A tale of two cities Housing Health and

A tale of two cities Housing, Health and Health Inequalities Stephen Battersby MBE Ph. D FCIEH FRSPH

Good health starts at home • The home is the main setting for our health throughout our lives – it is fundamental to our health • Housing is a social determinant of health the “conditions in which people are born, grow, live, work and age, including the health system” (Marmot)

Good health starts at home • Social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status • Persisting inequalities across key domains underscore this • Inequalities in early child development & education, employment & working conditions reflect housing & neighbourhood conditions which also affect mental health

A health map for the local human habitat Source: Barton H & Marcus Grant M, 2006, JRSPH, 126 (6)

Number of people killed or injured by location Per year UK Killed Injured 380 1, 500, 000 On the road 3, 600 317, 000 At home 4, 100 2, 700, 000 At work Source: WHO Europe 2005

Housing and Health • DWELLING – the physical structure providing shelter, the necessary space, facilities and amenities for the household. Unsatisfactory conditions may lead to one or more direct health effects (WHO)

Housing and Health • HOME - the social cultural and economic structure created by the household, representing a refuge from the outside & enabling the development of a sense of identity; any intrusion of external factors or stressors limits the feeling of safety etc (WHO)

Some issues • Housing condition – direct and indirect effects • Cost of housing - increasing debt and reduced ability to have control over one’s life (increasing health inequality) • Security – tenure relevant & frequent moves in PRS not conducive to stable home life – psychological stress (& end of AST most common reason for homelessness (32%) the “defining characteristic” (NAO)) • Local environment – no green space, poor air quality, noise, crime

Homelessness • 65, 000 families, 125, 00 children currently homeless • More than 300, 000 people in Britain sleeping rough or in temporary accommodation • Temporary accommodation often not properly assessed & can be hazardous • Children in temporary accommodation for > one year 3 x more likely to demonstrate mental ill health • Moving home many times in early life affects child behaviour and mental health (Shelter)

House to be used for homeless family – (roof space converted to two bedrooms) Open riser stair (of varying heights) to first floor from behind rear door in kitchen area of single ground floor room + irregular tread at top step & “ranch” style climbable guarding

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) • A damp home is also more likely to be a cold home

Cold – Direct impacts • Excess winter deaths 3 x higher in coldest quarter than warmest quarter; 40% attributable to cardio-vascular disease &33% attributable to respiratory disease • Children - >2 x more likely to have respiratory problems • Adolescents >1 in 4 at risk of multiple mental health problems (1 in 20 in warm homes) • Increased COPD, & cardio vascular diseases • Mental ill-health • Arthritis & rheumatism exacerbated (IHE, UCL)

Cold – Indirect impacts • Cold homes negatively affects – children’s educational attainment & emotional wellbeing & resilience – family dietary opportunities and choices (to eat or heat dilemma) – dexterity: increases risk of accidents & unintentional injuries • Time off work and loss of earning for occupiers as the result of ill-health (reinforcing poverty & health inequity) (IHE, UCL)

(Over)crowding & Lack of space • Adverse effects on children include negative educational performance and behaviour (Ambrose & Farrell 2009) • Children up to 10 times more likely to contract meningitis (Harker 2006) • Overcrowding linked to spread of TB (in 2011 there were 8, 963 cases reported (HPA) • Increase risk of accidents & unintentional injuries

Housing Health and Safety Rating System (HHSRS) • Underlying principle - a means of comparing different hazards arising from deficiencies and of reflecting the seriousness of these as identified by the ‘surveyor’ or building manager on inspection • It is NOT a standard – it is a means of assessing dwellings (not actually enforced but underpins any action by local housing authority)

The HHSRS principles • Any residential premises should provide a safe and healthy environment for any potential occupier (or visitor) • Dwelling unit (letting) should be capable of providing adequate protection from all potential hazards prevailing in local external environment • Some hazards inevitable but risks should be minimised

The HHSRS principles • A dwelling that is safe & healthy for the vulnerable age group will be safe and healthy for all • It is the effects of deficiencies that are important not the deficiencies themselves the HHSRS is solely about risks to health and safety

