Who can influence healthy urban development?

ABSTRACT

Built and green environments can influence population health and wellbeing. Creating healthy places involves multiple wider determinants of health considerations. It is complex, with many types of stakeholders who may have competing interests and priorities. This article presents learning from a regeneration project in a city in England by a practitioner and embedded researcher in local government. Based on learning from conducting a Health Impact Assessment for a regeneration project, structured around 11 wider determinants of health categories, we examine how health-related issues relevant to large scale urban development can be influenced by different stakeholders. This focuses on developers, local government, and members of the public. This experience may help inform how public health interventions can be developed and targeted to effectively influence creation of healthier places: using Health Impact Assessment approaches; understanding stakeholder influence; and benefiting from embedded researcher knowledge of complex systems.

KEYWORDS:

• Regeneration
• influence
• decision-making
• urban development
• Health Impact Assessment
• wider determinants of health

Introduction

There are many aspects of the built environment that can influence population health and wellbeing, including greenspaces, transport infrastructure, and quality and affordability of homes. Decision-making for new urban development is complex, with many types of stakeholder who likely have differing interests and priorities which can result in trade-offs (Le Gouais et al. 2023), for example, more greenspace will reduce the land available for housing. Despite health evidence demonstrating associations between environmental features and physical and mental health outcomes (e.g. SØrensen et al. 2013, WHO Regional Office for Europe 2016, Ige-Elegbede et al. 2020, 2023, Salgado et al. 2020), construction projects may not result in healthier places, which can lock in ill-health, including health inequalities, for generations. In recent years there has been greater focus within public health and built environment sectors on encouraging healthier place-making for towns and cities with multiple guidance documents available, for example, in the UK recent examples include Active Design (David Lock Associates 2023) and Green Infrastructure Guidance (Natural England 2023). These include case study examples which can be useful to inform decision-making. There is increasing public health research on these issues, with an emphasis on influencing policy and practice. Public health research often produces recommendations of changes to the environment, such as more cycling infrastructure, or more greenspaces, however, consideration of the processes and stakeholders involved in achieving these changes tends to be lacking. Although such recommendations can be helpful, they may downplay the challenges and complexities of influencing such change in practice which can make it more difficult for research evidence to be influential. Greater cross-disciplinary working is needed so that public health evidence can better understand how to target evidence to become more impactful within built environment decision-making.

This article brings learning from our experience working together on a regeneration project in an English city. MC is a regeneration practitioner in local government and ALG is an embedded researcher – a public health academic with a focus on large scale urban development. This article seeks to improve understanding of mechanisms and stakeholders that should be engaged with in order to support the creation of healthier environments for population health and wellbeing. We do this by bringing learning from developing a Health Impact Assessment (HIA) for a regeneration framework which set the principles for new urban design and development in an area of the city that is due to change from predominantly industrial and warehousing use, to a residential neighborhood, alongside greenspaces, employment and community spaces. We focus on consideration of the scope of influence of key actors associated with the wider determinants of health (i.e. the extent to which they can affect built environment decisions) to identify where public health evidence could be targeted to achieve greatest impact. This influence relates to differing levels of power held by actors, and structural issues that affect who controls urban development decision-making and therefore environmental factors associated with risk of ill-health.

HIAs can be used to identify potential health impacts of policies or plans (Public Health England 2020, Sharpe et al. 2022). Many local governments in England require HIAs for large planning applications, although there has been criticism about its value, particularly when conducted post-hoc, resulting in it being simply a ‘tick box exercise’ (Christie and Ortegon-Sanchez 2022). To avoid this, we conducted an early-stage HIA of the regeneration area, setting out local health issues, to inform the production of the regeneration framework from the outset to influence it for healthier place-making. The HIA sets expectations and requirements for future development and planning applications and in turn should influence more specific site-level HIAs within the regeneration area.

ALG’s embedded researcher role is part of the TRUUD (‘Tackling Root causes Upstream of Unhealthy Urban Development’) project which seeks to understand the complex system of urban development decision-making and identify, conduct and evaluate interventions to support healthier urban development (Black et al. 2021). This embedded researcher post has helped to examine the ‘black box’ of urban development decision-making and see from within the system how decisions are influenced by different types of stakeholder.

This article is important to inform public health researchers and practitioners to support impactful interventions that can influence healthier place-making across a system that is dominated by non-health stakeholders. By exploring wider determinants of health issues, through an HIA lens, we seek to provide insights into the scope of influence of different urban development stakeholders and thereby improve understanding of how healthier place-making could be supported.

What is healthy urban development?

