“Healthy Settings”…reinvigorating the public health debate

Before we talk about hospitals, we must define their role against a whole range of clinical health and social care setting interventions. The concept of healthy setting is introduced here as a means of defining the most appropriate setting (where hospitals are just one). Healthy settings is a concept that forms a principle driver behind Healthy Infrastructure. Specifically, the determination of the very best setting for health and social care prior to a commitment to invest. Public health is concerned with preventing and promoting healthy choices and reducing public and patient harms and threats. There is expanding evidence that built environments in some settings (such as housing and recreation facilities) have an impact on individual health, risk and behaviour. More recently, this discussion has expanded to include population inequality, poverty, and education. Healthcare infrastructures themselves and their contributions to clinical services, systems and population health status are not fully understood.

According to Dooris (2004) the theory and practice of delivering value across health settings (from public health across the whole system from health promoting hospitals to healthy cities, neighbourhoods, schools, workplaces, prisons and universities) is limited. The ideal is of course the holistic, and integrated contribution of the environment, economic and social wellbeing, regionally, nationally and globally. Dooris (2004) raised the problem in using the term “setting” to define scales beyond organisations, and where organisations such as hospitals are such diverse, formalised and structured multi-site institutions, while homes and communities are far more unsystematic and which conform to fewer rules and cultural baselines.

Health is defined by both static physical settings and dynamic social and technological systems that encourage individual health-related behaviour Dooris identifies the need to “…acknowledge the diversity of motivations that may drive healthy settings work” whether these are moral or ethical values. The problem however is according to him the coordinating between complex perspectives, underpinned by values, to “wrestle with conflicting interests and to know when to compromise …”.

Public health has contributed significantly to the method and evidence of problem analysis and made significant strides to investigate the causes and effects of various health interventions. Although, even though capital investment in built infrastructure is the third largest capital investment in the NHS behind procurement and staff, there has been relatively little research evidence to support capital asset decision making (objective formulation, priority setting, alternatives description, option evaluation, decision and optimization). Sharp (2006) strongly debates the changing shape of hospital building up until 2006. Sharp raises the threat faced by “cottage hospitals”, the move towards large scale urban centres, the long-term potential sacrifices that may be seen as a direct consequence of private finance and the dilemma’s faced in arriving at an affordable infrastructure construction programme. Many of the concerns raised by Sharp (2006) are only now being debated, however the complexity of the dilemma faced by many policy, clinical and business decision makers requires further exploration. Furthermore, the case for a joined up approach where public health professional and clinical researchers are working alongside capital programme and project planners, designers and researchers, is critical for effective spending. Service review and estates reconfiguration programmes maybe among the most important to consult on, as countywide Master Plans affect large populations, and inequalities can be widespread.

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