Health & Housing – Background and Current Issues

Number of people killed or injured by location

Per year UK France

Killed Injured Killed Injured

At work 380 1,500,000 700 1,150,000

On the road 3,600 317,000 7,600 170,000

At home 4,100 2,700,000 9,000 3,000,000

Source: WHO Europe 2005

Source: Dahlgren G and Whitehead M (1991) Policies and strategies to promote social equity in health. Stockholm, Institute for Futures Studies

Social determinants of health – Marmot & housing

• The conditions in which people are born, grow, live, work and age, including the health system

• These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices

• Those who can exercise greater control over their own circumstances are healthier

Social determinants of health

• Social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within (and between) countries

• Persisting inequalities across key domains provide ample explanation: inequalities in early child development and education; employment and working conditions; house and neighbourhood conditions.

Housing and health inequity

• In 2009, 41% of the PRS was “non-decent” –most common reason for “non-decency” is existence of “Category 1 hazard” using Housing Health & Safety Rating System (HHSRS)

• EHS 2009, 4.7 million (21% of) dwellings had one or more Category 1 hazards & 971,000 in the PRS - average of 2,969 per LHA

Housing and health inequity

• 33% of households living in poverty were living in non-decent homes

• 94% LAA areas prioritised new and/or affordable housing targets but <1/3

prioritised targets for the existing stock (Audit Commission, 2009)

Dampness

“Dampness is more likely to occur in houses that are overcrowded and lack appropriate heating, ventilation and insulation (Institute of Medicine 2004), the prevalence of indoor damp in low-income communities can be substantially higher than the national average”

WHO Guidelines for Indoor Air Quality_ Dampness and Mould, WHO,

2009

Highly visible and causes stress but not always the greatest health risk

Health Inequalities & the Housing Act 2004

• Part 1 introduced the notion of health and safety hazards in the home as the basis of interventions – identified by using the HHSRS

• Health is defined as including mental health

• In general greatest risk– Excess Cold hazard and Falls hazards

• LHAs‟ duty to review housing conditions to identify actions needed using a range of powers (s.3)

Category 1 hazards according to EHS

Housing conditions – homes failing DHS by tenure

Housing conditions and poverty

Housing conditions – Energy Efficiency Rating Bands by Tenure

Mean & median weekly rents

Housing Act 2004 – Part 1 courses of action

• Category 1 hazards- duty to take one of the courses of action & Category 2 hazards-power to take action

• Category 2 hazards can still pose a significant risk to health and safety – they should not have been rated unless deficiencies identified and hazard obviously worse than average

Housing Act 2004 – Part 1 courses of action

• LHA.s should not have a policy of never dealing with Category 2 hazards

• RPT decisions, particularly on excess cold have caused some disquiet recently –suggesting wrongly that affordability of heating cannot be taken into account

• In general rarely do decisions hinge on hazard rating but on the course of action taken, procedural issues, or remedial actions (works) required.

Other powers for dealing with inadequate housing in PRS

• Financial assistance

- Grants

- Loans

but Private Sector Renewal Budget for 2011/12 £0

• Management Orders

• Renewal areas

• Licensing of HMOs

CIEH Survey:– activity by LA type 06/07

District

(n=67)

Wales

(n=10)

London

(n=12)

Met Boroughs

(n=17)

Unitary

(n=24)

Improvement Notice 486 143 230 250 392

Emergency Remedial Action

44 0 1 5 26

Prohibition Order 74 14 15 18 51

Hazard Awareness Notice

90 58 11 237 101

Work in default 80 1 2 26 24

Informal action 2891 636 1113 1786 1340

Demolition Order 1 0 1 3 1

1. Number of complaints from or on behalf of residents (score 329)

2. Number of staff available to deal with private sector housing conditions (score 293)

3. Addressing risks to health and safety in housing (score 199)

4. HHSRS and the Regulations (score 197)

5. Priority given to HMO licensing (score 139)

(cf. “Risk of retaliatory eviction” & “Council‟s renewal policy” scored 58 & 55 respectively)

