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South East Regional Public Health Group Information Series 2

Health and Homes: A Basis for Wider Collaboration

Vision

Creating healthy, sustainable and live communities; decent, safer, warmer homes and ensuring the housing needs of all are met.

Audience

All those able to influence health by improving homes for people, including: Health and Public Health,Social Services, Environmental Health, Local Authority Housing and Planning, Housing Associations, Private Architects and Planners, Local Strategic Partnerships.

Produced with the endorsement of CIEH – Chartered Institute of Environmental Health

Health and Homes- the three domains:

The Built Environment The Home The Individual

This information series has been compiled by the Regional Public Health Group based in the Government Office of the South East. They aim to summarise key public health issues based upon evidence, in order to facilitate good practice and improve health at local and regional levels. They are NOT policy documents.

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Why it’s Important

Housing - the forgotten public health agenda?

The recognition of poor health and poor housing was the main focus of earlier public health reformers.

Influencing the design of earlier houses, improvements were made in ventilation, lighting, heating and

overcrowding, which made a major contribution to the decline of infectious diseases. Today’s legislation

now ensures basic structural and sanitary conditions. However, since the separation of Medical Officers of

Health from Local Authorities in the 1970s, housing has become a relatively marginal public health issue.

The following highlights the important role that housing still has in improving health and reducing

inequalities.

Additionally, there are wider aspects of Housing which affect health in the long-term via the impact of

housing on Climate Change. Maximising the use of active transport, insulation to reduce heat loss, and

ensuring maximum use of renewable energy sources all contribute to a sustainable future, where quality of

life is placed as a central value in the development of economic and housing growth.

Housing- a fundamental need: ‘Maslow’s hierarchy of needs’ places housing as central to achieving health

and well-being, with basic physiological needs and safety as fundamental needs placed at the base of the

pyramid.

Current Situation

Unsafe communities, poor housing conditions, lack of infrastructure and appropriate provision compared

to need affects health negatively in a number of ways:

Physical health: Cold and damp, indoor pollutants; design quality, injury and safety hazards; ease and safety of active transport (walking, cycling) lead to excess winter deaths, obesity and heart disease, asthma and respiratory disease;

Social and Mental Well-Being: Affected by noise, over-crowding, unstable housing tenure/ homelessness; poor neighbourhood quality and community safety; infrastructure deprivation, access to services, open spaces and transport.

Percentage of persons with limiting long-term illness living in accommodation with no central heating, 2001

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Source: Office for National Statistics. 2001 Census (Table ST018: Sex and amenities and central heating by limiting long-term illness).

Key: Coloured bars = Persons with limiting illness living in housing with no central heating = Persons without a limiting illness living in housing with no central heating

Hampshire &I sle of Wight

Kent &Medway

Surrey & Sussex Thames Valley

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Percentage of households living in fuel poverty by ward, South East England

Source: Centre for Sustainable Energy. A Profile of Fuel Poverty in the South East Region, 2004

What Works

The following is summarised from evidence of effective approaches (see References and Resources on

last page for further details).

1. The Built Environment:

Aspect of the Built Environment Impact upon Health

Promoting Active Transport: Safe Roads – reduced traffic and speed Cycle paths with priority for cyclists Safe paths Safe parks Good access to public transport Better air quality

Promotion of Activity: Reduction in traffic injuries Reduces obesity Improved Coronary Heart ‘fitness’ Activity in elderly reduces risk of falls and

improves physical and mental well-being Reductions in respiratory disease

Community Safety: Street lighting Good visibility ensured in urban design CCTV Community and Park Wardens

Reduces risk of harm and fear of crime: Increases participation in activity, including

after dark, especially by women and elder people.

