'Working together for a healthier Scotland' - a Government consultation paper on health
A response from TRANSform Scotland

TRANSform Scotland is Scotland's newly-formed campaign for sustainable transport-related policies and programmes. With the strong support of Transport 2000, and over 45 transport and environmental organisations in Scotland, TRANSform Scotland has already begun to foster changes in attitude towards the ways in which people travel, goods are moved and cities, towns and countryside are planned and developed.

From the beginning, TRANSform Scotland has been keenly aware of the public health implications of transport policies and practices. Local authorities and the Public Health Alliance Scotland are among the founder members of TRANSform Scotland.

1 General response to the Green Paper.

1.1 TRANSform Scotland welcomes the general approach of the Green Paper, in particular that it recognises the importance of inequalities in the health experience of the people of Scotland (para 2, para 6), and that it also recognises the role of life circumstances in creating health inequalities (para 49 - 57).

1.2 However, TRANSform Scotland is of the opinion that targets for the reduction of inequalities within priority health topics (para 90, para 138 et seq, para 198,199) and in life circumstances as they affect lifestyles (para 49 et seq, para 109 - 112) are essential if health improvement is to be seen. It should be remembered also that inequalities exist outside those described by deprivation categories (DEPCATs) (see note 1) and defined urban communities. Striking inequalities in life circumstances and therefore in health experience are seen in rural areas, for example.

1.3 Policy co-ordination at all levels is an admirable intention of the Green Paper. There is considerable evidence of local policy and practice co-ordination for health. However, the Government must ensure that co-ordination and integration take place equally at ministerial level.

2 Particular response in relation to transport and health.

In Working together for a healthier Scotland, transport is recognised as being a health-promoting or health-detracting factor in people's health (para 57, para 110). However, it is disappointing that transport issues are given slight coverage in the Scottish Green Paper. In contrast, the English Green Paper, Our healthier nation, shows a much broader understanding of the transport-health relationship.

TRANSform Scotland wishes to respond to five aspects of transport as they affect health. These are: exercise, accidents, pollution, access to services, inequalities.

2.1 Exercise.

The Green Paper reminds us that "exercise taken in Scotland falls well short of the levels regarded as beneficial to good health" (para 66). It is now well recognised that physical activity is a protection against coronary heart disease and other diseases of middle and later life. The Green Paper gives greater emphasis to the provision of organised sports facilities and opportunities (para 132 et seq) than to the promotion of forms of regular moderate exercise such as those provided by cycling and walking (para 137). Yet it is the latter approach which is advocated by the Health Education Board for Scotland (HEBS) (see note 2) and the BMA (see note 3).

It is recommended that good regular exercise habits should be developed in children, yet a recent local survey (see note 4), among others across the UK, suggests that both children and their parents are reluctant to get this exercise on roads where traffic dangers and pollution are major risks. The Scottish Office has recognised the health benefits of cycling in its policy statement Cycling into the future (see note 5). TRANSform Scotland considers that targets should be set for increasing walking in the general population, as well as targets for increasing the numbers of children walking and cycling to school, in the same way that Cycling into the future (see note 6) has set targets for increasing cycling. It would be helpful if the Scottish Office Health Department were to support the expansion of the Safe Travel to School initiatives developing throughout Scotland, in which the health benefits are specifically recognised.

It must be remembered that while car ownership is rising steadily in Scotland, many children in the poorest areas have no access to a car - while they have no choice but to walk to school, their route is often dangerous and polluted, making it an unsuitable context for regular exercise.

2.2 Road Traffic Crashes.

Road traffic crashes, of which a few are accidents, are still a major cause of premature death and disability in Scotland. At the beginning of the decade Scotland's pedestrian road death rate was the fifth worst out of 23 Western European countries, as well as 26% higher than the EU countries total and over 3 times higher than the lowest EU rates 6. Rates for child pedestrian fatalities are currently the second highest in Europe and nearly a third higher than in England and Wales, with pedestrian accidents being the major cause of death for children under 14 (see note 7). Pedestrian casualty rates for people living in disadvantaged areas are significantly higher than for those in more affluent areas (see note 8). With lower car ownership rates in Scotland, more pedestrians are at risk from traffic, especially in disadvantaged communities - this however is not an argument for increasing car ownership.