Other finding - top five factors influencing activity

Activity in perspective

• CIEH work found excluding HMO licensing –average about 77 dwellings improved per LHA per year using the 2004 Act in 2006/08

• A comparator - the mean number of vulnerable households in non-decent PRS homes per LHA in England was 1,073 in 2007

• Building Research Establishment work shows that the cost to society is £1.5bn per year –with £600m p.a. the cost to the NHS

• Now is the time for LHAs to use their powers –cuts and changes to benefits could provide opportunities for the irresponsible landlords

• There are also owner-occupiers on low incomes living in unhealthy housing

LHAs and unhealthy housing-implications

• Warwick University and BRE work has shown that there can be financial benefits to the NHS of low cost interventions

• There are potential health gains from other still significant but less severe (not Category 1) hazards – but the powers need to be used strategically

(Linking Housing Conditions and Health)

LHAs and unhealthy housing-implications

Further health issues

• BRE has shown that if the English housing stock below SAP 41 were brought up to at SAP 50+ through heating and insulation improvements, the health cost–benefit to the NHS would be some £750 million per annum (IP 16/10)

• Unintentional injuries more likely in cold homes and also those in noisy environments (sleep disturbance)

• Educational attainment is lower for children brought up in housing that is overcrowded or in poor condition – reinforcing inequalities

Improved action to help reduce health inequalities

• Part 1 of the 2004 Act should be used more strategically to reduce risks to health and safety from housing conditions - so far a missed opportunity

• Closer working between EHPs in local authorities and other health professionals (who could also advocate for those living in poor accommodation) needed

HMOs

• Relicensing – guidance from CLG awaited –but HMO licensing has been made a bureaucratic exercise

• HB (LHA) changes – more HMOs (more badly run HMOs by unscrupulous landlords)

• Seasonal workers

• Few IMOs made – so presumably all HMO landlords are “fit and proper” and the “Health and Safety” condition is never met?

Overcrowding (or Crowding and Space

• Whatever happened to the Review on Overcrowding? Increasing, most marked in PRS 96-97- 63,000 h‟holds overcrowded; in 2009-10 152,000 (out of 630,000 h‟holds total)

• Impact of HB changes? – will more landlords try to pack more single people in (HMOs), or move out of this part of the market?

• Impact on educational attainment and behaviour at school

• Mental health impacts

Pro-housing Alliance

• PHA so far includes CIEH, UKPHA, Care & Repair (England) , Z2K and hopefully merging with National Housing Forum.

• Seeking greater recognition of the role of housing in society as a determinant of health and well-being and as a vital element of infrastructure to service the growth of the national and local economies

• More formal launch in June

Pro-housing Alliance

The Pro-housing Alliance will work to encourage others to join it in efforts to bring about a greater recognition of the role of housing in society as a determinant of health and well-being and as a vital element of infrastructure to service the growth of the national and local economies; it will seek to develop the components of a credible and just national housing policy

Pro-housing Alliance

• Increase the supply of affordable housing in all tenures

• recent set of housing benefit cuts should not be implemented

• Define in statute both „affordable housing‟, using local evidence, and „overcrowded‟

• Assess the redistributive effects of housing support

• Devise reforms for the land supply system and land taxation

Acheson Report in 1998

“As part of health impact assessment, all policies likely to have a direct or indirect effect on health should be evaluated in terms of their impact on health inequalities, and should be formulated in such a way that by favouring the less well off they will, wherever possible, reduce such inequalities”

Conclusion

• Local authorities need well-constructed data collection and recording systems, which could be used to demonstrate the positive contribution to the individual householders and society of housing interventions (Linking Housing Conditions and Health)

• Health inequalities reflect the degree of personal control over circumstances – including the home environment

• More effective interventions needed to reduce the negative impact of poor housing (including cost) that leads to health inequalities