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The cost of doing nothing

The case for walking

Who are Natural England?

Natural England is here to conserve and enhance the natural
environment for its intrinsic value, the wellbeing and enjoyment of
people and the economic prosperity that it brings

We will achieve this by:

Promoting nature conservation and protecting biodiversity
Conserving and enhancing the landscape
Securing the provision and improvement of facilities for the study,
understanding and enjoyment of the natural environment
Promoting access to the countryside, open spaces and
encouraging open air recreation
Contributing in other ways to social and economic wellbeing
through management of the natural environment

Healthcare costs in the UK

We spend around 110 billion each year
on healthcare in the UK
Equal to 8.5 per cent of all income
Through advances in medicine we are
living longer and overcoming more and
more diseases
But the population has become more

The cost of doing nothing

Healthcare costs in the UK

There is a rise in diseases of 21st Century
living - obesity, diabetes and depression
The Department of Health has warned that
nine out of ten adults could be overweight
or obese by 2050
Around 2.5 million people now suffer from
diabetes, and this is predicted to increase
to 4 million by 2025
The cost of health care is increasing

Example: Chronic Heart

For example a major
contributory factor
for contracting heart disease is deposits of

fat in the blood system caused by high

levels of the wrong type of Cholesterol
A drug called a Statin can reduce
cholesterol levels, but so can regular
moderate activity such as walking
We are spending .73 billion a year on
statins in the UK, and 2.3 Million people
are taking them
Patients still need to be reminded to take
exercise and eat sensibly as well as taking
this drug

The inequalities of health

People on low or no wage are more
likely to:
be sedentary
to smoke
to have a poor diet
to abuse alcohol
to be overweight or obese
and less likely to get outdoors for

Children and sedentary


The childhood obesity crisis

Nationally, of those children measured,
12.3% of girls and 13.4% of boys in
Reception class were found to be
overweight, and 9.2% of girls and 10.7% of
boys in the same year group were found to
be obese.
In Year 6, 13.8% of boys and girls were
overweight, and 15.4% of girls and 18.9% of
boys were obese.
And its getting worse:
If actions arent taken to reverse this trend
two-thirds of children will be overweight
obese by 2050.

The indoor generation

80% of 7 to 8 yr-olds used to walk
unaccompanied to school in 1990,
now only 5% do it
Average amount of public play space
for each child under 12 in England is
the size of a kitchen table (2.3 sq
For every acre of land occupied by
playgrounds in England there are
now more than 80 acres taken up by
golf courses

The Effects of Obesity

The health effects of Obesity are
apparent even in children
It is an indicator for Chronic heart
For type II diabetes
For Hypertension

The Cost of Doing Nothing

Physical inactivity is said to cost the NHS
between 1bn to 1.8bn a year, a
Conservative estimate that could be
doubled by including conditions such as
falls or osteoporosis.
The cost to the economy from loss of
productivity amounts to around 5.5bn in
sickness absence and 1bn from the
premature death of working age people
(DH February 2009).

The solution
Everything in peoples lives is predicated
to encourage the sedentary lifestyle
It is vital to change their behaviour, we
cannot continue to allow rising health care
Nationally government is committed to
encouraging a more active society
People who live near good quality green
space are more likely to be regularly active
Bristol study E. Combs , Hillesden et a l?

The policy context

Saving lives: Our Healthier Nation
(July 1999)
Choosing Health (November 2004)
Healthy Weight, Healthy Lives
(January 2008)
Be Active, Be Healthy (February
The Olympics 2012
Active Travel Strategy 2010
Marmot Review 2010

A Fair Society, Healthy Lives

report by Sir Michael Marmot
Government report begun in November
2008, launched February 2010
sets out recommendations in 6 key areas
for reducing health inequalities in England
Which currently cost the NHS more than
5.5 billion per year
Predicts cost of treating obesity related
conditions alone will rise from 2 billion to
nearly 5 billion per year by 2025

Fair society, Healthy Lives

Rebalance public spending towards
early years
Boost education and employment
Healthy living wage
Better green space provision and
green policies such as encouraging
active travel
It is crucial investment in public
health continues through recession

The Department of Healths

The DH is investing in getting more
people active
Lets Get Moving a care pathway
for patients
Vascular checks
Walking for Health

Lets Get Moving

Lets Get Moving provides a physical
activity care pathway which can be
used by service providers
systematically to recruit patients and
screen for inactivity using a validated
questionnaire (GPPAQ)
Patients identified as not meeting the
CMOs recommendations for physical
activity will be offered a brief

Lets Get Moving

These interventions will draw upon
motivational interviewing techniques,
based on the principles of the NICE
public health guidance 2006
These endorse the delivery of brief
interventions for physical activity in
primary care as both clinically and
cost effective in the long term

Vascular checks
The NHS Health Check programme aims to help
prevent heart disease, stroke, diabetes and
kidney disease
Everyone between the ages of 40 and 74, not
already diagnosed with one of these conditions,
will be invited (once every five years) to have a
check to assess their risk of the above
They will be given support and advice to help
them reduce or manage that risk
Implementation of the programme will be phased
and the full implementation is expected by

What is the value of this?