To understand how to influence healthier place-making, firstly it is important to be clear about what we mean by ‘healthy’. There are widely recognised factors that increase risk of ill-health within our environments. Although there are differing contexts across and within countries, the principles of healthy place-making are universal: minimising pollutants and noise, safety and low levels of crime, greenspaces and access to nature, quality and affordable homes, spaces for social interactions, access to employment, accessible for active travel, and resilient to climate change. Epidemiology research provides evidence about these links between environmental features and health outcomes. Although there can be linear relationships between health behaviours and outcomes, such as time spent doing physical activity and reduction in mortality (Ekelund et al. 2019), and environmental features are associated with behaviours, such as physical activity (Kärmeniemi et al. 2018), there is lack of clarity about specific infrastructure requirements or quality needed to maximise health.

Some health impacts associated with environmental features are more obvious than others and receive greater public attention. Air quality, for example, has immediate impact on people, from unpleasant smells, to breathing difficulties. These short-term impacts of poor air quality are generally recognised, although longer-term impacts may not be discussed so regularly, such as associations between air pollution and dementia (Peters et al. 2019). Previous research conducted by ALG and colleagues identified subjectivity by urban development stakeholders around what was needed for healthy urban development (Le Gouais et al. 2023). This lack of objectivity means that stakeholders seeking to enable healthier placemaking may not achieve this when others seek to maximise other outcomes, such as profit. This is highlighted in the two quotes below from public sector urban development stakeholders in that study. In the English planning system there are policies that can outline expectations from developers, but there is scope for negotiation between the local government and the developer.

… you’ve got this horrendous policy in the [National Planning Policy Framework] which says we can only refuse things if the impact is severe. Now define severe, you know, I was asked this in a public inquiry … people living in high buildings, mental health issues associated with that, isolation, that’s very hard to quantify. (Local government, transport)

… they’ll be some in society who think a healthy place is basically an open meadow and there are others that think it’s a well-designed pair of houses, there are different definitions … the lack of a common view as to what it looks like allows people to kind of come up with their own interpretations. At which point they can just build a 5,000-home housing estate and one small play park in the middle of it and say ‘look it’s healthy’. (National government, policy)

It is very unlikely that all health outcomes can be maximised for all people. Some compromise is needed, as required for urban planning decisions, and these health trade-offs need to be acknowledged, so that decisions are made based on evidence, rather than rhetoric or pressure from particular interest groups. For example, we know that for people with insecure, poor quality accommodation large health benefits can be achieved from providing them with quality homes. However, the size of homes will affect how many can be built on a set area of land. It may affect the height of buildings, or the amount of green or open spaces in the area. Taking more land for homes can reduce the space available for cycle lanes, limiting opportunity for active travel. Taking the view that trees should never be cut down supports ecological outcomes, but may limit the opportunity to provide new homes or cycling infrastructure. There can be differences in opinion about what should be done by different types of people, with differing needs and wants. These are therefore political issues, as well as commercial.

Working in regeneration we have been involved in numerous community engagement events. During these we have talked with many people about their concerns and aspirations for their local area. These conversations often focus on single issues, without acknowledging the complexity that can inevitably lead to trade-offs and compromises. This can result in frustration or anger, and may stem from a lack of understanding of planning processes and stakeholder influences. Therefore, greater understanding of how different stakeholders may, or may not, influence certain environmental features can help to manage expectations and target efforts, including community activism, more effectively.

Understanding a multi-disciplinary, complex system

Global health has been described as ‘a collection of problems rather than a discipline’ (Abimbola 2016). This is certainly the case for the creation of urban environments where multiple disciplines and stakeholders are involved. Spanning public, private and third sector organisations, the policy and practice of changing the urban environment involves skills and knowledge in urban planning, transport, environment, sustainability, law, real estate and management, amongst others. Public health as a sector may not be a major actor in this complex system (Le Gouais et al. 2023), although the historical connections between health and urban planning are strong, going back to early sanitation measures, such as sewers in London following cholera pandemics and ‘the great stink’ of 1858; and new towns or urban areas being built outside of major polluted towns and cities, originating in Ebenezer Howards’ garden city movement that led to satellite towns built in the 20^th century.

Different stakeholders in the system will have differing interests and priorities (Le Gouais et al. 2023): the public sector will likely seek social benefit from urban development change, while the private sector will likely be profit-maximising, although the aims of these broad stakeholder groups may overlap. Understanding their objectives and their opportunities to control or influence decisions is important so that researchers joining this multi-disciplinary space can effectively design and evaluate interventions. Therefore, although local contexts can differ, academics, and the public health community, can benefit from better understanding the system of urban development decision-making so that effective interventions can be implemented for healthier place-making.

