GP Health service use: visit to GP more than once in past year

Health impacts of urban programmes 2 Measures of social stress e.g. crime & incivilities Quality of life e.g. neighbourhood satisfaction Mortality & morbidity: limiting long term illness, low birth weight babies, coronary heart disease, cancer, stroke, smoking Self-reported health improvement/deterioration

Conclusions Links between health and regeneration investment have varied over time - presently an explicit link Direct efforts to include health measures have proved problematic and patchy Regeneration programmes achievements on evaluation have been variable for: –Direct health measures (self-reported health, morbidity etc) or, –Indirect health impacts (use of health services), and; –Social determinants of health (neighbourhood poverty etc)

A non-story? Review indicates a lack of evidence so… A remaining need to identify effects, accumulate knowledge to improve effectiveness Political rhetoric on links of health to ABIs proves hard to unpick with existing evidence: –Storage, indexing and accumulation of local evaluation evidence lacking at central level –Methods of evaluating regeneration need further development - baselines/measures

Implications for EBP What have we learned from twenty years of ABIs/health? –Long-run health impacts vs short-run policies –Can programme evaluations be sustained by case studies? –Lack of measures does not necessarily mean lack of impact –Policy amnesia or limited programme and knowledge lifespans? –Incremental or cyclical models of policy-making –How can policy-makers at national level gather evidence when systematic searches like this ‘fail’? EBP and SRs: should be used to challenge the belief that: a) the evidence is out there; and b) that the evidence can be transformed into recipes for policy