Reduces social isolation and enhances social cohesion

Promotes mental well-being

Social Capital: Aesthetic and clean environment Shops and services Schools and Education Community centres Health centres

Reduces inequalities in health: Improvements in Mental Well-being Increased social capital benefits social and

mental well-being Local access to fruit and vegetables Improved access to services Promotes local active transport

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2. The Home

3. The Individual:

Nationally approximately 15% of total households have vulnerable individuals. The housing needs of

specific groups or individuals need to be adapted according to their circumstances. Addressing housing

need adequately and preventing homelessness has been shown to have positive health and social benefits,

especially for the following groups:

Aspect of the Home Impact upon Health

Structure and design: Temperature Damp Ventilation Noise Overcrowding Sanitation Safety from intruders Accessibility

Excess winter and summer deaths – related to insulation, heating and ventilation

Excess respiratory and cardiovascular diseases related to temperature and dampness

Noise levels affect sleep and mental well-being Ventilation affects temperature, dampness, infectious diseases and

radon Over-crowding increases infectious diseases and increases stress

levels Increased security reduces fear of crime, potential injury and reduces

the need for re-housing (from burglary or violent ex-partners) Mainstreaming the accessible design of houses for disability decreases

social exclusion.

Interior Design:

Injury Prevention Child Safety Fire Safety Falls Prevention

Decoration

Home Improvements

Child friendly windows and stair gates decrease the risk of falls Free distribution of smoke detectors shown to reduce fire related

injuries Lighting, grab rails and reducing trip hazards can reduce the risk of

falls

Re-decorating housing association houses has shown a reduction in depression

Improved physical, mental health and reduced health services use after home improvements.

People with physical health problems People with a disability (physical or learning) Mental Health problems Older People Looked After Children / Vulnerable Young

People

Temporary accommodation Homeless people Victims of domestic violence Ex-prisoners Recovering substance misusers Travellers and gypsies Asylum seekers Teenage parents BME groups

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Example of what works - Preventing Homelessness:

Homelessness Strategy- 2005 ‘Sustainable Communities: Settling Homes, Changing Lives’ Homelessness

levels reduced by actively preventing homelessness via mediation, sanctuary and secure housing for

domestic violence, rent deposit schemes, debt counselling, fast tracking housing benefit and housing

advice.

The diagram below summarises good practice approaches developed nationally and in the South East to

prevent homelessness.

Ways Forward

Homelessness Prevention

ODPM Targets:•Halve the numbers living

In temporary accommodationBy 2010

•Reduce Rough Sleepers•Maintain avoiding use of Bed& Breakfast accommodationFor families with children for

Over 6 weeks

Prevention Measures

Causes of Homelessness:•Parents/ relatives or friends No longer willing or able to

Accommodate•Violent/ non-violent breakdown

Of a relationship•Termination of assured

Short- hold tenancy•Other: mortgage/ rent arrears,

Harassment, leaving Institutional care, Rough sleepers.

Best Value Performance Indicators for homelessness:

•BVPI 183a & b: Length of stay in temporary Accommodation (a= B& B; b= hostels)•BVPI 202: Number of rough sleepers

•BVPI 203: Change in number of familiesin temporary accommodation

•BVPI 213: Repeat homelessness•BVPI 214: Housing advice service:

Preventing Homelessness•BVPI 225: Actions against Domestic

Violence

Prevent Homelessness:•Carry out home visits once received

Application for homelessness acceptance•Use a spend to save policy

•Put Housing advice at ‘front of the shop’•Provide financial support & practical

Assistance•Use mediation

•Support/ assist families experiencing DV•Encourage Tenancy sustainment

•Adopt pre court work

Identify High Risk situations & intervene early

•Fast track referrals for vulnerable groups-Including ex-offenders, homeless admitted

to hospital, LAC, victims of domestic violence, those with mental health or

substance misuse problems•Ensure good partnerships with LA

homelessness strategy, including health, DAAT & probation

Maximise supply of settled housing•Allocations scheme, monitor voids,

under occupancy, out of borough movesMaximise use of local housing stock•Private sector, leasing schemes, good

Quality hostels, accredit landlords/ agentsImprove uptake of housing benefit

•Rent in advance & deposit schemes & •discretionary housing payments

VisionTo reduce homelessness-Offering a wide range of

Preventive initiatives-Increasing access to

settled homes

‘Sustainable communities: Settled Home; Changing Lives,

A Strategy for tackling Homelessness’ODPM, 2005. www.odpm.gov.uk

Risk Factors for Homelessness•Young age: 16-19

•Male•History of being Looked After•Alcohol/ Substance Misuse

•Mental Health problems•Domestic Violence victim

•Ex-Offenders•Asylum seekers

Administer Homelessness Differently:•Better understanding of local causes

•Offer options at the outset•Identify possible repeat homelessness•Have the right people in the right place

