The health challenges that the UK faces and health beyond the high street – Dr Ruth Hall, NRW

Dr Ruth Hall, Board member, NRW and former Chief Medical Officer for Wales delivered  a presentation at the conference on the health challenges that the UK faces and health beyond the high street.

Dr Ruth HallRuth’s presentation looked at UK health headlines, talked about rural health (well beyond the High Street), about the evidence base, and the special offer of Areas of Outstanding Natural Beauty.
The video of Ruth’s presentation can be viewed here.
Summary notes from her presentation are below to accompany the presentation slides.

During the presentation, Ruth shared that the UK home countries now have different ways of working and we have a great opportunity for sharing experiences, and that she would be including some Welsh perspectives.

Previous generations took nature’s benefits as a given; they knew intuitively natural environment was good for you. Most of us also believe this and we have evidence to confirm it.

But we live in a world with many other attractive, less-healthy options; with competing interests and conflicting values. We have to hold on to what nature has to offer. Nature is a shared asset – combined effort is needed to realise and sustain its benefits.

So can we make the case more convincingly? Can we do more to optimise nature’s amazing health and well-being offer; if so, what and how?

Health in the UK
The health challenges we face in the UK are a familiar story.

In a nutshell: life expectancy has increased, more for men than women. Many more people live to be 100 – the Queen now has 14 cards a day to write. However sickness levels have risen. The strong association of poor health with poverty and deprivation is still there; in some places health inequalities have become more marked even between neighbouring localities.

Over recent years, the pattern of illnesses has changed, due partly to the ‘ageing’ population; and to improvements in medical practice. People tend to be healthier until later in their lives, when they may face several different conditions at the same time. Older people experience a ‘revolving door’, in and out of hospital in their final years.

Illnesses due to lack of exercise, inappropriate diet and obesity are growing rapidly. They affect us younger and now account for much of the illness across the UK. The resulting range of health conditions is huge: diabetes, heart disease, strokes, many cancers, depression, bone and muscle disorders, pregnancy risks and more.

And one thing leads to another: poor mental health is not simply a mental health problem: it may mean poor diet; lower immunity to infections; alcohol dependency; and more; and each of these has other potentially serious consequences.

The great tragedy is that much of the burden is needless; it’s preventable; while it persists it has implications for us, our children, and theirs.

Social and life style factors
Social factors strongly influence how we live, the choices we make and ability to change our behaviours: this can be really difficult – smoking and seat belts needed legislation to generate sufficient momentum for change.

Changes in everyday life can be subtle – internet shopping with home delivery has lots of advantages, but may also help explain increasing alcohol consumption by older people. We need to watch out for unintended consequences of new opportunities.

My mother brought the weekly shopping home on her bicycle – she had the exercise and we probably ate less. Now, outdoor activity levels continue to fall despite all our efforts, while obesity rates grow and childhood obesity is a serious concern – a quarter of reception-class children (and over a third of adults) overweight or obese.

Air pollution is the largest environmental health risk – traffic is a significant contributor. In England, resulting adult male deaths (25,000 annually) range from 2.5% in rural areas to 8.8% in the most polluted London boroughs. This costs the UK around £16bn a year.

We are major consumers of medicines – Britain takes 6,300 tons of paracetamol each year when other drugs may be better and it’s no use for chronic pain. Drugs help symptoms; they may have no impact on the cause. Anti-depressants are taken in huge quantities by those who suffer most, the poor in disadvantaged communities. This just doesn’t make sense.

Illnesses have profound impacts personally and on families, friends and future generations. Overall, the costs are massive. Prevention is far and away the best economic solution. Prevention makes sense, from every point of view.

Global considerations
The UK doesn’t exist in isolation: global trends have implications for our health personally, as well as nationally.

Science brings mixed blessings: huge possibilities for medicine, through genomics, telemedicine, robotics, new drugs; however new technologies also bring uncertainties – what will driverless cars mean for health?

Viruses enjoy free international travel. They adapt rapidly and unpredictably, hence new infections – remember SARS, swine flu, avian flu, Asian flu even? Antibiotic resistance is now a serious global concern. CMO England recently warned “the golden age for antibiotics, taken for granted for more than 50 years, has ended” and infection-related deaths could return to pre-antibiotic levels.

Climate change may alter the distribution and risks of infectious diseases. In fact climate change is likely to have a variety of health impacts – some harmful, others beneficial. We can expect more frequent extreme weather events, like flooding, with risks to physical and mental health. As the UK population ages, more people will be vulnerable to hot weather. However milder winters could mean less flu, falls and fractures.

The more we understand the impacts, the better prepared we can be. People will need to adapt and many initiatives are already addressing this. ‘Working with Climate Change’ is an example of advice one AONB partnership has already produced.

Rural health
Statistics do suggest rural health is better: life expectancy slightly longer with less long-term illness. Rural people are more active and rates of obesity tend to be lower. There are occupational hazards: farmers’ suicide rates are higher and all outdoor workers have raised risk of sunlight-induced skin cancers. Accidents happen with machinery and on rural roads.

