3.4 Design, Build, Operate: what are the health and equity impacts?

How capital investment projects can address wider equalities and health impacts  

Spending on transport, education, social justice, energy and the environment, and economic development may not be 'health spend', but spending in all of these areas impact the health of a nation.

Most public spending impacts health and inequalities either directly or indirectly. Economic development is an area where government, businesses, public sector bodies and community organisations can work in partnership to lessen inequalities in the wider determinants of health. The Capital Investment Health Impact Assessment (CHIA) resources support project teams in thinking about the wider determinants of health when planning capital investment projects. Health inequalities are closely linked with the social and economic features of society; reducing health inequalities is not solely a health policy matter, but requires actions in all areas.

The Health in All Policies approach emphasises the consequences of public policies on determinants of health and aims to create the social, physical and economic environment in which people can have the best, and equitable, health outcomes. The population's health and wellbeing depends not just on being able to access NHS services, but on the economic, environmental, and social conditions in which people live, including financial security, active community participation, feeling safe, climate resilience and access to cultural and green spaces.

Economic development provides a pathway to improve the resources and assets of communities beyond a focus on gross domestic product (GDP), or its component gross value added (GVA). The way in which economic development is achieved is key to contributing to an inclusive economy that benefits the health and wellbeing of the entire population. Capital investment programmes are already working to embed practices such as sustainable and progressive procurement and community benefits which can positively impact health determinants, such as employment opportunities. Progressive procurement refers to practices that aim to create positive social impacts through the procurement of goods and services, for example sourcing ingredients or materials locally or making contract sizes manageable for smaller businesses. These practices can also form community benefits; however, community benefits encompass a wide variety of activities that will specifically benefit a local area.

A wider and consistent approach to embedding health and equity considerations in investment decisions is needed. The CHIA is a process through which all proposed projects can do this.The CHIA process focuses on the wider determinants of health, complementing existing processes in business case development which consider economic and environmental dimensions.

The CHIA process facilitates teams to ask questions such as:

-          Will the proposal bring the changes needed in this area?
-          Who will benefit and how?
-          Will anyone be excluded?
-          Could this project make existing inequalities worse, or create new ones?
-          What steps can be taken to reduce existing inequalities and avoid new ones?
-          How will this project contribute to community wealth building?

The CHIA does not seek to duplicate the extensive national and regional guidance on progressive procurement. Rather, it aims to highlight that pushing for more progressive procurement aimed at reducing economic inequalities will also contribute to tackling health inequalities.

The following sections link the three core stages of infrastructure projects (design, build, operate) to the ways in which different approaches to infrastructure builds can positively influence health and equity.

Design: Inclusive growth, wellbeing economy and community wealth building approaches to infrastructure development

This section shows how decisions in the design phase of a capital project might influence wider health and equalities impacts. The examples given may not be exclusive to the design phase of project development as many impacts occur throughout the project lifecycle.

Scotland's national inclusive growth agenda, aims to achieve more equitable economic growth

• It aims to do this through promoting good quality jobs, equity in opportunities, and distributing returns from economic growth in a way that reduces the wider inequalities that lead to poorer health outcomes.
• As outlined in 3.1, national funding programmes and strategies relevant to capital investment spend including NSET, NPF4 and Fair Work First are designed to move Scotland towards inclusive economic growth using elements of a wellbeing economy such as community wealth building.

Inclusive growth in the Glasgow City Region City Deal

• The Glasgow City Region City Deal has a set of guidelines and a points system for suppliers of goods and services to support inclusive growth through sustainable procurement, fair work practices, and community benefits.
• Embedding inclusive growth principles in City Deal capital investment proposals ensures they will support national and regional priorities in improving health and equity across the City Region.
• The CHIA process is designed to support project development, providing a process for consideration of whether projects are as equitable and inclusive as possible so that reductions in health inequalities can be achieved.

Maximising health and equity in the design stage

• The design stage is an ideal time to consider the impacts of a proposal as teams have the greatest scope to maximise the positive health and equity impacts of a development, while minimising negative outcomes.
• Thinking about health and equity at the design phase of the project means that plans can be developed and budgeted (where necessary) from the outset.
• Choices made at the design stage influence how communities are impacted by a development in terms of health and equity, for example:
  • Ensuring the impact of noise and light pollution is minimised in new housing developments.
  • Creating segregated pedestrian and cycling routes to minimise risk of injury where developments are close to busy roads.
  • Bringing vacant or derelict land back into use
  • Improving/enhancing nearby greenspace and community meeting spaces within the design
  • Ensuring housing mix in developments i.e., social and affordable housing, in a development as well as accessibility to transport links.
• Capital projects can also support existing local businesses and groups, for example:
  • dedicating resources where appropriate, such as meeting and activity spaces
  • supporting business volunteering programmes
  • providing mentoring to independent businesses, social enterprises and community groups
  • investing in the future of a region through supporting all-ages education - this could be through funding technology updates, teaching/instructor posts, or partnering with colleges to offer placements and jobs.

