Improving the publicâ€™s health 2010-2020 A crisis and an opportunity
Manifesto from the UK Public Health Association
Manifestoâ€Ś â€Śabout what? This is an urgent call for those with the power to shape public policy to take swift and radical action to address the impending public health crisis in the UK. It sets out the proposals of the UKPHA membership for ways of managing the far-reaching change that we know is needed if the UK is to flourish socially and economically into the future. The proposals reflect the collective experience and thinking of committed experts. Our ideas are not demands. They are the fruits of long debate and discussion within the UKPHA and with our partner organisations. The proposals represent a sincere offer from the membership to deploy their skills and expertise in the service of this agenda - and to act collaboratively, as a resource for policy makers and others, in stimulating and taking action.
â€Śwhy needed? No political party that is serious about improving public health can neglect the real opportunities that exist now. Good work in public health is going on across the UK; but, in general, it is fragmented and poorly resourced. Meanwhile, a crisis is developing on the back of demographic and other changes. Efforts need to be harnessed into a major drive to improve public health in the UK, drawing on
1 the key understandings outlined in the manifesto.
We can't go on like this… The health of the population and the social and economic success of the nation are inextricably connected. But, as many informed politicians and people in positions of influence acknowledge, we are currently facing a public health crisis. The associated social and economic costs are huge, and overshadow the future. New wave of health threats New threats to health and wellbeing include rising levels of obesity, poor mental wellbeing amongst young people, and the long-term effects of widespread alcohol misuse. Meanwhile, other challenges are emerging that, in our lifetimes, are likely to shake systems to the core. These include: The potential impacts on human health of climate change (for example, flooding) and environmental degradation (for example, loss of green space and contact with nature, leading to reduced physical activity and mental ill-health) The need to respond to the issues posed by an ageing population The long term impacts of protracted economic crisis, with wide-spread unemployment and increasing levels of poverty amongst key social groups, including children and young people.
Potentially huge benefits are associated with a shift in thinking and planning from the current focus on disease to that of wellbeing, where health is seen as a positive state rather than simply the absence of illness. It is estimated that even a small shift in the numbers of people who feel they enjoy wellbeing and so are better able to respond to illness or adversity would achieve massive benefits, including:
iImproving the health and wellbeing of all across the social gradient Reducing the prevalence of illness More efficient use of current health and social care services Development of new arrangements that would add social and public value.
The evidence for this There are two main sources of evidence for the benefits which might accrue from such a shift in thinking: The Marmot Review, 'Fair Society, Healthy Lives', Strategic Review of Health inequalities in England post 2010, published in February 2010 (and its global forerunner for the World Health Organisation Closing the Gap in a Generation 2008) Burgeoning work on the importance of wellbeing as a core concept for population health
The six main recommendations of the Marmot Review are: Giving every child the best start in life - which the review emphasises as its highest priority recommendation Enabling all children, young people and adults to maximise their capabilities and have control over their lives Creating fair employment and good work for all Ensuring a healthy standard of living for all Creating and developing sustainable places and communities Strengthening the role and impact of ill-health prevention
Professor Marmot commented on the findings of the review: "There will be those who say that our recommendations cannot be afforded, particularly in the current economic climate. We say that it is inaction that cannot be afforded, the economic and more importantly human costs are simply too high. The health and wellbeing of today's children, and of those children when they become adults, depend on us having the courage and imagination to do things differently, to put sustainability and wellbeing before a narrow focus on economic growth and bring about a more equal and fair society." 1
The evidence of the Marmot Review is borne out by the recent work of Richard Wilkinson and Kate Pickett, which emphasises that it is not only the poor who suffer from the effects of inequality, but the majority of the population.2 For example, rates of mental illness are five times higher across the whole population in the most unequal societies compared to the least unequal societies in their survey. One explanation, they suggest, is that inequality increases stress right across society, not just among the least advantaged.
Wilkinson and Pickett show that the different social problems that stem from income inequality often form circuits or spirals. Babies born to teenage mothers are at greater risk, as they grow up, of educational failure, juvenile crime, and becoming teenage parents themselves. In societies with greater income inequality, more people are sent to prison, and less is spent on education and welfare. In Britain the prison population has doubled since 1990; in America it has quadrupled since the late 1970s.