In this article, we examine the scope of influence for decision-making by key stakeholders of features of the built environment that are associated with population health and wellbeing, based on the 11 categories in the London Healthy Urban Development Unit (HUDU)’s HIA framework (NHS London Healthy Urban Development Unit HUDU 2019): housing quality and affordability, access to social infrastructure, access to nature, air quality, noise, accessibility and active travel, crime and community safety, access to healthy food, access to work and training, social cohesion, use of resources, and climate change. This structure can be used to evaluate urban development proposals and identify opportunities to support healthier urban development and has been used to guide HIAs for planning applications in various local governments in England. We focus on three key stakeholder groups: local government (officers, including urban planners, and elected councillors), developers (predominantly from the private sector, including landowners, developers, architects, planning agents, consultants and contractors), and the public (existing local residents, community groups and businesses, and future residents). Drawing on our regeneration project experience, we identify opportunities for influence to enable healthier environments to be created. This is important to help influence change for healthier places by identifying stakeholders and leverage points within the system of urban development decision-making for each of the 11 issues in the HUDU HIA framework.

Embedded research with local government

From October 2020 to 2024 (ongoing) ALG has been working as an embedded researcher within local government in a major English city (seconded from her university part-time at no cost to local government). She worked on a large-scale urban regeneration project, which was managed by MC. This provided opportunity to understand the complex system of urban development decision-making through observing (attending relevant events and meetings with local government officers, elected councillors, local residents, and private sector developers) and contributing to local government projects by using health evidence to influence urban development decision-making (Le Gouais and Peake-Jones 2022). Through emersion in a live case study project, she learnt about what influences decision-making by different types of stakeholders, as well as contributed to projects to influence healthier urban development.

The regeneration project sought to develop a guiding spatial regeneration framework for future housing and mixed-use development in a predominantly industrial/warehouse area in a deprived community near to the city centre. This will include over 1000 new homes and accommodation for 500 students, as well as workspaces, community facilities, public realm improvements and physical infrastructure required to enable growth. An artist's impression of the future vision for the regeneration area is shown in Figure 1. As an embedded researcher ALG was able to attend relevant meetings to help her understand the system of urban development decision-making, with internal, local government stakeholders spanning planning policy, transport, property, economic development, parks, sustainability, housing, community development and public health practitioners, and also external stakeholders, including developers, landowners, businesses, third sector organisations and the public. When attending meetings as an observer, ALG made clear that she was a researcher and shared a participant information sheet so that people understood the purpose of the research (to understand the system of urban development decision-making and support interventions for healthier policy and practice), as well as information on how data may be collected (e.g. through field notes to capture relevant issues), stored and used.

Figure 1. Vision for the regeneration area (Allford Hall Monaghan Morris 2023).

The embedded researcher role provided opportunity to collaboratively produce interventions for healthier urban development involving local government and academics, and evaluate the impact this has had (publication forthcoming). As a public health researcher within the regeneration project team, ALG was able to provide health evidence and data to inform the project. She led HIAs, based on the HUDU framework (NHS London Healthy Urban Development Unit HUDU 2019) for the regeneration framework. This included identifying responsibilities and recommendations for different stakeholders to enable healthy environments. We developed this together and findings and recommendations were incorporated into the regeneration framework document, with the HIA also published alongside the consultation version of the framework in November 2023. Throughout the production of the regeneration framework, we considered the scope of influence for decision-making by key stakeholders, particularly local government, developers and the public, on design decisions for the regeneration area, and actively encouraged conversations about the scope of community influence during early-stage engagement activities, led by local government. This sought to help people to understand what issues local government and local people were able to influence, compared to what developers would have the most power to influence. These discussions, learnings from the HIA process, and other experiences working on the regeneration project, have informed this paper.

The Health Impact Assessment (HIA) and scope of influence

The regeneration project’s HIA was an iterative process. We based it on the HUDU framework (NHS London Healthy Urban Development Unit HUDU 2019), with minor amendments¹ following feedback from local government colleagues across different service areas. The HIA was initially part of the baseline data collection and analysis process of the regeneration project to ensure that relevant issues were considered and additional information sought where needed, such as through early-stage community engagement activities. During development of the regeneration framework, we updated the HIA and findings from it were shared with the design team to inform the design process and decision-making for the framework. The final version of the HIA was published alongside the framework document, highlighting how the framework responds to the findings of the HIA, and outlining expectations from developers and other stakeholders to support healthy place-making. It also included key local relevant planning policies. We included key health messages to clearly communicate why each of the environmental issues related to health and wellbeing, to emphasise their importance and try to influence design proposals. Table 1 outlines the items included under each of the 11 HIA categories with a summary of the scope of influence for decision-making identified for three key stakeholder groups: developers, who bring forward development proposals; local government, who have a role in both facilitating and controlling development (Le Gouais et al. 2023); and the public, who may be affected by the development. Developers have been used as a term combining landowners, developers, architects, planners, consultants and contractors.