Doing the right thing at the right time

Austin G & Nurse J, 2006

1. The Built Environment

Local Development Frameworks- ensure health aspects and supported housing needs of vulnerable groups taken into account within the framework and for individual projects included within Section 106 and advocate for the inclusion of the ‘Secure by Design’ standard for housing and urban plans;

Encourage uptake of Eco- Homes Standards and Code for Sustainable Homes in planning and design. Seek opportunities to “green” the wider environment;

The Growth agenda: ensure public health engagement with Renaissance Partnership Boards and influence planning process;

LAAs: Adoption of housing targets that benefit health: LSP community strategies, LPSAs, LAAs;

Regeneration money funding community development- sustainable communities and healthy built environments- encouraging active transport;

Safer Communities: Participation in Crime and Disorder Reduction Partnerships and advocate for safer communities, including street lighting, increasing urban design to enhance visibility, CCTV, community wardens, and secure housing for victims of domestic violence;

Housing Associations: work in partnership to reduce social exclusion and enhance the health gains with local ‘In Business for Neighbourhoods’ campaigns.

2. The Home

Use health inequalities data to direct housing improvement schemes;

Winter Warmth: Partnership working to address fuel poverty and improve winter warmth (Environmental Health Practitioners with the HHSRS, health, HECA, VCS), see diagram;

Injury Prevention: Develop multi-agency injuries prevention approaches to address fire safety, child safety and falls prevention;

Home Improvement Agencies and Handyperson repair schemes: direct provision with assistance in small repairs, minor adaptations, odd jobs, safety checks, falls and accident prevention for low income and elderly households;

Influence Housing Process: Engagement with local authority housing partners and housing

strategies to ensure health needs are taken into account.

3. The Individual

Homelessness: Contribute to Local Authority Homelessness Strategies and Groups:

PCTs and LAs to improve health care access for Homeless people

PCTs to develop joint protocols for homeless people admitted to acute trusts and

CMHTs, to produce joint guidelines with DAATs;

Environmental Health: Raise awareness and engagement in wider public health workforce (EHPs) of opportunities of ‘Decent Homes Standards’ and Housing, Health Safety Rating System (HHSRS) (Housing Act 2004). The HHSRS considers the vulnerability of occupants as part of a hazard assessment, addressing winter warmth and falls prevention. Use public health skills to develop a strategic approach for prioritising HHSRS assessments;

Winter Warmth: develop referral pathways from health professionals concerned about individuals housing warmth for an HHSRS assessment, (see diagram);

Promote independence and address housing needs of vulnerable groups: via engagement with local Supporting People plans, Direct Payments, Mental Health LITS (Local Implementation Teams for the National Service Framework), Drug Action and Alcohol Teams, and Probation with local Housing Strategies;

Plan for demographic changes: with an increasingly ageing population with changing housing needs. Combine census data, local and regional housing surveys to predict and plan for changing housing needs to ensure that older people live in homes of decent standard, in a safe environment, with good access to services and transport, which promotes independent living and social integration.

Ways Forward - Good Practice Example

Partnership work to address fuel poverty and improve Winter Warmth:

Older people are at particular risk of excess winter deaths associated with fuel poverty. The risk is higher for those living on low incomes, in under-occupied older houses, in privately rented or owner occupied housing. Aside from reducing excess winter deaths, improving winter warmth has wider physical, mental and social well-being benefits.

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Below is a summary of good practice partnership work within the South East.

National Drivers

The Housing Act (2004)

The Housing Fitness Standard (HFS) has been replaced by the Housing, Health and Safety Rating System (HHSRS);

Focus on improving private sector housing with licensing landlords of Houses of Multiple Occupation (HMOs) and areas with anti-social behaviour;

Maintain availability of social housing and extend powers of the Housing Corporation to provide grants for developing new housing.

The Housing, Health Safety Rating System (HHSRS)

Provides an assessment system for Environmental Health Practitioner’s (EHP’s) to identify (and act upon), dwellings that pose a threat to occupants’ health and safety, according to need (e.g. cold, damp, fire, trip hazards, noise, security, environment and sanitary hazards).

Homelessness Strategy (2005) ‘Sustainable Communities: Settling Homes, Changing Lives’

Target to ‘halve number of households in insecure temporary accommodation by 2010’ by preventing homelessness and supporting vulnerable people;

Significant funding to modernise hostels (£90m) to prevent homelessness (£130m).

