Determinants Health In All Policies Prevention Public Health

parks and bike lanes vs cath labs and cancer drugs.  The value of different forms of investment

Parks are a social good. Almost everyone accepts that. Yet they are under pressure. The Heritage Lottery Fund tell us this annually. NESTA and many others are rethinking parks. 38 Degrees write to me about three times a week asking me to sign petitions to protect parks. Id expect millions have done so

We don’t cycle enough. If we cycled more we’d be fitter and there would be less air pollution. I could say the same about walking, and maybe that’s a more powerful example. But stick with cycling for now. There are many reasons why we don’t cycle – one of which is lack of infrastructure to do so safely.

We under invest in cycle lanes. Also the revenue budget for parks is under threat everywhere, this is a part of the shrinking of LA budgets. That’s well documented. Also I’d be no doubt that property developers everywhere are eyeing up all that juicy land to build houses in. The scale and size of the challenge is pretty similar everywhere I’m sure.

Meanwhile in another part of the public sector the world is full of low value investments. Let me pick on the Cancer Drug Fund, you know drugs that NICE have said are not cost effective for taxpayers investment, given the cost and return (mostly expressed on days to months of life not years). Yet we continue to spend hundereds of millions of pounds here.

Don’t just think Im picking on cancer drugs and the CDF. Its emblematic yes, but there are plenty of others.

Here are one or two thoughts on value, cost and return on investment across sectors


I have seen – and actively contributed to – many attempts to quantify the social return on investment of parks and other social goods. Obviously there are many issues in the conceptualisation of cost vs cost effectiveness vs ROI vs SROI. These are not irreconcilable issues, but they are not easy. Also there are issues re cash-ability.

The BBC picked up on a paper recently- I have some issues with the methods but still it’s a good effort. Can talk to you about the science off line if you wish.


Often Social Return on Investment arguments are not expressed in a language that the NHS understands.

Yesterday Andrew Furber dug out a piece in the press – Reuters- on the value of bike lanes expressed in QALY terms.

The NHS facing value of bike lanes

I quote “Every $1,300 New York City invested in building bike lanes in 2015 provided benefits equivalent to one additional year of life at full health over the lifetime of all city residents, according to a new economic assessment. That’s a better return on investment than some direct health treatments, like dialysis, which costs $129,000 for one quality-adjusted life year, or QALY…..”.

It’s worth reading the article. For those of you with a scientific bent the academic piece is by Gu et al The cost-effectiveness of bike lanes in New York City

In a nutshell the methodology looks as sound as it could, it can always be improved and the clever economists will tell me how, no doubts. It was a regression and Markov model to show how more lanes = more biking, and a number of downstream health benefits at individual and population level. The health gain for each person in population is low 0.0022 QALY, but for low costs ($2.79 pp). Thus a cost per additional QALY of $1,300.

If “bike lanes” went to NICE, on the basis of this evidence the answer would be “build them”.

As I say, I’ve no doubt the methods can be improved.


I don’t know how I missed this before but James Woodcock and others really nailed this one

Effect of increasing active travel in urban England and Wales on costs to the National Health Service – ‬Table 5 and fig three are the key bits

The NHS value of parks – a thought experiment

Here is a thought experiment on parks expressed in QALY terms.

So say we are considering paying for a new drug for big toe cancer.

And that this drug buys 0.4 extra years of life (that’s pretty good in cancer terms) and 40 people would be eligible at an additional cost of £55,000 per patient (not unusual)

That in a population of 560,000 buys 16 additional “life years” (40 * 0.4) when comparing having the drug available vs not. At a cost of £2.2m (40 * £55k).

Then assume that park is a social good, everyone benefits but only by a very small amount. Lets say adds 0.01 extra life years (compared to having no park) – maybe that’s very conservative, maybe it’s not, I don’t know but stick with it. So having a park gives 5,600 additional life years

Obviously there is the revenue cost of running the park, and doing the job properly you’d also have to factor in value of land. It is an interesting way of framing an argument. Of course there are many fatal flaws in this, but…………..