Table 1. Summary of scope of influence for health-related issues [based on the HUDU framework (NHS London Healthy Urban Development Unit HUDU 2019)].

HIA category	Stakeholders’ influence on decision-making
	Developers	Local government	The public
1. Housing design and affordability
2. Access to health and social care services and other social infrastructure
3. Access to open space and nature
4. Air quality, noise and neighbourhood amenity
5. Accessibility, active travel and road safety
6. Crime reduction and community safety
7. Access to healthy food
8. Access to work and training
9. Social cohesion and inclusive design
10. Minimising the use of resources
11. Climate change

 = strong influence = moderate influence  = some influence  = minimal influence.

The following sections describe the influence that the three key stakeholder groups have on decisions associated with wider determinants of health issues, for each of the 11 HIA categories.

Housing design and affordability

Local government policy, guidance and/or design codes can supplement national government policies and legislation in England to define expected proportions of accessible and adaptable homes for wheelchair users, design requirements relating to layout and space standards, orientation and glazing (which can affect overheating, ventilation and daylight, as well as requirements for dual aspect apartments), adaptation for climate change and private outdoor spaces, including balconies, as well as construction methods for energy-efficient buildings. Planning policy can also specify housing mix, types, size and tenure, including type and percentage of affordable housing. However, despite policy and local evidenced need, the actual delivery of some policy requirements, including design and affordability, can be the result of negotiation between the developers and the local government, within England’s discretionary planning system. In our experience, development viability is the most significant influencing factor in negotiations. For example, the amount of affordable housing proposed on any individual planning application needs to be weighed up alongside other developer contributions such as physical infrastructure, affordable workspace or green space enhancements. In many cases, developers are not able to deliver against policy requirements for affordable housing (typically about 40%) while making contributions to other infrastructure requirements and achieving expected profit levels. Therefore, while the public may express a need for a particular type of home, such as larger family homes, we found the market may be unable to provide this if smaller apartments, for example, are likely to be more profitable. To overcome this market failure, the public sector may need to provide public subsidy to enable property development to meet local needs.

We identify that local government may also seek to influence developers’ designs in other ways, including early and proactive vision setting and relationship building between local government regeneration teams and developers, to inform development principles and outcomes from an early stage. The regeneration framework we produced for this project was a key tool to facilitate this. However, proactive engagement between local government and developers early in the design process for new development (before planning applications have been developed) is significantly influenced by the resource and capacity of local government.

Access to health and social care services and other social infrastructure

Policies may specify that certain spaces for social infrastructure are provided, such as at ground floor level for apartment buildings, and developers make decisions about the design of these spaces. These may be informed by community views so as to meet the needs of local community groups. However, some social infrastructure services for primary care in England are delivered directly by healthcare providers and neither developer nor local government can control the type of organisation that occupies buildings, including by primary care services because within the UK’s NHS GPs are independent service providers. There is often misunderstanding from the public about who can influence this and our local government teams often have conversations with communities about the provision of services (such as GP surgeries or dental practices) to accommodate new homes and a growing population in their area. In our experience, this is one of the most commonly raised issues during public consultation events despite these services not being delivered by local government. Furthermore, we find that there can be public conflation of different primary care challenges involving either lack of GPs or lack of GP surgery space, which are quite different issues, although local government has little influence over either. Instead, the role of local government may be to communicate growth trajectories for the area to enable primary care providers to plan ahead for increased demand on services, or to facilitate re-location through connecting organisations and service providers with developers who provide spaces. However, it appears that service providers (such as the NHS) may have limited resources to expand service provision.

Access to open space and nature

Planning policies can define protections for open spaces. They can also specify biodiversity requirements and play spaces for new developments. We believe that changes to existing greenspaces should be done with local community engagement to ensure needs and wants are met for different types of user, and to avoid adverse gentrification effects.

Long-term management and maintenance of green spaces, to ensure they continue to evolve and respond to ecological and public needs, can be challenging in England as local government funding cuts have meant many local governments have had to prioritise the delivery of frontline and statutory services over things such as green space management, maintenance and investment. This in part has meant that local governments have increasingly encouraged communities to take on the management and maintenance of green spaces, though there are other reasons for this too, such as building a sense of community pride and ownership and giving communities more say and control over these spaces. This funding context means that local government can require developers to deliver green space enhancements as part of developments, but they may not financially be able to take on the management and maintenance of these spaces, instead requiring developers to do this themselves. This has resulted in green spaces that are semi-private, e.g. for residents of individual residential schemes alone and not for the wider public, which is creating nuances to public access. Guidance can include the need for natural surveillance and active frontages to improve safety and inclusivity for these spaces which will be designed by developers.