Other national level evidence Â„ The 2008 Foresight Report on Mental Capital describes
mental wellbeing as a dynamic state referring to an individuals' ability to 'develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their community.3 It has also been defined as 'a positive sense of
wellbeing and an underlying belief in our own, and others' dignity and worth'.4 The new economics foundation (nef) says that 'wellbeing is more than happiness and satisfaction. It includes developing as a person, being fulfilled and contributing to society'5
Friedli reported in 2009 on the strong relationship between inequalities and mental health.6 Â„ The Department of Health's New Horizons7 , replaces the National Service Framework (NSF) for Mental Health (1999). In contrast to this framework, which focused on service improvement for mental health services, the new policy embraces the wider health, social and economic benefits of promoting good mental health for everybody (such as improved educational attainment, reduced anti-social behaviour, fewer days off work and improved health), summing this up in an evidence-based model that emphasises the broader social determinants of health such as employment, education, housing, community cohesion, and makes links to physical health and wellbeing.8
Â„ Lord Ara Darzi in his 2007 report
emphasises the necessity
of improving the mental health of the population, making promotion of good mental health one of six goals for the local NHS which is tasked with commissioning services that promote wellbeing in partnership with the local authority. The National Institute for Health and Clinical Excellence (NICE) has produced a number of reports on promoting wellbeing
10 11 12
in relation to physical activity
and various guidance on living well and public involvement.14
Â„ The social innovation centre, the Young Foundation, is involved in practical research and has created The Local Wellbeing Project, one of the first policy trials to target improving community wellbeing by working directly with three local authorities, experts on wellbeing, and the Improvement and Development Agency (IDeA).15 The project includes practical initiatives to promote wellbeing; an apprenticeship scheme to develop 'soft skills' and employability of young people, a school based resilience programme and a peer volunteer programme to build older people's resilience to mental health problems. Â„ A 2007 study of deprived constituencies in Britain concluded that there is no single 'protective factor' for resilience.16 The main ingredients for resilience are a combination of progressive policies and practices and the community's ability to draw effectively upon its own resources. A number of social and cultural factors may be protective, including the political, economic, ethnic and religious characteristics of the local population. More resilient communities are better equipped to deal with the health effects of economic decline and are better protected in economic recession.
Â„ International studies suggest that for nations as a whole, reported happiness and wellbeing is less related to overall Gross Domestic Product (GDP) than to equivalence of income levels. For instance where there is high observed inequality of wealth such as the UK and USA both rich and poor are less satisfied with their lives.17 Where countries appear to have more similar income
levels across social groups such as Sweden or Costa Rica, populations tend to report higher levels of life satisfaction irrespective of income.18 These measurements are somewhat crude and not easy to interpret but other evidence also suggests that levels of inequality are strongly related to poor mental wellbeing and that people are more likely to report positive mental wellbeing if their experience is that society is fair. A move away from the dominance of the market is needed if sustainable wellbeing is to be truly valued by society. Production, consumption and non-market activities should be taken into account when measuring economic performance and social progress, rather the reliance on GDP. This will also assist in identifying changes in inequality. "If inequality increases enough relative to the increase in average per capital GDP, most people can be worse off even though average income is increasing".19
Research summary Â„ Feeling good and functioning well are closely allied, and mental wellbeing and resilience is essential at population level to economic and social productivity affecting success in education, work, and family and community life. Â„ Feeling good and functioning well influence physical health, in particular because motivation, knowledge, aspiration and people's sense of autonomy affect people's behaviour related to smoking, exercise, healthy eating, sex, and alcohol and drug use. The ability and willingness of someone with illness to play an active role in their recovery or long term management of their condition is also dependent on their motivation to take control. Â„ Feeling good and functioning well influence a person's perspectives and preparedness to engage with others and with their wider environment. Promoting mental wellbeing and resilience helps to strengthen communities and foster citizenship.20 21 22
Intervening to specifically promote a 'mentally healthy society' (where homes, schools, workplaces, neighbourhoods and communities, and institutions such as government, enable a larger proportion of the population to 'flourish' rather than 'languish')
can do more to enhance wellbeing and reduce mental disorder than 24 9 a 'multitude of interventions with individuals'.