You can see however that the cancer drug doesn’t look like a good investment compared to a park in these terms.

Parks, bike lanes and public service reform.

There is a consistent notion that “health” benefit from parks, but don’t invest (I use my terms advisedly). This is common across lots of other things (better air quality, sport centres, social care etc). nothing unusual here – cross sector investment and ROI. I would refer you to the excellent NAO report (reference below) and especially this graph:


Here are some specific ideas around parks and the NHS:

Should the NHS contribute to the revenue budget for running parks. What if “health” ran parks. What would the model look like. Danger of medicalising the space – may be some benefit to some medicalization of some, but not all of the agenda.

What about the concept of building preventive activity in parks with tariff based activities to ensure that money flows activity. Say about £3-400 per patient per year (or maybe episode). Of course this may be medicalise it around certain and specific pathways – OA knee, low back pain, falls and gait, some mental health.

Has the NHS anywhere invested in the Park Run concept, and used that investment to focus on the most inactive cohort.

Parks then can become venues for providers of activity for clinical therapeutic activity and possibly for skills and apprenticeship development. This may provide routes to recovery post mental health, drug service recovery

This is neat and develops the concept of the park as a venue for this and develops a market. Obviously would need a provider, a service specification, a pathway and a commissioner.

more broadly  – Should we give businesses a rebate off their business rates if you adopt a park + a day a year for all employees to look after it, invest in infrastructure to support the park.

So investment in park and bike lanes remain in a difficult space, we continue to under invest in bike lanes etc.

Dear NHS, if you want to get into the business of well being seriously, then maybe it is time to think of social investments in infrastructure to run and protect these social investments and policies not just services to treat folk who are poorly.

Yes I know there’s no money, this one is about using existing money to buy the best outcomes and the opportunity cost of what may happen if we don’t have parks or the use of money to crowd out lower value investments that don’t provide cost effective return on investment. These are social interventions are not directly medically related but have an extremely positive effect on giving us more life years

You can have your parks sponsored by PepsiCo or by McDonald’s if you want

I suspect you know where that one will go.

Thanks to Prof Eugene Milne for some very bright ideas. I like talking to clever folk!

Postscript – quick thought from one of my team

… but on a positive note from your blog Greg (re green spaces) – here are some interesting snips from the People, Places and Health Conference I attended a couple of weeks ago –

Sorcha Daly – Institute of Health Equity at UCL

• 20% of most affluent neighbourhoods have 5 times the amount of green space than the most deprived 10% of neighbourhoods

• Income deprivation related health inequalities are lower in populations living in the greenest areas

• Use of green space may be declining – 29% spending less time in parks

David Buck – King’s Fund

• Increasing access to parks and open spaces could reduce NHS costs of treating obesity by more than £2bn; several SROI cases.

• Green walls and trees could remove some air pollution, though overall effects are low, and some noise pollution; overall value of London’s tree cover (including amenity value) estimated at £130bn.

• Access to green space can reduce mental health admissions; Ecominds evaluation (of 5 cases) suggests benefits in terms of reduced NHS costs, welfare benefits etc; SROI cases include NHS demand reduction. BTCV evaluation of green gyms suggests for every £1 spent, £2.55 is saved in reduction in physical illness.

Tim Townsend – Newcastle University

• Studies (early 2000s e.g. Giles-Corti etal 2005 etc) associated greenspace proximity with increased recreational activity

• Newcastle research (Gallo et al, 2015):

o Urban parks and social equity for younger people

o Study of two urban parks and their peripheries in disparate neighbourhoods

o Provision (PA opportunities) in the park poorer in poorer neighbourhood

o PLUS – surrounding food environment much less healthy

o (i.e. supporting a deprivation amplification hypothesis)



HLF state of parks –

Reuters Bike lanes are a sound public health investment –

Inj Prev doi:10.1136/injuryprev-2016-042057. The cost-effectiveness of bike lanes in New York City.

Kings Fund report on park and green space and more recently –

NAO public service reform –

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