The Natural Health Service

Coastal access
NHS Forest
Walking for Health
Green Exercise
NHS Alliance
1 million children
Blue Gym
Green Gym

Evidence linking health and

the natural environment

Reduces Chronic Stress

Increases Physical activity
Strengthens Communities

Biophilia Hypothesis
The proposition of EO Wilson in the 1970s
This theory describes how we humans feel an
innate, inherited connection to the natural
environment because we are living organisms,
and feel better in the outdoors,

Beauty lies in the genes of the beholder

Attention Restoration

Formulated by Stephen and Rachel Kaplan in the mid 1980s

The natural environment provides an effective restorative
environment which has four qualities:
Being away from day to day routine,
a feeling of Extent allowing exploration and a
Compatibility to our expectations.

The benefits occur in the right

Frontal cortex

Psycho-physiological stress
recovery theory
Formulated by Roger Ulrich in the
mid 1980s
Based on empirical findings of an
immediate positive response to
views of nature.
This response causes a rapid
reduction in stress (Blood pressure,
muscle tension pulse rate) usually
within minutes of exposure of nature
and is most obvious when the body
is already stressed




From EEG studies alpha waves (more

calming) are highest in a) second highest in
b) and lowest in c).
Nakamura and Fujii (1990)

The evidence for how green space

can benefit the health of the
Senior citizens lived longer
with more space to walk and with nearby
parks and tree lined streets near to where they live
Tanaka A, Takano T,Nakamura K, et al. Health levels influence
by urban residential conditions in a megacity Tokyo.Urban
Stud 1996; 33: 879945.

For every 10% increase in green space there was a reduction in health
complaints equivalent to a reduction of five years of age
De Vries, S.Nature and health; the importance of green space

in the urban living environment. Proceedings of the symposium Open space functions under urban pressure. Ghent: 19
21 September 2001.

Being within access to Green space can increase levels of physical

Giles-Corti B,Donovan RJ. Relative influence of individual, social environmental, and physical environmental correlates of walking. Am
J Public Health 2003; 93(9): 15831589.

How can the Natural Health

Service help?

A recent Bristol study funded by Natural

England concluded that people living
closer to green spaces were:
more physically active, and were less
likely to be overweight or obese
these trends were apparent
independent of peoples income or
social group
the most significant findings showed
that people who lived furthest from
public parks were 27 percent more
likely to be overweight or obese

Walking the evidence

Examples of research into the health
benefits of walking include:
Walking more than four hours a week reduces
hospitalisation for heart disease by 30 per cent
compared with walking for one hour (LaCroix et al 1996)
Heart disease is halved in men who walk over
1.5 miles a day (Hakim et al 1999)
women who walk four hours a week had a 35
per cent reduction in risk of heart disease (Manson et
al 1999)

Changes in diet and daily walking were found to

be more effective in treating type2 diabetes
than medication 58 per cent v. 31 per cent
reduction (DPPRG 2002)

Walking: The evidence

Walking can improve self-esteem and relieve
symptoms of depression and anxiety (Mobily et al 1996)
Older women who walk between 1 and 1.25 hours per
week reduce the risk of breast cancer by 18 per cent,
rising to 30 per cent for women of normal weight
(McTiernan et al)

People with chronic obstructive pulmonary disease

(COPD) who walk more than halve their risk of an
emergency admission (Garcia-Aymerich et al 2003)
Walking has been described as the nearest activity to
perfect exercise (Morris and Hardman 1997). It is recommended as
an intervention in NICE guidance relating to a range of
health conditions.

Walking for Health

Walking for health is a Natural England
supported scheme
Targets sedentary people at risk of ill health in
areas of health deprivation
Encourages them to walk, regularly for thirty
minutes, close to home,
Supports the development of led health walk
schemes by local delivery partners
Due to expand four fold supported by the
Department of Health
Local delivery supported by national enabling
including training, public liability insurance,
evaluation and accreditation

What is a health walk?