Rural GPs say elderly people can appear healthy when in reality they depend on major amounts of care and support. Culture and language affect people’s attitudes to accessing care – screening and immunisation uptake is lower. However, there are lots of fit older people, keen to stay active and a valuable potential resource for communities.

Local people themselves complain of loneliness: families move away; parents have little spare time and transport difficulties. Loneliness and depression have a wide range of potential consequences for health and well-being. The sense of ‘place’ is an important part of many people’s identity, especially in relatively stable rural populations.

Everyone agrees while Health and Social Care is important, transport, housing and community infrastructure are fundamental for healthy communities, for their cohesiveness, self-sufficiency and resilience. Local Authorities are pivotal in this.

Transport is a major determinant of health outcomes. The issue in rural areas is less about access to green space, more about access to services. Many older residents are enthusiastic about internet-based services including tele-medicine. Technology hubs based in communities which integrate access to services are a great idea.

Many rural houses are unsuitable structurally for old, frail or disabled people. A terraced cottage with narrow stairs can’t take a stair lift or wheelchair. Designers and planners need to address this urgently, given current demographic trends.

Whole-community well-being is underpinned by the local economy, employment and education; and by creative partnership working. Community infrastructure in most places is not fit for purpose: we need freedom to experiment with different approaches – social enterprises such as this one, set up with AONB Partnership, Local Authority and National Park help, resourced by voluntary as well as paid commitment.

The evidence base
There’s lots of evidence about the importance of green environment for health, less about the mechanisms producing these effects; we don’t have a co-ordinated view of what works best to optimise outcomes.

Benefits from nature are seen in disease prevention, treatment, rehabilitation and long term care; in physical, mental and social well-being. People recognise the value. In rating daily activities, time in nature tops the lot (White, Dolan).

How much and how green does the environment have to be? Some evidence supports a ‘dose-response’ relationship; in essence, the more green space people live near to, the better their life expectancy. Bio-diverse environments rich in wildlife improve health outcomes: whether fen, forest or farmland have different effects isn’t clear.

Natural well-being mechanisms
We are starting to understand more about natural well-being mechanisms.

Direct contact with outdoor micro-organisms is important for children to develop healthy immune systems (implications for asthma). Making mud pies may be good for you. This is an overlooked ecosystem service.

Humans need darkness as well as daylight; melatonin and cortisol are more complex than we realised. Herefordshire gets dark but Wembley is light enough at night to be visible from space. Helping children sleep without artificial light has a strong health rationale.

Urban noise is stressful – rural areas aren’t always quiet, but likelihood of finding tranquillity is higher. Many people value the sense of spiritual well-being that comes from quietness.

Understanding more about the deep emotional connection humans have with land and landscape might help us communicate its importance better. This approach underpinned the National Trust COAST campaign, using creative arts to involve people, especially children. If you have rewarding experience of nature as a child you are more likely to value nature in adult life.

Links between aesthetics and health are proven, although it’s not clear what mediates the effects. A beautiful view through a window improves convalescent progress: would a picture on the wall do as well; if not, why not?

In building the evidence, we need to explore more pro-actively ‘what works’. Promoting outdoor physical activity has proven health benefits; while combining environmental with social action increases activity levels.

Many different approaches have been tried and formally or informally evaluated – Natural Health Services, Green Prescribing, Care Farming, Green and Blue Gyms, Wales Coastal Path. We need a national systematic register of these.

AONBs’ special offer
AONBs and National Parks have a disproportionate richness of attributes to bring to health. They underpin prevention; support care and recovery. They are there for everyone; and will benefit the neediest most. Children are important – healthy behaviours need encouraging from childhood. Many Partnerships are actively involved in improving opportunities for outdoor recreation and access.

However, getting people outside is not just about access, it’s often also an emotional challenge. The practical experience of ‘community engagement’ AONB Partnerships now have is a big asset – others including the NHS, need help. Working across sectors isn’t easy: different languages and systems of resourcing and governance that don’t readily fit.

New industries are emerging within the rural economy linking high-quality landscapes with recreation. The ‘local’ focus is important for small rural businesses. Partnerships already support local fresh-food producers and wider opportunities will present.

AONBs are inspiring landscapes. The best evidence of benefits for people is the testimony of users. Many offer space, for reflection and creativity as well as adventure. This is no surprise: the landscape appreciation movement originally promoted the value of landscape beauty calling it ‘sublime’.


For health and well-being, our identity with land and landscape is crucial; we are part of it, not by-standers.

In Wales we are now legally required to manage our natural resources in an integrated way – for people, economy and environment. Good landscape management can fulfil all these needs, bringing better health outcomes in the process. Areas of natural beauty are at the heart of this.

Can we make the case more convincingly? We can; we have ample evidence.

Can we do more to optimise nature’s offer? Yes, much more. We need to get on with it.

Everyday life is changing rapidly; new technologies are set to take us potentially somewhere quite different. We mustn’t lose sight of the fundamental fact that nature provides what we need, in every sense, to optimise our health and happiness.

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