'Business as usual' isn't an option In the face of this vast and growing body of evidence, it is clear that we will continue to be let down by traditional ways of thinking about the public's health and how to improve it. At the heart of these traditional ways of thinking and doing is the focus on illness rather than health, on negatives rather than positives, on services that 'do to' people rather than work with people to create health-enabling conditions and environments. Professional practice in the public services is disjointed, and geared to reacting to problems rather than preventing them in the first place. 'For every problem', remarked one experienced commentator, 'the service provider's answer is "more of me"'.25 Increasingly, organisations in the public sector - particularly in the health service and local government - are recognising that even when money on reactive services is spent well, the need tends to recur year after year. They are finding it makes sense, therefore, to shift effort and resource towards building an environment and a society that prevents such problems in the first place. This approach is strongly supported by research evidence and examples of good practice from around the world. Our systems are reaching the limits of their health giving power.
Even if we wanted to carry on with 'business as usual', running to catch up, this option will soon not be available. Looming financial austerity will end our ability to respond to increasing health and social need by providing more and more public services. The big challenge facing us now is how to achieve more health and wellbeing for less investment. As Charles Leadbetter points out in the Health Services Journal (March 2010)26 'we need radical
and innovative social innovation if we are to transform this situation.' A plethora of recent policy papers and informed commentaries point to the need to shift the focus. This must go far beyond the development of new techniques to 'make people eat their greens'. Rather it is about helping individuals - and communities - to help themselves. We ignore the assets in our communities at our peril. As Professor John McKnight has said 'local assets are the primary building blocks of sustainable community development. Building on the skills of local residents, the power of local associations, and the supportive functions of local institutions, asset-based community development draws upon existing community strengths to build stronger, more sustainable communities for the future'.27 We already have evidence that there is untapped potential in the UK population. More than 40 per cent of people in the UK volunteer each year and Mulgan et al inform us that hyper local citizens are much more likely to respond to national campaigns or very local work, over involvement opportunities at a borough level.28
The potential strength of this approach has been acknowledged in the recent Conservative Party Policy paper on Public Health which states that national programmes must be 'evidence-based and linked to the latest advances in social psychology and behavioural economics, so that they work intelligently with the way real people live their everyday lives.'29 'Our approach to improving public health is based on strengthening society and helping people take more responsibility for their own health' [page 4] The UKPHA endorses the view propounded by Mulgan and others that a more sophisticated approach would enable governments to do this in ways which command greater public engagement and therefore greater effectiveness.30 31 This requires Government, public services and civil society to work together in new and more vibrant and experimental ways.
A NEW APPROACH
So, what's the alternative? It is time for a new approach to health and wellbeing that will enable effort, commitment and available resources to be harnessed into a major drive to ensure that as we progress further into the 21st Century, the population of the UK achieves its full potential for health and wellbeing. Policy makers have a once-in-a-lifetime opportunity to turn the crisis facing us into an opportunity. For too long, debate on policy has pitted the primacy of the individual against broader issues of society as a whole. But the people of the UK need policy makers both to acknowledge that a functioning, fair and prosperous society enables individuals to flourish and live meaningful lives and also to create the social economic and environmental conditions for this.
The central question is:
How can individuals and communities be enabled to thrive, to be healthy and resilient to illness, to live within sustainable carbon limits - and to have these enhanced levels of wellbeing more fairly distributed across social groups at the same time as public resources are diminishing?
A NEW APPROACH
The great breakthroughs of the last two centuries in public health have always sprung from passionate social and environmental activism. Last century, for example, committed public health professionals worked with others to bring about a wide range of reforms in housing, sanitation, food protection, education, environmental safety, prenatal support, infection control and contraception. Since then, the framework for action to improve public health and wellbeing has become dominated by thinking about disease and risk factors. But it is clear that the new public health agenda must involve a return to the roots - a focus on the conditions in which health and wellbeing are created and on action that creates and sustains these. There are strong signals that the general public are taking action on their own behalf to address the range of discontents and challenges that have not, so far, been addressed by Governments. The Transition Towns Movement, for example is growing in the UK and elsewhere. This grass-roots movement and others like it provide the creative social energy for positive change which should be viewed as a mandate for bold change by those at the top.32
The example on page 16 is taken from the Marmot Review [Page 132] and highlights the important role of the UKPHA in identifying and sharing good practice across different agencies. The example shows how key partners can work together effectively to make a real difference to fuel poverty - an issue that blights the life of many people in communities across the UK. (A household is said to be fuel poor if it spends more than 10% of its income on fuel for heating.)