Larger greenspace proposals, for bigger public parks, are still likely to be led by local government, which can involve influence by the public, when invited to engage. However, we recognise that the scale of ambition for green space enhancements (and therefore their ability to respond to community, public health and environmental objectives) can be influenced by the consideration of how costly those enhancements will be to maintain.

Air quality, noise and neighbourhood amenity

Building design and location can affect internal air quality and noise. Policies and guidance can outline ways for development to limit exposure, but developers produce designs and design quality can be negotiated on the grounds of viability, as discussed above, and so may not include the desired protections and mitigations.

Where local government controls busy roads adjacent to new development, they may be able to influence traffic flow which affects noise and pollution, although this may require community and political support for change. Wider and more holistic measures can be used to reduce air and noise quality issues, such as investment in active travel infrastructure, electric vehicle charging points, and freight consolidation projects which seek to reduce the amount of ‘last mile’ deliveries and/or facilitate the delivery of these by e-cargo bikes or electrical vehicles, for example.

Accessibility, active travel and road safety

Policies, guidance and design guides can state expectations for infrastructure that supports active travel and reduces car use. Developers’ building designs can affect permeability for active travel routes, car parking, and cycling facilities such as lockers, showers and drying areas. Building design can also influence perceptions of safety for pedestrians, such as sight lines for entrances. Large developments will include transport infrastructure design.

Transport issues can be very emotive and the topic is commonly raised during our public engagement events. The regeneration area we worked with is on the edge of the city centre and well connected to public transport links, and a significant upgrade to the highways and active travel network was built into the vision for the area. Local government officers and elected councillors may support low/no car development to encourage modal shift for active and sustainable travel modes. A challenge, however, is the limited control by local government over the public transport network – in most of England public transport is privately run, with limited influence by local government (although some routes receive public subsidy). Information sharing and partnership working is possible, but in our experience, transport issues can involve misunderstandings and tensions between local government and the public as local people often ask about plans to upgrade the public transport network to accommodate growth, despite local government’s lack of influence on this.

Crime reduction and community safety

Local communities should be engaged with to understand local concerns about crime and safety, which can be used to improve designs. Community engagement can also increase a sense of ownership and empowerment.

Developers’ designs will influence safety, such as through natural surveillance of streets and public spaces, as well as lighting. If local government is able to take a strategic approach to urban development, such as through developing a regeneration framework to establish design and development principles for an area rooted in its local context, opportunities and challenges, we believe it is possible for them to champion things such as natural surveillance, including through active ground floor uses, from the outset. Therefore, safety should be increased through designing for a vibrant area, rather than relying on developers engaging with police to comply with ‘Secured by Design’ (UK Police Service 2024) (although this has been criticised for not following good place-making principles (Harper 2022)) and measures such as inclusion of CCTV or police on the streets. A local government-led strategic approach can also be designed to try to maximise pathways to training and employment for local communities which can remove barriers to employment, improve socio-economic outlook, reduce inequalities and crime and improve quality of life and health and wellbeing. This is a long-term approach which may require resources from local government and proactive working with landowners, communities and wider stakeholders. We highlight that the ability of local government to take this holistic, proactive and long-term approach is subject to its resource and capacity to do so, and there is much variation between local governments in England on this, with many relying only on policies and responding to individual planning applications ad hoc. We believe that this can result in less benefit for local communities because they are not rooted in a vision for the wider area based on their needs and potential.

Access to healthy food

Local food growing spaces can be incorporated in new or existing greenspaces within developments, particularly if there is community support. Policies can define requirements for allotment spaces and public open spaces could be used for fruit and vegetable markets, again where there is local support. However, in our experience, limited local government budgets may make these more challenging because of maintenance costs and there are examples where allotment rents have significantly increased which may impact on accessibility for low-income residents (Seabrook 2024).

While buildings can be designed for food shops by developers, we identify that there is limited ability to specify particular food outlets for new development, which are affected by market conditions. However, policies can restrict certain uses, such as to avoid over-concentration of hot food takeaways (Keeble et al. 2019).

