Building Sick Cities: Who’s Responsible for the Health We Build In?
29th September 2026
Professor Sarah Ayres, Bristol University, led the intervention team working with central government on a 6.7 million pound, 50 scholar research consortium into the systems behind unhealthy places, that has put a monetary value on the health costs of urban development, and what it means for housing providers.
At a Glance
No government department holds a remit for the health effects of urban development, so decisions on housing, transport and infrastructure are made without health evidence attached.
The HAUS model, developed through the TRUUD research programme, puts a monetary value on the health costs of poor urban design and traces where those costs land, mostly on families and businesses rather than the health service. It has now been added to MHCLG’s national appraisal guidance.
Community testimony and video evidence have done as much to shift decision makers as the economic case, particularly on issues such as damp, mould and fear of using public space.
No part of government holds a remit for the health effects of urban development. Housing, transport and infrastructure decisions are taken by people whose remit is delivery, not the illness that follows from poor design. A senior official at the Ministry of Housing, Communities and Local Government put it directly: we build houses, we don’t deal with asthma cases. That gap in responsibility is the starting point for TRUUD, Tackling Root Causes Upstream of Unhealthy Urban Development, a £6.6 million research consortium that ran from 2019 to 2025, led from the University of Bristol by Professor Sarah Ayres, involving 50 researchers across six institutions.
At the centre of the programme is an economic valuation model built with economists at the University of Bath, developed from an earlier Wellcome Trust funded project led by TRUUD’s project director, Dan Black. The model traces three things: the link between features of the built environment and health outcomes, the costs of the resulting ill health, and where in the system those costs land. Noise pollution in cities, for example, is linked to ADHD in children, disruption in schools and costs to the education sector. Air pollution is linked to respiratory illness, lost working days and costs to the Treasury and to employers.
That model, known as HAUS, the Health Appraisal of Urban Systems, has been added to MHCLG’s national appraisal guide, the document used to assess value for money in government spending. It shows that the costs of poor urban design fall mainly on families and businesses rather than on the health and social care system. The figures used are described as conservative estimates, stress tested with government departments and peer reviewed. A small change to a housing scheme that prevents 15 cases of childhood asthma produces costs, tracked over 30 years, that increase substantially once family, productivity and wider system impacts are included.
Alongside the economic case, the research draws on community narratives and video testimony, covering conditions such as damp, mould and overcrowding, and barriers such as women avoiding parks and cycle paths because of harassment. That evidence has been used with civil servants and ministers alongside the spreadsheets, on the basis that it identifies problems the numbers alone would miss, such as facilities that go unused because of fear rather than a lack of provision.
TRUUD identified around 50 potential leverage points across the urban development system. Central government incentives, objectives, funding and reporting mechanisms are not currently structured around health outcomes. Devolution, including the new public health duty for mayors and strategic authorities, is identified as an opportunity, though mayors currently have limited funding and remit to act on it. TRUUD’s review found that existing health impact assessments are not applied systematically by local authorities, and are often used poorly where they are. HAUS is intended to support those assessments rather than replace them.
Host: Jenny Danson, CEO and Co-Founder, Healthy Homes Hub
Guest: Professor Sarah Ayres, Professor of Public Policy and Governance, University of Bristol
Practical steps for housing providers
Review how health outcomes are weighed against cost and delivery speed when appraising new housing and regeneration schemes.
Establish where the health impacts of a scheme are recorded, and by whom, before design decisions are finalised.
Where a health impact assessment is already required, check how consistently it is applied and whether it changes decisions or acts as a formality.
Build resident and community testimony into scheme appraisal alongside cost and delivery data, particularly on issues that are otherwise invisible, such as fear of using public space.
Identify which costs linked to health, such as damp, cold or noise, are likely to land on residents, the health service or the wider public sector when scoping a scheme, and factor that into design choices.
Treat national guidance on health appraisal as a prompt to revisit how value for money is assessed locally, rather than as a single compliance exercise.
Reflect on which decisions in the development pipeline are effectively made before health is considered, and where earlier intervention would be possible.