A NEW APPROACH
The positive learning from this initiative is summarised in the example and can be followed up on the UKPHA website. In essence it points to a transformation in the ways in which professionals and public agencies work with local communities and with each other. This is a profound challenge to the silo cultures which appear to be an immovable feature of our public systems which have, mostly, not evolved at the service delivery end in spite of years of policy rhetoric about partnership and structural change. The negative learning - by no means confined to work on fuel poverty - is summarised in the words with which the Review ends its description of the initiative. 'The funding received ends in 2010, yet the project is improving local delivery systems, increasing the numbers receiving funding to reduce fuel poverty. Like many other ill health prevention projects, funding only invests in a pilot, regardless of the outcomes. In this case, this means a project showing successful short-term outcomes may not be rolled out.' The short-termism that is another 'wicked' feature of our social landscape stifles innovation at the margin and ensures that the great juggernaut of the mainstream remains unchanged!
Working in partnership to reduce fuel poverty The programme originates from the UKPHA's Health Housing and Fuel Poverty Forum, funded by DEfRA. The forum, made up of national figures from the health, housing and energy sectors, and practitioners from across England, develop the 'Clearing House' (CH) model. Their research concluded that a model of local are partnerships that linked health, housing and fuel poverty services was the most effective approach for directing services to the vulnerable. The Clearing House model identified the key systems and processes necessary to access the vulnerable fuel poor, identify high risk groups, streamline referrals and delivery systems and implement monitoring and evaluation processes. The Clearing House model was first piloted in Manchester, with the implementation of the Affordable Warmth Access Referral Mechanism (AWARM). Funded by the Department of Health, the pilot was a partnership with Salford City Council and Primary Care Trust. The Manchester Business School is evaluating the programme. Lessons learned from the pilot include: There are numerous opportunities to share data between local authorities, GPs and PCTs to improve how referrals are targeted A pop-up system on GP electronic records would help to immediately direct referrals to a one-stop-shop Involving energy companies as active project partners can help identify novel ways to target vulnerable
individuals and neighbourhoods.
A new framework for a shifting mindset ... So how we might act on the growing evidence and the resulting public debate to make a real step change in policy - and begin to achieve a real transformation in health and wellbeing at the pace and scale required to avert the worsening crisis. We are asking policy makers to commit to working with communities and our members to create an enabling policy framework which emphasises the goal of sustainable health equity.
Five Strategic Shifts: towards a new system for health and wellbeing In a recent paper in the National Civic Review, Tom Wolfe identified the three components, in the US context, that are 'the enabling conditions' for effective public health action: 'Supporting healthy communities requires that government (1) understand and endorse the concept of the social determinants of health, (2) support working in a comprehensive and integrated manner across all government departments and (3) cede power to communities for them to identify issues and implement solutions'. National Civic Review, vol. 92, no. 2, Summer 2003. The Healthy Communities Movement: A Time for Transformation. We believe that these conditions are only partially in place in the UK now and that there is much more to be done. There are particular deficits in relation to the ways in which local people may be enabled to control their own destinies. We note, for example, that the Conservative Party proposes to rename the Department of Health the Department for Public Health, but a change of name alone will not create the cross-governmental focus that is required to tackle the cross -sectoral determinants of public health. The UKPHA would add a further two components to the creation of a comprehensive policy for the public's health capable of achieving the required transformation. These are: Â„ Shift the focus from illness to wellbeing Â„ Create a public health workforce and an infrastructure which is capable of responding to the new policy environ-
ment and changed expectations.
Our membership proposes the following five strategic goals and suggestions for supporting actions:
Strategic Shift 1 Government will understand and endorse action to address the social determinants of health. Supporting actions 1. Accept and implement in full the recommendations of the Marmot Review of Health Inequalities in England and establish an independent Standing Commission on Health Inequalities to monitor and report on progress. 2. Account for wellbeing in measurements of economic performance and social progress. 3. Maintain existing commitments to support well-evidenced programmes to improve the position of families living in poverty. 4. Protect vulnerable groups from the impacts of the recession, especially unemployment and fuel poverty.
