In the third of our special series based on the contributions made to the London Labour Housing Group Conference on 25 October, Environmental Health campaigner and former President of the Chartered Institute of Environmental Health, Dr Steve Battersby MBE, looks at the vital links between housing and health.
Housing is a key social determinant of health and as such is crucial to tackling health inequity. Those lower down the social gradient of health are not only on lower incomes but have less control over their lives. That is particularly true for those living in the PRS and in the worst of the PRS.
Yet as the size of the PRS increases, the number of EH staff dealing with housing is reducing. EH is often ending up in “regulatory services” which do not make the link between housing and health, nor do they establish effective links on housing with the Directors of Public Health and the Health & Wellbeing Boards. Elected members have a role in making sure there are adequate resources.
The lack of resources means that officers deal only with complaints, which are least likely to come from those living in the worst conditions and who are most vulnerable. So there is a lack of any strategic approach to housing and health.
Enforcement of the provisions in the Housing Act 2004 is inadequate and is unlikely to get better. Even allowing for the faults in the drafting of the 2004 Act there are many provisions that are not used to best effect. I hear too often of the “informal approach” to getting landlords to do works. By all means councils should talk to landlords to decide the best course of action but they should not be strung along. It is better to act and then negotiate (especially if there is a statutory duty to act). Retaliatory eviction may be a concern but too often it is an excuse for inaction. With the right approach by local authorities and a more coherent approach to enforcement it is possible to reduce the risk of such evictions – as Liverpool have shown. It is also another reason why intervention should not be dependent on complaint.
The housing and health connection has been demonstrated by BRE using methodology based on the Housing Health & Safety Rating System – the system for assessing the risks from deficiencies in dwellings. BRE has shown that the real cost of poor housing to society could be in the order of £1.5bn per year.
If Category 1 hazards (as defined using the HHSRS and on which local authorities have a duty to take action under the 2004 Act) were reduced, savings to NHS would be £600 million per year (for the one off costs of remedial action which can sometimes be relatively cheap). In addition there are the social costs over and above the costs to the NHS that probably represents only 40% of total costs
Including the worst energy efficient homes (those with a SAP <41), interventions to improve heating and insulation gives potential savings to the NHS of a further £700 million p.a.
How much is it worth investing to keep people away from needing the NHS – that is reducing demands on the NHS?
To give some indication of the scale of the problem, the English Housing Survey indicates 3.1 million dwellings have at least one Cat 1 hazard and 500,000 have more than one such hazard. In the private rented sector around 780,000 have at least on Cat 1 hazard (19%).
The first criterion of the Decent Homes Standard is that any home should be free of Category 1 hazards. So the HHSRS applies to all sectors, it is only that local housing authorities cannot take legal action against themselves (so Part 1 of the Housing Act 2004 cannot be enforced by the council if it is the organisation in control of the house). That does not mean that the home cannot be inspected and hazards rated using the HHSRS. A Justice of the Peace for the area can even require that the Proper Officer carries out such an inspection and reports to the local authority itself.
To be clear, despite what is sometimes said, local housing authorities can enforce Part 1 of the Housing Act 2004 against housing associations in the same way as they should enforce against private landlords. Housing Association properties may be exempt from the HMO definition and those provisions in the Act, but they are not exempt from Part 1.
Finally, when it comes to housing the NHS 5 Year Forward View mentions housing only in the context of “Accelerating innovation in new ways of delivering care” saying ……” the refurbishment of some urban areas offers the opportunity to design modern services from scratch, with fewer legacy constraints – integrating not only health and social care, but also other public services such as welfare, education and affordable housing.” It does not mention the health impacts of existing homes, those that are crowded and lack space with mould or cold or containing falling hazards. Poor housing not only causes ill health, it prevents people being discharged from hospital.
More than this, if we are to address health inequalities we must look at housing. Think of crowding and lack of space (not the overcrowding standard from the 1930s) and its effect on children. It makes it more difficult to do homework, it affects behaviour at school as well as at home, so compromises educational attainment. The costs of poor housing are exported and the task of addressing inequalities in health is made more difficult.
So local authorities should have a key role in improving health by action on poor housing. Too often this is not recognized but to put it in financial terms alone can be problem because the potential financial gain from action is accounted for elsewhere. We need a fresh approach, which is possible with the new public health structures, in which local authorities (who can charge for enforcement action) also get wider recognition of the public health improvements achieved by their interventions.