Access to work and training

Employment spaces can be provided by developers. In our experience, engagement with local groups can influence the types of spaces to be provided, or be influenced by the market. Developers may be required to work with local government to maximise opportunities for local employment, skills and training. Local government can influence this by taking a strategic approach to ensure the economy grows in a way that brings benefits to local people and can reduce inequality. For example, our regeneration area will have an Inclusive Economy Strategy and Workplace Design Guidance. These strategic approaches need tailoring to the local context and local government likely needs to play a direct service delivery role to ensure benefits are achieved, such as skills training and English language training. While space can be planned for childcare facilities by developers, to increase access to employment, we recognise that these may rely on independent service providers, otherwise the public sector may need to facilitate childcare provision. Low-cost workspaces may also need public subsidies.

Policies can be designed to protect existing businesses so that new residential development does not negatively impact on their viability (e.g. requirements for sound insulation of new homes to protect night-time venues from noise complaints).

Social cohesion and inclusive design

Developers can be encouraged to engage with local people to ensure local needs are met, and consultation requirements can be regulated; however, the extent of public influence may be decided by developers. Meaningful community co-design and involvement in the design and management of public spaces (indoor and outdoor) that genuinely facilitates community cohesion and social integration is a very involved process and not commonplace due to budget constraints (although there are good examples available e.g. (Greater London Authority 2020)). Our experience shows that local government can liaise between community groups and developers to facilitate appropriate accommodation in new development, although success is not guaranteed. The public may have greatest opportunity to influence public realm, highways, green and open spaces and community spaces, when invited to do so. We highlight that local government can support wider place-making initiatives, such as strategies for public arts and cultural programmes which enhance local character and distinctiveness and support community cohesion and celebrate diversity, however we caution that funding for these initiatives can be de-prioritised against frontline services and statutory services that local government performs in England. Policies may affect provision of types of homes, including intergenerational living, but we know that developer decisions will also be influenced by market conditions.

Minimising the use of resources

Strategic planning policies produced by local governments in England should identify appropriate sites for development, which can affect whether development is possible on green or brownfield sites. While these should be informed by environmental and public health objectives, market conditions will affect developer plans and the type of development achieved. Policies and guidance can also define appropriate densities and sustainable design and construction requirements, but developers determine design details. We see many competing issues, with pressure on local government to enable delivery of new homes, therefore decision-makers must balance competing demands and trade-offs.

Local government can also seek to influence minimising use of resources to the public and businesses, however this may only be through providing advice.

Climate change

Planning policies can include requirements for energy efficiency of buildings, renewable energy requirements, designs to avoid overheating and other adaptations for a changing climate, including green infrastructure provision to reduce heat island effects and reduce flood risk (e.g. sustainable drainage). An example of local government further influencing uptake of these measures for new development is requiring all new development in regeneration areas to connect to low carbon district heating networks. However, we recognise that it is up to developers to provide details about designs of buildings and public realm on their sites. Developers can be required to advise occupiers on effective use of renewables, such as heat pumps.

Comparing scope of influence across stakeholders

We outlined above how the three key stakeholder groups (developers, local government, and the public) can each have differing influence in decision-making for environments associated with wider determinants of health. This is important to understand for public health academics and practitioners so that they can target interventions and health evidence more effectively.

Developer influence

Developers have the most control over development designs, particularly for building design, within the local and national policy and regulatory context. They expect to make profit from development and negotiations will occur between developer and local government where trade-offs are considered, particularly in relation to financial viability. This is likely to be highly influential in the creation of healthy environments (Pineo and Moore 2022).

In our experience, the areas where developers appear to have less influence are health and social infrastructure and access to healthy food since these require third parties to be involved in providing services. However, some developers may choose to be more involved in curation and long-term management, in which case they may influence the type of tenants who take on leases. Conversely, developers may choose to sell on spaces and have no involvement from that point on, therefore they will not seek to control social infrastructure provision.

Local government influence

Urban development decisions are made within the local and national policy and legislative context. At local government level in England, this includes the local plan, which is a set of urban development policies that includes issues such as potential sites for development, locations for protected greenspaces and sustainability requirements, however, there are rules about the policies that can be included within the local plan, which has an emphasis on delivery of housing numbers (Department for Levelling Up Housing and Communities 2024). Other local policies, guidance and issues considered as material considerations in deciding planning application decisions (such as the regeneration framework that we worked on) can also be used by local government to influence developer designs as they will approve or reject planning applications, therefore granting some influence to local government in development designs. However, in our experience, the multitude of issues and quality requirements needed to genuinely meet health, environmental, and community needs is often beyond what is financially viable for development to be delivered. Therefore, to avoid stalemate and deliver urban development compromise is needed. Local government is tasked to both promote, and control development: they need to promote it in order to increase housing supply, with annual house building targets for each local government area in England, while also aspiring to provide benefit for local residents. Increasing housing supply is considered by many as a way to tackle the ‘housing crisis’, which is a complex issue that has seen UK homes prices increase in recent years. Therefore, while local government can have a lot of influence in creating healthy urban development, it appears that continued lack of investment in local government in the UK means they are not able to make the most of this influence and may have to prioritise spending on other things, including on statutory services such as adult social care. This results in a necessity to de-prioritise some elements of control, potentially passing influence over to developers, who likely prioritise profit over social benefit.