As needs will vary widely, it is valuable to involve community members at an early stage of project development so that investment benefits can be realised. Supporting community wealth building will enhance the region over and above the economic growth achieved through capital investment alone.

Build: Community wealth building through progressive procurement  

This section focuses specifically on progressive procurement as one element of a community wealth building approach. It shows how progressive procurement decisions in the build phase of a capital project can lead to wider health and equalities impacts. The examples given may not be exclusive to the build phase of project development as many impacts occur throughout the project lifecycle.

Procurement decisions can have significant consequences for the structure of the economy and the labour market, and therefore for economic inequalities.

• Public sector spending on infrastructure in Scotland averages £4 billion per year meaning procurement is a crucial way to address economic inequalities due to the length and breadth of supply chains.
• By ensuring fair and ethical practices are in place at each stage, organisations can minimise the risk that infrastructure developments could inadvertently contribute to unethical practices that exacerbate inequalities.
• Procurement strategies can be an effective way to tackle economic and health inequalities using funding that has been allocated for capital infrastructure projects.

Sustainable procurement aligns with inclusive growth

• Glasgow City Region's Sustainable Procurement Strategy and City Deal Sustainable Procurement Supplier's Guide make clear the intention that City Deal projects deliver improved social, environmental and economic wellbeing for residents.
• The Centre for Local Economic Strategies has identified key areas to advance this agenda across the region, central to which was the need for resourcing for the role of community benefits officers.
• The evidence is clear that addressing health inequalities requires action to reduce economic inequalities. Those actions which promote inclusion economically (e.g. fair pay and promoting local spend) are particularly important.
• Project teams should consider how to support community wealth building further through financial investment in communities beyond the actual build itself. 

In a report on inclusive economies, Public Health England (2021) identified a range of actions that can achieve social and economic benefit from economic development, many of which are relevant to the build stage of project development. This includes

• actions such as securing opportunities for the voluntary sector, communities and social enterprises
• offering spaces for community use
• ensuring spend is focused on local suppliers
• offering apprenticeships
• reducing energy consumption and emissions
• reducing waste.

Decisions made at the build stage of a project can influence whether the local economy around the project is inclusive and more equitable. This can help in tackling health inequalities in the longer term.

Operate: Community wealth building through fair work and socially productive use of land and assets

This section focuses on how fair work and land and asset use principles applied to the operation phase of an infrastructure project has positive health and equalities impacts in the longer term. The examples given may not be exclusive to the operate phase of project development as many impacts occur throughout the project lifecycle.

Fair Work

• Fair work is one of the main ways through which community wealth building can be championed in the operational phase.
• All recipients of  public sector contracts in Scotland must pay at least the real Living Wage to directly employed and sub-contracted staff, but employers can and should go further in fully adopting the Fair Work First principles.
• Many people, and disproportionately women in areas of high deprivation, are excluded from work due to caring responsibilities. Flexible working arrangements can support those previously excluded from the workforce to gain employment, reducing risk of poverty and the gender pay gap.
• Eliminating inappropriate use of zero hour contracts can also help to tackle the ethnicity pay gap given that those from minority ethnicities in the UK are most likely to be in zero hour contracts.

Land and building assets

• Developments can contribute to inclusive economic development once operational through use of the land or building asset for community benefit. This will depend on the type of development, of course, with some lending themselves to community use more easily than others.
• Where the land or assets cannot directly benefit communities, could profit generated be redistributed within the community to develop other assets? For example, sporting facilities, community spaces for work and social activity, regeneration of disused spaces for community needs are some ways in which infrastructure investment can build additional community wealth. The examples given could benefit both the physical and mental health of groups within a community.
• Project teams could consider how to include community spaces within a development. These spaces would likely be decided in the design phase, but it is important to consider how they will be maintained and operated following the build and handover. For example, if a community garden is included in a development, provisions may need to be made to transfer it to community ownership in the longer term.