To tackle inactivity and obesity and make cycling a real option for people we need to do more than ‘prescribe it’
I’m an advocate of cycling, and I’ve witnessed how getting on a bike can promote good health and address ill health, and more broadly be good for the health of communities, public services, our economy and our planet.
And whilst I’m not a fan of the language of ‘prescription’, I am in favour of the concept of social prescribing – I’d love to see people leave their doctors with a bike, route map and information about local cycling groups and other support on offer.
BUT, the language and approach portrayed in headlines over the summer left me anxious, so here is what I’d like to see happen next:
1. Follow the principles of behaviour change
Any idea that GPs should simply tell obese patients to get on a bike, and loose weight, flies in the face of behaviour change science. It undoes in one breath the positive shift in both approach and language that we’ve achieved in recent years.
Whilst cycling can bring about many benefits, there is no one ‘magic bullet’ or ‘miracle pill’ when it comes to obesity or people’s health more broadly. When we follow the evidence it shows us there are a myriad of reasons why our population is increasingly obese, inactivity being one.
To suggest people just need to be told by their GP to get on a bike is insulting and dangerous. Activity has been designed out of our lives and work. Active travel is one great way we can design it back in but enabling people to cycle takes more than a prescription and to tackle obesity it needs to go hand in hand with other measures, to include access to affordable, healthy food and multiple options for moving more.Telling people what they should do, as if it’s just a question of personal ‘lifestyle choice’, ignores the structural barriers that impact on people’s actions and health.
2. Be person-centred
By prescribing ‘exercise’ for ‘weight loss’ Boris’ announcement undoes the progress made in thinking and talking more broadly about how we design ‘moving more’ back into everyday life in a way that works for people, through a person-centred approach. People are more likely to increase and sustain levels of activity when they are supported to design new, sticky habits, into their everyday lives in a way that builds on their existing patterns and social connections.
3. Take a whole system approach
Getting about by bike simply isn’t an option for many people currently, if we want to make it a viable option we need to address the multiple barriers across the whole system. I want to see the government take a whole system approach to population level behaviour change, both in their obesity strategy and in their cycling strategy and in the interplay between the two.
In Greater Manchester, we have committed to GM Moving as our whole system approach across the city-region, to grow a movement for active lives and to reduce health inequalities. Whether we are talking about obesity or active travel, we apply our whole system way of working as captured in the model below.
Source: GM Moving whole system approach ‘the onion’. Adapted version of the Socio-Ecological Model, Sport England
‘The onion’ helps us to find some clarity and simplicity in the complexity and provides a useful tool for checking our blind spots, the gaps in our research and insight, and to mind the implementation gap.
At a quick glance, you can see that whole system change can’t be achieved without paying attention to the physical environment. There is vast amounts of research to show that infrastructure changes are needed if we are to create safe space for people to ride bikes.
But without paying attention to all the other layers of the onion, population level behaviour change can not be achieved.
4. Mind the gaps – tackling inequalities
If infrastructure is to fulfil societal needs, then social inclusion – and the uncomfortable realities of power, privilege and oppression – must feature more prominently.’ Cycling and the Right to Safe Urban Mobility, Tiffany Lam
To genuinely deliver whole system change for all people in all places and deliver a more just and equitable future, we must continually reexamine each layer of ‘the onion’ from the perspective of each of the different protected characteristics, and socio-economic groupings. Using a tapestry of qualitative and quantitative data and insight and layering the multiple lenses for an intersectional perspective, e.g, to consider what may get in the way of a young, black woman getting on a bike in Oldham?
The ‘uncomfortable realities of power, privilege and oppression’ mean our current structures, infrastructure, spaces and ‘offers’ do not work for all. To ‘reach out’ and ‘include’ assumes the norm is right. Instead we must be prepared to dismantle and disrupt, working with those most impacted to redesign for diversity.
So, this is what I’d like to see happen:
- Social Prescribing – let’s equip our healthcare professionals, with the knowledge and tools they need to be able to add cycling to their offer. But let’s not use bikes as a tool for shaming people and without regard to the wider social determinants of health in play. And rather than telling healthcare professionals how they best treat their patients, let’s enable them to take the time needed to better understand and respond to the realities of people’s lives and personal motivations, starting with the question ‘what matters to you?’.
- Infrastructure – to make cycling a more accessible option for more people we do need to build more safe cycling infrastructure and fast! I welcome the growing commitment to create safe segregated space for cycling. I’d like to see more of our leaders being unapologetically honest about the fact that to make cycling a viable option for a significant proportion of the population requires the reallocation of road and land away from cars and the redistribution of resources away from car subsidies to invest in active travel and in more integrated, bike friendly, public transport.
- Participation – to make cycling a viable option and support more people to get on a bike more often, we also need to:
- Paint a clear and compelling vision and ambition that invites others to join us on a journey to a greener, fairer, healthier, happier nation. This must support a cultural shift to address the perception that ‘our weather is awful’ and that the car is king and a symbol of status.
- This vision should be inclusive of people, in all their diversity. ‘You can’t be what you can’t see’; we need to grow a far more diverse network and movement of advocates, as visible role models and advocates across all protected characteristics and across the life course.
- Nurture greater ambition and investment in urban design, the development of more attractive, green public realm and environments and make this everyone’s business. Put people’s health and wellbeing at the heart of all policy and all development – creating safer places for people to move around.
- Provide choice – in the current climate, this includes having an honest look at how we save our leisure centres, swimming pools, community centres, libraries and local high streets which currently hang on a knife’s edge so people have choices, and places to ride to!
- Engagement of businesses, to support and promote active travel to work and more active workplaces, to include changes to working times and culture providing greater flexibility as to when people work and where to enable active travel at off peak times, including immediate measures as furloughing comes to an end and we grow resilience to prepare for future waves.
- Work with our schools, colleges, universities to enable and promote cycling and more active travel with school streets, active travel routes and buddying.
- Work with our public services, housing associations, health and care sector.
- Give people greater access to bikes, secure storage and the professional and social support to help them to regularly ride.
- Grow a movement for equal movement, make it normal for everyone and anyone to get on a bike, for whatever reason or journey works for them.
- Co-design and co-produce – ‘Nothing about us without us’
..”too often, urban and transport planning are framed in a technocratic way. This makes it seem like how we build our cities and transport systems are matters of engineering, economics and technology, which leaves little room for considerations of social inclusion and the diversity of people’s lived experiences.’ Cycling and the Right to Safe Urban Mobility, Tiffany Lam
Infrastructure, cycle training and activation programmes shouldn’t be designed in isolation from each other or the other layers of the onion or without challenge as to who is doing the designing and who seeks to benefit. The principles of co-production and human-centred design should be applied when shaping new routes and comms plans, working with people who have a granular understanding of place and the realities of people’s lives.