Public influence

Early engagement with different types of community is recognised as important to improve urban development designs, so that they can meet the needs of local people, without having negative impacts. This is particularly relevant for tackling health inequalities since the built environment can influence risk of diseases and research has explored how to conduct meaningful and inclusive engagement with affected publics e.g (Brownill and Parker 2010). However, it should be recognised that there can be differing views across communities, and the needs and wants of existing and new residents may also differ (with engagement of future residents difficult to achieve). Despite these challenges, it is important to understand the extent that the public are able to influence urban development decision-making so that efforts to engage them are meaningful and expectations can be managed. In our experience, local government staff genuinely seek to create opportunities for local communities to be involved in regeneration projects, particularly to help understand the local context and needs of the community, as well as provide feedback on proposals. In our project there was extensive early-stage community involvement seeking to reach a wide range of local community members. This involved multiple public events, walking tours, an Artist-in-Residence, and targeted engagement sessions with key groups, such as a local mosque, women’s groups, and young people via youth organisations and a local primary school, as well as bespoke sessions for local businesses.

In one engagement event we included an activity about scope of influence, to help people understand what issues they, and local government, could influence for the project. It involved a series of cards covering various place-making considerations, including many issues relevant to the wider determinants of health, such as community and cultural assets; climate emergency response; design and management of public space; street and highways design; movement and connection; building types and mixes; flood risk management; land use; and amount of affordable housing. People were asked to place these cards under one of three headings: ‘Parts of the framework which the community will be invited to develop and deliver solutions with us’; ‘Parts of the framework which the community will help to shape alongside other factors’; ‘Parts of the framework which the community will be informed about but have little influence over’. Local government officers used this activity to help explain the complexities of urban development decision-making and manage expectations since the scope of influence for the public is quite limited across the HIA categories, as described above and in Table 1.

Despite legislative processes whereby the public must be given opportunity to comment on planning applications during statutory consultation periods, their comments may hold little weight where other planning issues dominate, including financial viability. The HIA categories where the public are likely to have the most influence are those that involve community engagement. This may occur in contexts where decisions to conduct co-design have already been made, and then, when invited, the public can contribute. There can also be more community influence where community management is sought, such as for green spaces. The English planning system is very complicated and technical, which can make it difficult for lay people to understand. Community groups may only engage with processes when they object to designs; however, at that late stage, there are limited mechanisms to influence decisions. This can result in tensions and lack of trust in local government. We suggest that better understanding of the system, and where efforts could be focused for most impact, could support healthier place-making, rather than wasted efforts and misplaced anger.

Recommendations for healthier urban development

Using Health Impact Assessment approaches

We have described how different stakeholders can influence decisions about urban development, based on consideration of 11 categories of a HIA that relates to wider determinants of health. In the final HIA that we published we included specific recommendations for developers and other stakeholders for each of these categories, and also included key health messaging related to these within the framework, to try to influence developers to produce designs that would support good health and wellbeing. Although we are still to evaluate the impact of the health messaging in the framework, we have received positive feedback from local government stakeholders about the approach and therefore suggest that following similar processes in other projects could bring benefits, particularly when HIAs are conducted early, iteratively and collaboratively.

Understanding stakeholder influence to target interventions

We hope that by highlighting the multiple aspects of healthy urban development and the scope of influence of different stakeholders it can encourage public health researchers to consider how their research findings and recommendations can be considered within a wider system, acknowledging the trade-offs that may be needed in urban development decision-making, and differing power of various actors. This can help to plan and conduct impactful public health interventions. For academics and public health practitioners working with urban development professionals increasing understanding will help stakeholders to appreciate each others’ worlds, so they can effectively collaborate as equal partners. It can also help public health stakeholders to be more aware of the stakeholders with whom they should engage. This may help to ensure that: i) co-designed projects are feasible; ii) expectations are managed with the public to build trust and avoid frustrations; iii) avoid wasted resources; and iv) identify where to focus efforts to change the system so that public interests may become more influential in future to improve health and tackle health inequalities.

We have highlighted some issues where public misunderstanding of responsibility can result in reduced trust between local government and communities. One example was around public transport, which local government often has limited control over. Another was for primary care provision in relation to new urban development, which also does not fall on local government, despite this being a commonly held view. However, greater collaboration between local government and service providers could help to ensure service provision matches long-term growth trajectories, and a more joined-up approach to funding this. Shining a light on the limited influence of local people in decision-making may help to highlight the need for better policies that reflect the interests of local people, therefore reducing negative impacts of limited public influence, after all decisions made today will affect people for generations to come. We need to plan for future generations, not simply respond to the powerful voices of today, to support healthier environments and tackle health inequalities.