•Reduce Heat Loss-individual and home

•Improve Heating Efficiency•Increase affordability

-Tariffs & Income

StrategicLeadershipLSP/ LAA

EstablishPartnership

Target highrisk groups

Trainingawareness

& protocols

ActivitiesAwareness

Monitor &Feedback

LA: HECA, Housing, EH, EEC, Social Services:Home CareHealth: Public Health,Community Matrons,OT, HV, Dist. NursesVCS: Age Concern, Eaga, Help the AgedDWP: Pensions & Benefits

•Older People•Young Families•Poor Health•Deprivation•Poor Housing

Mainstream Training &protocols

•Community events•Flu Campaigns•Targeted Mail Outs•Media

Resources & Info:Fuel Poverty & Health Toolkit

www.heartforum.org.ukWarmfront: www.eaga.co.uk

Helpline: 0800-33-66-99Nurse J, 2005

Simplify Referral & Delivery

pathways

Establish local shared Pathways or single point of contact-Link to HHSRS & SAP

To increaseAwareness & motivation

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Supporting People

Supporting People Programme (£5bn over 3 years) administered by local authorities; housing related support services help people live independently in the community, e.g. people with learning disabilities, teenage parents, older people (community alarms, sheltered accommodation), support for substance misusers and low level preventative sources for people with mental health problems;

‘Our Health, Our Care, Our Say’ (2006), emphases promoting independent living and social well being, care at home, increasing activity, individual choice and prevention.

Public Service Agreements (PSA’s)

Department of Communities and Local Government (DCLG) Tackle social exclusion and deliver neighbourhood renewal, working with other departments,

in particular narrowing the gap in health, education, crime, worklessness, housing and liveability outcomes between the most deprived areas and the rest of England, with measurable improvement by 2010;

By 2010 reduce the number of accidental fire- related deaths in the home by 20% and the number of deliberate fires by 10%;

By 2010 bring all social housing into a decent condition with most of this improvement taking place in deprived areas and for vulnerable households in the private sector, including families with children, increase the proportion who live in homes that are in decent condition;

Lead the delivery of cleaner, safer and greener public spaces and improvement of the quality of the built environment in deprived areas and across the country, with measurable improvement by 2008.

DEFRA/ DTI/ DT: To promote sustainable development across government and in the UK and internationally.

(DEFRA); To reduce greenhouse gas emissions to 12.5% below 1990 levels in line with Kyoto

commitment and move towards a 20% reduction in carbon dioxide emissions below 1990 levels by 2010, through measures including energy efficiency and renewables. (DTI/DT);

Enable at least 25% of household waste to be recycled or composted by 2005-6, with further improvements by 2008 (DEFRA);

Eliminate fuel poverty in vulnerable households in England by 2010 in line with the Government’s Fuel Poverty Strategy objective (DEFRA/ DTI);

Improve air quality by meeting the Air Quality Strategy targets for carbon monoxide, lead, nitrogen dioxide, particles, sulphur dioxide, benzene and 1,3 butadiene.(DEfRA/ DT);

By 2010 increase the use of public transport (bus and light rail) by more than 12% in England, compared with 2000 levels (DT);

Reduce the number of people Killed or Seriously Injured (KSI) in Great Britain in road accidents by 40% and the number of children KSI by 50% by 2010, compared with 1994-98 average, tackling the significantly higher incidence in disadvantaged communities. (DT).

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Local Area Agreements: Indicators proposed guidance followed by areas to consider

Children and Young People’s Block Number of 0-15 year olds killed or injured in road traffic accidents; Numbers of families with children placed in temporary accommodation under the homelessness

legislation/ aggregate number of days spent by families with children in temporary accommodation;

Percentage of social housing and vulnerable households in the private sector in a decent condition;

Number of low income families in fuel poverty.

Suggested areas to consider developing into an LAA: Modal share of active transport to school (incorporated into school travel plans), as a proxy for low

speed limits, good urban design, decreased parental car journeys etc.