While Working together for a healthier Scotland acknowledges Scotland's poor record of pedestrian casualties and the inequalities within this (para 29, paras 33-35), it fails to make explicit the role of sustainable transport systems in the prevention and reduction of accidents. It is hoped that the Scottish Office will see fit to alter the statutory instruments enabling local authorities to create and enforce lower speed limits generally, with 20mph speed limits in residential areas. Equally, it is hoped that the role of public transport will be enhanced, and walking and cycling given greater encouragement.

2.3 Pollution.

The numbers of vehicles licensed in Scotland rose to 1.73 million in 1996 (Scottish Transport Statistics), while all parts of Scotland showed continuing growth in road vehicle miles on major roads. This level of road traffic makes a major contribution to the burden of air pollution with its demonstrable effects on health. It is likely that the dramatic rise in cases of asthma and resultant hospital admissions over the last ten years is in part due to rising levels of air pollution. Over 1000 deaths a year in Scotland are now attributed to levels of health-damaging particulates in the atmosphere (see note 9). People living in disadvantaged areas are disproportionately affected by traffic pollution. While the Green Paper says that strategies for local air quality management are to be adopted (para 111) it under-emphasises the key contribution to be made by a radical shift in transport policy, involving a radical reduction in and modification to the roads programmes and the development of locally sustainable forms of transport, such as cycling, walking and public transport. TRANSform Scotland would like to stress that no appreciable improvement to air quality will be made through technical modification to vehicles. Again, it is hoped that the forthcoming White Paper on Transport will put forward detailed strategies for the transport contribution to air pollution reduction.

2.4 Access to services.

Poor access to services of all kinds, including health services, has a major effect on health. People living in disadvantaged communities suffer doubly by having none of the access advantage which car ownership brings, and by having to live with inadequate local transport provision and poor local facilities. Where families in poor communities do own a car, it is often needed by any member of the family who is working, thereby marooning the rest of the family with poor facilities and poor transport. Poor local transport systems reduce demand for services and foster lower expectations, thereby reducing supplies and services. Buying good quality food locally, reaching community and preventive health services and taking up educational and recreational opportunities can all become too difficult if no local services are available and there is no local affordable public transport, no safe pedestrian walk-ways or cycle tracks. While walking to school strategies are developed in many parts of the country, it must be remembered that children in many communities have to walk to school through polluted and unsafe streets, made so by the car owners from more affluent communities.

2.5 Inequalities.

Transport makes a major contribution to much of the picture of inequalities in health experience (paras 33 - 42) and life circumstances (paras 49 - 57) described in Working together for a healthier Scotland.

2.5.1 Poor transport access to essential antenatal services and to affordable good quality food supplies can affect the lifestart of infants and children in disadvantaged communities (paras 37, 38).

2.5.2 In disadvantaged areas, the lack of safe, clean accessible exercise opportunities such as are afforded by active transportation contributes to obesity and poor fitness levels in children and inequalities in coronary heart disease rates (paras 22 - 24, para 40). Rising car ownership in all communities further mitigates against exercise opportunities.

2.5.3 In such areas also, the risks posed by the car-dependent travel patterns of the more affluent contribute to the unacceptable inequalities within accident rates, particularly as these affect children (para 29).

2.5.4 The poor mental health experience of many people living in disadvantaged communities is largely attributable to inequalities in life circumstances - poor local transport provision contributes to lack of community safety and restricted access to health and shopping services, as well as to opportunities for education, employment and recreation (para 57, para 148).

2.5.5 Access to eating for health is a major factor in inequalities in the incidence of childhood illness, coronary heart disease and cancer (paras 61 - 64). Poor access is mainly determined by poor public transport provision, as well as poor planning practice.

3 Other issues.

3.1 Health impact assessments: (para 103): TRANSform Scotland notes the intention to evaluate the health impact of all new Scottish Office policies. It will be essential however to quantify the impact in each policy area. TRANSform Scotland looks forward to a detailed evaluation of the health impact of the policies put forward in the forthcoming White Paper on Transport.