An holistic approach to public funding could also be explored to tackle the problem that local government is unable to make full use of its opportunities to influence urban development due to budgetary pressures. This could recognise how healthy placemaking could bring long-term reductions in the demand and need for healthcare service provision by enabling healthier lifestyles. This could see funding which would typically be allocated for the NHS be redirected to local government, for example, to deliver more preventative approaches to health and wellbeing through the creation of healthier urban environments. It would support more strategic approaches by local government to holistically maximise public benefits from urban development, rather than being reactionary and achieving only minimum requirements. We have highlighted how developers in the existing system hold large amounts of power. This can suggest that the system could benefit from shifts in power dynamics so that public-interest organisations may be more influential. For example, through changes to legislation and local and national policies.

In the existing system developers could be the focus for more public health interventions, since they can make many environmental change decisions that influence population health and wellbeing outcomes. This can raise questions for public health researchers about the appropriate level of engagement with commercial interests. Some public health researchers limit engagement with commercial actors, such as from alcohol and tobacco industries, because of the potential negative impacts of close association with these groups, having historically sought to undermine research evidence of the negative health impacts of their industries (Brandt 2012, McCambridge and Mialon 2018, Maani et al. 2022). This raises questions around the level of engagement with private sector urban development actors in research to avoid potential bias from commercial interests.

During ALG’s time as an embedded researcher she has helped to identify opportunities for public health interventions to support creation of healthier environments. This includes developing and trialling a modelling tool to estimate the health economic impacts of changes to the environment, which was used to influence decision-making (publication forthcoming); conducting a review of local planning policies to support healthier local plans (Callway et al. 2023); supporting public engagement activities, including creation of short videos; and the HIA work described in this article. The local government has been very receptive to collaboratively developing, conducting and evaluating interventions for healthier urban development and there is broad scope for similar academic-practitioner endeavours for researchers working with local government.

Learning from embedded research

ALG’s experience of embedded research has helped her to understand complex systems and bridge between academia and practice. Working on a multi-disciplinary research project, it is clear that many academics, as well as public health practitioners, do not have a good understanding of how urban development decisions are made, as it is a complex system involving many stakeholders with differing levels of influence and differing interests and priorities. By sharing learning, we hope to lift the lid on the ‘black box’ of decision-making and identify opportunities for intervention development to support healthier place-making.

ALG has been able to bridge not only between research and practice, but also between public health and urban development. These are too often siloed, not least because of limited resources that could enable cross-disciplinary learning. This embedded research role has provided opportunity to trial and test new approaches, and share learning to support healthier place-making more widely.

This embedded research approach could be used more widely to understand and tackle other complex public health issues in towns and cities. We believe it can be an effective way to improve understanding across disciplines and contexts, including to support the development of collaborative interventions with practitioners.

Ethical approval

Ethical approval for the TRUUD project was obtained by University of Bristol’s Faculty of Health Sciences Research Ethics Committee (REF: 94162).

Acknowledgements

Many thanks to all local government colleagues, developers and members of the public involved in the regeneration project described in this article. Thanks also for the support of TRUUD project colleagues, especially Judi Kidger for her feedback on this manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

ALG’s role was supported by the UK Prevention Research Partnership (award reference: MR/S037586/1), which is funded by the British Heart Foundation, Cancer Research UK, Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Health and Social Care Research and Development Division (Welsh Government), Medical Research Council, National Institute for Health Research, Natural Environment Research Council, Public Health Agency (Northern Ireland), The Health Foundation and Wellcome.

Notes on contributors

Anna Le Gouais

Anna Le Gouais is a Research Fellow at University of Bristol - Population Health Sciences, Bristol Medical School. She is part of the TRUUD (‘Tackling Root causes Upstream of Unhealthy Urban Development’) project that seeks to influence policy and practice for healthier urban development. She is also currently a Researcher-in-Residence in Bristol City Council, where she works with Regeneration, Planning Policy and Public Health teams.

Marc Cooper

Marc Cooper is a Regeneration Project Manager at Bristol City Council with particular interest in climate change adaptation, healthy place-making and community development.

Notes

1. Changes from HUDU included moving ‘Maintaining or enhancing biodiversity’ from the climate change category to the open space and nature category; adding ‘energy efficiency’ in the climate change category; and adding ‘road safety’ in the active travel category title to highlight this issue.