Safer and Stronger Communities Block Increase the proportion of prolific and other priority offenders judged as having sustainable and

settled accommodation at the end of their contact with probation; Measurements of ASB – environment or other criminal activity which are recorded as a crime type

(usually by the police) – e.g. criminal damage, incidents of graffiti, abandoned cars and fly-tipping; Improving the energy efficiency/ carbon performance of operational property and/or community

organisations (VCS and private) and/ or housing stock; Public access to green spaces or condition of green spaces.

Suggested areas to consider developing into an LAA: Increase the use of green gyms to increase social capital, decrease fear of crime, improve

environment and facilitate cross generational social networks.

Healthier Communities and Older People Block Improved access to employment, training and housing for those in drugs treatment or leaving

drugs treatment (consider other groups- alcohol misuse and offenders); Number of people aged 75 or over admitted to hospital as a result of falls; Proportion of older people supported to live in their own home/ adults receiving direct payments; Reducing fuel poverty/ increase winter warmth - e.g. level of energy efficiency of housing; numbers

of vulnerable households living in fuel poverty; successful referrals to Warmfront; increased take up of eligible benefits for older people.

Suggested areas to consider developing into an LAA: Housing needs actively assessed, incorporated into care pathways, outcomes recorded and

audited for vulnerable groups in contact with health care services.

Economic Development Block Reduce the incidence of child poverty, contributing to the national targets of halving child poverty

by 2010; Percentage of new housing within the growth point that meets level three in the Code for

Sustainable Homes; Level of local transport congestion; Percentage of food products used being locally produced and supplied;

Suggested areas to consider developing into an LAA: Integrate economic regeneration with environmental design to improve the built environment;

consider previously neglected areas.

Above Indicators are in LAA Guidance: http://www.odpm.gov.uk/index.asp?id=116135

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References and Resources Chartered Institute of Housing: www.cih.org

‘Good Practice Briefing: Health and Housing’ Issue 29, Oct 2004; Developed by Chartered Institute of Housing and DH. Email: gpu@cih.org)

Chartered Institute of Environmental Health: Guides to: Decent Homes Standards; Area Renewal Urban Regeneration; Health and Housing Safety Rating System (HHSRS) www.cieh.org

National Housing Federation- supports 1400 Housing Associations in England with 5 million residents. Not for profit organisation, promoting decent, affordable housing; safer, sustainable neighbourhoods; development of mixed communities to reduce social exclusion. www.housing.org.uk

‘Healthy Sustainable Communities- What Works?’ Ben Cave et al, Milton Keynes South Midlands Health and Social Care Group, www.mksm.nhs.uk

Thomson et al (2001) ‘Health Effects of Housing Improvement: a systematic review of intervention studies’ BMJ 323:187-190, www.bmj.com

‘Housing and Public Health: a review of reviews of interventions for improving health’ Evidence Briefing Summary and Full Report, NICE 2005, www.publichealth.nice.org.uk

‘Our Health, Our Care, Our Say’ DH, 2006, http://tinyurl.com/c8ne2

Housing and Public Health: a review of reviews of interventions for improving health’ Evidence Briefing Summary and Full Report, NICE 2005, www.publichealth.nice.org.uk

Supporting People – www.spkweb.org.uk

Homelessness Strategy- 2005 ‘Sustainable Communities: Settling Homes, Changing Lives’ ODPM, 2005. www.odpm.gov.uk

Shelter: National organisation for homelessness, www.shelter.org.uk

Care and Repair: A national charity aimed at improving housing conditions of older and disabled people; www.careandrepair-england.org.uk

Foundations: a national co-ordinating body for Home Improvement Agencies in England: www.foundations.uk.com

Housing Learning and Improvement Network, Department of Health Change Agent team, a resource network for health, social care and housing providers on accommodation with care solutions for older and vulnerable people – www.changeagentteam.org.uk/housing

Building our Futures- Meeting the housing needs of an ageing population: - Guidance on what data to use to predict demographic and housing changes, changing housing needs with age, including estimated changes in home adaptations, when older people move, and need for sheltered and care homes. International Longevity Centre, UK, www.ilcuk.org.uk

Commission for Architecture and the Built Environment: publications and news sharing good practice in quality design which improves health and well-being, for the built environment and for health care facilities. www.cabe.org.uk

For further information please contact: jo.nurse@dh.gsi.gov.uk

For additional copies of the Information Series please visit the SE Regional Public Health Group website www.gose.gov.uk/gose/publichealth