3.2 Strengthening communities (para 104 - 108): Area regeneration (para 113 - 117): TRANSform Scotland would like to emphasise the contribution made to these strategies by good transport systems and by land use practices which promote walking and cycling. TRANSform Scotland urges those carrying forward these strategies to put in place measures to improve the quality and lower the cost of local public transport systems - through integrated local transport systems, integrated ticketing, concessionary fares, improved frequencies of service and extending of local zones. It should be remembered also that much inequity of transport provision lies outside urban regeneration areas, and especially in rural communities. Here, an enlarged Rural Transport Fund could expand the frequency of longer services and initiate local transport systems (using taxis and car-sharing), as well as support walking and cycling. These measures will only be effective however in tandem with planning policies which encourage mixed use development.

3.3 Healthy living centres (para 118): opportunities will arise in these centres for promoting healthy transportation. In particular, experimental community bicycle projects could be based in HLCs: a fleet of bicycles could be stored and maintained on the premises, and lent for shopping and recreational purposes. The Centres could also offer repair facilities.

3.4 Local authorities (para 154 - 157): TRANSform Scotland recognises the major health-promoting role of local authorities, and considers that a significant element of this role is to promote healthy transportation policies and practices and to evaluate the health impact of current systems. Additionally, local authorities are able to develop creative partnerships for health with the voluntary sector. Increased local authority support of healthy transportation systems should enable, in the long run, reduced demand on acute health services.

3.5 The National Health Service in Scotland (paras 158 - 175): TRANSform Scotland acknowledges the NHS in Scotland as having a major part to play in promoting public health (para 158 et seq), and specifically, to promote the health benefits of integrated and sustainable transport systems: first, as a major employer it can facilitate non-car travel to work; second, it can promote the health benefits of active transportation; and third, it can promote equitable access to services, including NHS services, through pressing for better local public transport systems. TRANSform Scotland s sister organisation in England, Transport 2000, has set up the Health Transport Network for this purpose.

The NHS should seriously consider the health-travel implications when siting new hospitals and other services.

3.6 Working together: the title of the Green Paper is reflected in the concept of Partnerships for Health, referred to specifically in para 95 and implicit throughout the Paper. TRANSform Scotland welcomes this emphasis and reminds The Scottish Office that there are already successful transport partnerships for health in Scotland. One such partnership locally is that between Spokes, the campaigning cycle interest group, and the local authority in the interests of creating safer and healthier routes to school. The role of the voluntary sector is often of crucial importance in successful partnerships. TRANSform Scotland itself is a voluntary campaigning body with a broad range of members, bringing together the perspectives of transport policy makers, providers and campaigners. TRANSform Scotland is already working with its members on issues of transport and health among a range of topics.

4 Opportunities for healthy transport created by the Scottish Parliament.

TRANSform Scotland considers that the setting up of a Scottish Parliament presents a unique opportunity to develop transport policies and practices which will have demonstrable benefits on the health of the people of Scotland, in terms of promoting equality of access to services, developing safe healthy alternatives to car travel and improving the quality of the environment.

References:

1. Carstairs, V. and Morris, R. (1991) "Deprivation and health in Scotland", University of Aberdeen Press.
2. The Health Education Board for Scotland (1997) "The promotion of physical activity in Scotland."
3. British Medical Association (1997) "Road transport and health."
4. Save the Children and Edinburgh Health Challenge (1998) "Safe and healthy travel to school: a survey carried out in two Edinburgh primary schools."
5. Scottish Office Development Department (1996) "Cycling into the future: the Scottish Office policy on cycling."
6. "Road Accidents Scotland" (1992).
7. Cleary, J. (1995) "School travel, health and the environment - a report for Nottingham County Council."
8. McGuigan, D., Bull, M. and Gorman, D. (1996) "Connecting scoial deprivation and involvement in road accidents."
9. Friends of the Earth Scotland (1996) "The state of Scotland's air."