A health walk is a led walk lasting between
30 minutes and an hour and a half
It should be led at a pace which is brisk for
the individual
It should take place over easy terrain with a
level surface and no barriers
It should start at a slow pace to allow warm
up, speed up for the main part of the walk,
and then slow towards the end once more
to allow cool down
It should make the individual feel warmer
and sweat a little, increase their rate of
breathing and raise their pulse, but not so
fast that they cannot talk

Walking for Healths successes

600 walking schemes
Over 11,000 active volunteer walk
Around 4,000 walks
Over 63,000 regular walkers

How the model works

Natural England support local delivery via
intermediate organisations delivery
Who support volunteers to lead walks
Natural England trains local cascade
trainers who train the volunteers to lead
walks safely and enjoyably
Trainers are offered support via one to one
coaching and training materials on line,
and also a quality control system to
identify any problems or issues arising

Schemes are offered accreditation by
Natural England
This provides standards for the
schemes to meet, and a way of
demonstrating to would be
participants, referral organisations or
funders that they do in fact meet
these standards.
It is assessed locally and must be
renewed every year

Evaluation / Endorsement
from NICE

Single Item Metric fully validated has undergone: Cognitive Testing:

Test-Retest Reliability: Concurrent Validity

Definition of cost
to NICEs Definition:

Cost effectiveness equates to Value

for Money
A specific health care treatment is
said to be 'cost-effective' if it gives a
greater health gain than could be
achieved by using the resources in
other ways

Demonstration of the socio-economic

benefits of the environment.
Economic analysis and evaluation is being undertaken as part of
the WfH research programme to identify health and environmental
costs, benefits and effectiveness overall and for individual

Pilot data suggest an average cost of a dose of walking for an

individual participant to be 0.84p.
Early basic models indicate that:
over the 3 year period of the WfH Expansion 2817 QALY
(Quality Adjusted Life Year) would be delivered at a cost of
4000 per QALY, well below the NICE cost-effectiveness
a life-cost averted saving to the health service of
81,167,864 over the 3 year period; and
a cost-benefit ratio of 1:7.18.

How much does it cost?

We know that there are many different
sizes of schemes.
A volunteer scheme can cost as little as a
1000 per year to run and may get an
attendance of say 20 per week or 100 over
a year
A medium sized scheme can cost up to
60,000 but may get around 1200 through
a scheme in a year
A large city wide scheme can cost up to
200,000 but may get as many as 2-3000
to walk in a year, from harder to reach

Case story 1:Walking for

Health in Wolverhampton

Walking for Health in Wolverhampton (WFHW) has been going

since 2001
With a focus on two particular deprived wards within the city
which make up the ABCD (All Saints and Blakenhall Community
Development) area
In year 1 they increased numbers of walks by 69%
In year two by 24%
They led 1900 walks over this period
This increase in numbers speaks for itself but it was aided by
creation and renovation work on three parks in the locality
This led to significant increase in the use of the parks
Sixty percent of the population in the ABCD area are from black
and minority ethnic groups, many of them now regularly join the
Direct contact within the community via a community worker has
brought this result

Case Story 2: Working With GPs

The Forest of Dean is a deprived rural area
A health and wellbeing manager was
appointed for the area
Good take up for GP referral
A Fancy a walk? Programme was set up
alongside this by the health and well being
At very little cost, the scheme has grown,
Most participants are referred by GPs
Walkers have trained as volunteer walk

Case story 3: A sustainable

The Chesterfield Way
this Way scheme began life
as a county council initiative employing two
people to set up and run the health walks
When Funding ended out of 10 walks, nine
Walkers and volunteers got together, with the
help of a park ranger, formed the Chesterfield
Walk this Way Network
Appointed a chairman, secretary, treasurer,
training officer , publicity officer, set up a
constitution and created a bank account
The scheme continues to reach new walkers, and
work with frontline health care

National Indicators that WfH can

help deliver (1)
NI 120: All-age all cause mortality rate.
NI 121/122: Mortality rate from all circulatory
diseases and all cancers at ages under 75.
NI 137: Healthy life expectancy at age 65.
NI 8: Adult participation in sport and active
NI 110: Young peoples participation in positive
NI 55/56: Obesity in primary school age children
in Reception and year 6.

National Indicators that WfH can

help deliver (2)
NI 119: Self-reported measure of peoples overall
health and wellbeing.
NI 2: % of people who feel that they belong to
their neighbourhood.
NI 5: Overall/general satisfaction with local area.
NI 6: Participation in regular volunteering.
NI 138: Satisfaction of people over 65 with both
home and neighbourhood.

In summary
Obesity is rising dramatically as is
mortality from chronic disease
caused by obesity and inactivity
Access to the natural environment
can help to keep people active
Walking is a good and cost effective
way to get people to be regularly
It is a low cost simple model that

How can you get involved

You can fund or support a local
health walk scheme in your area
Develop a local partnership
Set and up run a scheme
Volunteer to lead walks
Become a participant
Information on all of the above can
be found by visiting our website or
talking to ....

Web Addresses to contact for

further information

Thank you for listening