Healthy Spaces: building better places

How a physio helped design a healthy new town

Claire Powell: healthy spaces: building better places

As a physiotherapist, Claire Powell had no experience of environmental design but her vision for encouraging people to be more physically active in urban spaces was shortlisted in an international landscape design competition to create the first garden city in a century. Her Everyday Adventures concept, in collaboration with a Kent-based landscape architectural firm, and environmental charity Commonwork Trust, was selected in July for the first stage of the Ebbsfleet Garden City Landscape for Healthy Living International Design Ideas Competition.

‘There were thousands of entries for the first stage. It’s an international competition, so it’s an achievement to get to the final five,’ says Ms Powell, who is a musculoskeletal physiotherapist with the osteoarthritis charity Horder Healthcare. The design didn’t win the second stage, but it did receive positive feedback, highlighting the role of physiotherapy in designing healthy spaces.

‘An impressive multidisciplinary collaboration with a physiotherapist and Commonwork Trust to envisage the site as a “green prescription” for preventative healthcare and everyday healthy living,’ said the Landscape Institute judging panel.

The competition was designed to stimulate ideas and creativity for NHS England’s 10 Healthy New Towns programme. One of the judges, Dr Sara McCafferty, NHS England national programme lead for Healthy New Towns, began her career as a physiotherapist. She explains: 'This is  

'Changing behaviour is difficult. As physios, we think we can, but without being able to affect people's environments we are only ever going to have a little influence.' Claire Powell

our first opportunity in quite some time to think about how places are designed, bearing in mind that health is affected by places where people spend most of their time, across school, work and in the activities of daily living.’ The aim of the three-year programme (2016-19) is to reduce pressure on the NHS by putting health and wellbeing at the heart of urban design planning.

Green route framework

Ebbsfleet Garden City in north Kent is the largest of the demonstrator sites, with plans for 15,000 new homes and improved transport links to reduce traffic, in partnership with clinical commissioning groups (CCGs) and Ebbsfleet Development Corporation. The health priorities for Ebbsfleet are reducing childhood obesity and creating an environment that will promote healthy lifestyles. The Everyday Adventures concept aimed to capitalise on the locality, which is close to the River Thames, marshland, historic quarries and two existing towns, Northfleet and Swanscombe, by developing a framework of accessible, active and sociable green routes that connect communities.

The architecture practice, Huskisson Brown Associates, had previously involved health professionals on designs but, says landscape architect Laura Jazwinski, ‘The Ebbsfleet competition is the first time we have worked with a health professional on wider public health issues to gain an understanding of human movement and incorporate this into the early stages of design’.

She adds: ‘As designers we have found this invaluable.’ 

Ms Powell, who has a personal connection to the firm, seized the unusual opportunity. ‘As a physiotherapist I have an important role to play in promoting health, and we are always trying to find ways of breaking down barriers to physical activity. The environment is such a massive element, but usually we have no influence on it.’

Her main contribution was providing evidence on physical activity recommendations, including the current public health advice of completing 150 minutes of moderate intensity activity a week, and the common barriers to achieving this goal.

Fun and interesting

An informal survey of her own patients suggested that most of the barriers they face are around accessibility. These included: worrying about not having a place to rest at regular intervals; wheelchair users concerned about inclines, with even those meeting minimum requirements feeling too dangerous; and unmarked changes in surfaces that had resulted in a blind runner falling and not wanting to return to the activity. Ways of addressing these issues were incorporated into the shortlisted design.

‘With the Everyday Adventures concept, I am trying to make outside spaces accessible to people of all abilities – from those with disabilities to elite athletes,’ Ms Powell says.

The idea is to build physical challenges into everyday routes to school and work based on the idea of parkour, or free-running – the physical discipline of freely moving over or through terrain. ‘We wanted to create an environment where you’re generally more active,’ says Ms Powell. ‘We also wanted it to be fun and interesting, so you might choose to take a route because it’s more enjoyable than driving. There would be different paths for different abilities. With the school path we’d hope parents would do it with their children.’

She adds: ‘The main point of the competition is about prompting debate about what a healthy town is like.’ 

Seeing the bigger picture

The collaboration has opened Ms Powell’s eyes to the disjunct between providing public health advice as physiotherapists and the general lack of opportunity to have an influence on patients’ surroundings. ‘Changing behaviour is hard.  As physios, we think we are able to do more than we can, but without the ability to affect people’s environments we are only ever going to have a little influence. We are asking them to do things without being able to make those changes ourselves,’ she says.

The CSP’s former head of practice, Steve Tolan, agrees that physios need to get more involved in influencing environmental design. ‘Research by the Health Foundation shows that only 10 per cent of a population’s wellbeing is linked to access to healthcare while 90 per cent is down to social determinants, and our surroundings are a key health determinant,’ he says.

Mr Tolan believes physios need to be thinking of the bigger picture and more proactively engaging with initiatives such as the Healthy New Towns programme. 

‘This is an example where new houses are being built and land is being re-purposed. It presents opportunities for physios to think beyond health in a clinical setting to community wellbeing. We can have greater impact if we can reduce the avoidable issues and see only the patients that need to be there,’ he says. 

    How can physios get more involved in environmental design?

    Dr Sara McCafferty is well placed to answer this question, having begun her career as a physiotherapist before moving into public health policy. Under the Healthy New Towns (HNT) programme, she says there are opportunities for physios to exert influence via their CCGs.

    ‘Each of the 10 demonstrator sites has a partnership with a CCG with a lead health professional on the team whose job it is to link planning with other health professionals in the area.’

    The demonstrator sites must also incorporate a health hub, taking learning from the separate NHS England New Care Model programme, which is about creating more joined-up and accessible health and wellbeing services. She points to the Barking HNT pilot, which will have a health hub attached to a leisure centre. 

    Each site has a New Care Model workstream that holds workshops to take the strategic vision into the community. ‘Most sites have had at least two workshops to co-produce what the health offer should look like. Lots of health professionals have been invited and I have met physios on at least two of these workshops,’ says Dr McCafferty.

    Outside the HNT programme, physios can also find out about planning applications for housing and community developments in their area. Local authorities have a duty to cooperate with CCGs on planning applications that relate to health or population growth, she explains. 

    ‘There is a variable take-up in response to the duty across the country, but potentially it’s a really good opportunity for the CCG to put a call out to health professionals to ask if they want to be involved in shaping that design.’ 

    As well as thinking about accessibility, physios can be thinking about how to build activities of daily living into planning; for example, community infrastructure, where interventions such as falls prevention classes can take place in the community rather than in hospitals. 

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    Author: Louise Hunt

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