Strategic Shift 2
There will be a comprehensive and integrated approach to improving public health across all government departments and at regional and local levels. Supporting actions 1. Create a senior Cabinet Office post to achieve a cross-govern mental impetus for this agenda. 2. Extend the Total Place initiative which looks at how a 'whole area' approach to public services can lead to better services at less cost, seeking to identify and avoid overlap and duplication between organisations - delivering a step change in both service improve ment and efficiency at the local level, as well as across Whitehall. 3. Formalise partnerships to effectively link the resources and activities of health and housing agencies to tackle excess winter deaths tar gets to ensure that the UK can be free of fuel poverty by 2016.
Strategic Shift 3 Communities will have real power to identify issues and implement solutions. Supporting actions 1. Promote greater use of the Sustainable Communities Act to enable local citizens to engage in this bottom-up democratic process. 2. Require commissioners and providers of publicly funded services to work with community resources, organisations and assets to achieve improved health and wellbeing and minimise harms. 3. Extend financial and clinical governance dimensions of local NHS organisations to include a social governance dimension to enable local people to set priorities and shape strategy. 4. Promote and support asset-based community development approaches, particularly in deprived localities. 5. Support and enable bottom-up initiatives such as Transition Towns and remove obstacles to the formation and functioning. 6. Support the development and adoption of a Social Value Framework for communities and require the NHS and Local Government to stimulate, nurture and provide sustained support for radical social innovation.
Strategic Shift 4 Shift the focus from illness to wellbeing Supporting actions 1. Require statutory authorities to use existing powers more effectively to improve and sustain health and wellbeing and strengthen these where required. 2. Mandate the use of health and wellbeing impact assessments for all local decision makers. 3. Incorporate social value and wellbeing impacts into NHS Quality Accounts and incorporate into the capabilities required of senior managers and leaders in the NHS and local authorities.
4. Put in place a national Framework to enable the development of a distributed health and wellbeing system that will integrate the expertise of the UKPHA membership, which includes professional knowledge, para-professional support, lay knowledge with new approaches to mass community self help and engagement 5. Provide strong guidance to local authorities to enable local communities to sustainably produce, sell and buy their own food wherever possible 6. Strengthen the regulatory powers available to local authorities to ensure that planning and economic development polices maintain an appropriate balance between the needs of the economy and the health and wellbeing needs of local people. This will require a reappraisal of, amongst other things, the stimulation of night-time economies, the promotion and sale of alcohol and fast food, trans port and the built environment.
Strategic Shift 5
Create a robust public health workforce and infrastructure. Supporting actions 1. Create an integrated and effective public health system with effective links from the strategic level to the delivery level and ensure that there is transparent governance and local engagement. 2. Pilot and evaluate new modes of multi-professional working to improve health and wellbeing and set standards for professional education and training in collaboration with the Royal Colleges and registration bodies and higher education and funding bodies. 3. Support the establishment of a funded task force to develop the health visiting workforce so that all families have equal access to this vital resource. 4. Support the development of partnerships which will equip the public health workforce with the leadership, learning and knowledge base to take meaningful action on climate change, mitigation and adaptation. 5. Identify and ringfence budgets for the core functions of public health. 6. Establish clear mechanisms of accountability with local communities for the delivery of public health.
There has been a great deal of innovation in the treatment and management of previously neglected diseases. However inefficiencies and fragmentation of services and unacceptable inequalities in health outcomes are still present. We need to rethink what transformation in health and public health might look like. There is a clear requirement for a new mindset amongst professionals in the NHS, local government and the wider public health community. We need new tools - and new ways of thinking about public health with the aim of producing the best health and wellbeing from the optimal use of available resources. Implementing the approaches outlined in this Manifesto will harness the skill and professionalism of the UKPHA membership and many others in a new relationship with national and local government and civil society. This is the only approach which will prevent the diseases which are the avoidable consequences of our social and environmental conditions. It will also create more health and wellbeing - and provide a new foundation for a fair and successful society. It is time for real change!
Over to policy makers... Below are the questions we want to pose to those with the power to make policy we invite you to contact us to talk about how we can work together to find the answers: What is your approach to changing the behaviour of the public in relation to health issues and what evidence do you have for your chosen approach? How will your policies reduce the forces in society that contribute to and reinforce unhealthy and damaging patterns of behaviour? How will you actively invest in and support the people, communities and organisations who actually do most for the health of the public?
1 Marmot. M (February 2010). The Marmot Review, 'Fair Society, Healthy Lives', Strategic Review of Health inequalities in England post 2010. Executive Summary. The Marmot Review. 2 Pickett. K & Wilkinson. R (2009). The Spirit Level 'Why Greater Equality Makes Societies Stronger'. Bloomsbury Press. 3 Feinstein. L, Vorhaus. J & Sabates. R (September 2008). Foresight Reports, 'Mental Capital through Life: future challenges; Wellbeing and Work: future challenges.' Government Office for Science. 4 Health Education Authority (1997). 5 Shah. H & Marcks. N (Spetember 2004).The New Economics Foundation: 'A wellbeing manifesto for a flourishing society.' New Economics Foundation. 6 Friedli L (2009). World Health Organisation. 'Mental health, resilience and inequalities.' WHO Regional Office for Europe. 7 Department of Health: Mental Health Division (July 2009). 'New Horizons: Towards a shared vision for mental health: consultation.' Department of Health. 8 Department of Health (June 2009). 'New Horizons: Flourishing People, Connected Communities. A framework for developing well-being'. Department of Health. 9 Darzi. A (June 2008). 'High quality Care for all: Next Stage Report final review'. Department of Health. 10 Taylor. L, Taske. N, Swann. C, S (January 2007). Public health interventions to promote positive mental health and prevent mental health disorders among adults: Evidence briefing. NICE. 11 NICE (March 2008). 'Promoting children's social and emotional wellbeing in primary education. NICE public health guidance 12.' National Institute for Health and Clinical Excellence. 12 NICE (September 2009). 'Promoting young people's social and emotional wellbeing in secondary education. NICE public health guidance 20.' National Institute for Health and Clinical Excellence.
13 NICE (January 2009). 'Promoting and creating built or natural environments that encourage and support physical activity. NICE public health guidance 8'. National Institute for Health and Clinical Excellence. 14 NICE (February 2008). 'An assessment of community engagement and community development approaches including the collaborative methodology and community champions. NICE public health guidance 9.' National Institute for Health and Clinical Excellence. 15 The Young Foundation. http://www.youngfoundation.org.uk/ourwork/localinnovation/strands/ wellbeing/wellbeing 16 Tunstall H. et al. (2007) 'Is economic adversity always a killer? Disadvantaged areas with relatively low mortality rates.' Journal of Epidemiology and Community Health, 61, p337-343. 17 Pickett. K & Wilkinson. R. ibid Friedli L The Spirit Level. ibid 18 Abdallah. S. et al. (June 2009). 'The unHappy Planet Index 2.0: Why good lives don't have to cost the earth.' New Economics Foundation. 19 NEF op cit 20 Bartley. M (ed.) (2006) 'Capability and Resilience: Beating the Odds.' UCL Department of Epidemiology and Public Health. 21 Nurse, J. (2009) 'Creating just, healthy, resilient communities to promote wellbeing. A Public Mental Health Framework for Wellbeing.' Department of Health. 22 Hothi, M. et al (2008). 'Neighbourliness + Empowerment = Wellbeing: Is there a formula for happy communities?.' The Young Foundation. 23 Mentality (November 2004). 'Models of mental health promotion.' Department of Health. 24 Mentality (November 2004). 'Models of mental health promotion.' Department of Health.
25 Eisenstadt. N 'Address to an open space in Lambeth in 2009 : developing a Mental Well Being Strategy for Lambeth'.
26 Leadbetter , C. Innovation- Harnessing the Power of Local Communities. HSJ.March 10th 2010 27 McKnight. J L. (May 2003). 'The IPR Distinguished Public Policy Lecture Series. Regenerating Community: The Recovery of a Space for Citizens.' Institute for Policy Research, Northwestern University. 28 Halpern. D et al. (February 2004). 'Personal Responsibility and Changing Behaviour: the state of knowledge and its implications for public policy'. Cabinet Office. The Prime Minister's Strategy Unit. 29 Conservatives. (2009). 'A Healthier Nation. Policy Green Paper No. 12.' 30 Mulgan et al. ibid 31 Reeves R. (February 2010) 'A Liberal Dose? Health and Wellbeing - the role of the state. An independent report'. Department of Health. 32 Transition Towns. http://www.transitiontowns.org/
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