Potential Housing Hazards Arranged into four groups A - Physiological Requirements B - Psychological Requirements C - Protection Against Infection D - Protection Against Accidents

Potential Housing Hazards A - Physiological Requirements Hygrothermal Conditions § Damp and Mould Growth § Excess Cold § Excess Heat § § § § Pollutants (non-microbial) Asbestos (and MMFs) Biocides Carbon Monoxide etc Lead Radiation Uncombusted Fuel Gas Volatile Organic Compounds

Potential Housing Hazards B - Psychological Requirements Space, Security, Light & Noise § Crowding and Space § Entry by Intruders § Lighting § Noise

Potential Housing Hazards C - Protection Against Infection Hygiene, Sanitation & Water Supply §Domestic Hygiene, Pests and Refuse §Food Safety §Personal Hygiene, Sanitation & Drainage §Water Supply for Domestic Purpose

Potential Housing Hazards D - Protection Against Accidents Falls § Falls associated with baths etc § Falling on the level § Falling associated with stairs and steps § Falling between levels Electric Shocks, Fires, Burns & Scalds § Electrical Hazards § Fire § Flames and Hot Surfaces etc Collisions, Cuts and Strains § Collision & Entrapment § Explosions § Position and operability of amenities § Structural Collapse & Falling Elements

Deficiencies & Hazards • One deficiency could give rise to more than one hazard – disrepair to a door and frame & self-closer could give rise to “Entry by Intruders” “Noise” “Excess Cold” (draughts) “Domestic Hygiene Pests & Refuse” depending on the location and nature of disrepair • Many deficiencies could give rise to only one hazard – mould in the bathroom, penetrating damp under to window and through the ceiling all contribute to “Damp & mould” - single hazard rated once, but greater exposure greater risk

Relating People & Hazards Potential hazards are assessed in relation to the most vulnerable class of person (by age) who might typically occupy or visit the dwelling, regardless of who actually occupies e. g. ~ potential hazard from gaps in banisters judged in terms of young child The principle is that if a dwelling is safe or healthy for the most vulnerable then it will be safe for all

“Harm” is: The possible health outcome(s) from an occurrence, whether temporary or permanent. That is, the adverse physical or mental effect on the health of a person, such as physical injury, illness, or other health condition or symptom that would justify medical attention

Hazard rating • Identified hazard is rated by a formula that takes account of: 1. Likelihood or probability of an occurrence (event or exposure that could cause harm) over next 12 months 2. Percentage spread of possible harm outcomes, from extreme to moderate • The formula produces a hazard score or rating

Part 1 Housing Act 2004 Enforcement by local authorities– • Category 1 Hazards (Bands A – C or Hazard rating of 1000 or more) duty on LHA to take the most appropriate enforcement action in Part 1 Housing Act 2004 • Category 2 Hazards (Bands D – J or Hazard rating of 999 or less) power on LHA to consider action

Points to note • Hazard arises from deficiencies and is rated by reference to the “vulnerable age group” where this has been identified, regardless of actual occupation (an empty property could be rated) • The actual occupation will be taken into account when the LHA considers which if any course of action under Part 1 of Housing Act 2004 e. g. Hazard Awareness, Improvement Notice or Prohibition Order etc

Local authority action • 2015 -16, 4. 5 million households were renting in the private sector (second largest tenure) • 28% of private rented homes failed to meet the Decent Homes standard (0. 795 m with any Cat 1 hazard – 0. 229 m Excess Cold) • Evidence is many local authorities not using their powers effectively; in 2013/14 – Median no. Improvement Notices = 6 – Median no. Prohibition Orders =1

Cost of poor housing The HHSRS Formula allows an assessment of the costs of poor housing to be made as harm outcomes can be “monetised” – although “exported” or social costs not included Costs & benefits to the NHS of reducing Cat 1 Hazards to acceptable level Country England No. Cat 1 hazards Total cost Savings to Payback of remedial NHS p. a. (£) period action (£) 4, 752, 000 17. 6 bn 602 m 29. 3 Wales 363, 433 1. 5 bn 67 m 22. 9 N. Ireland 144, 458 0. 4 bn 33 m 12. 8 Scotland 458, 434 1. 5 bn 58 m 26. 4

Costs and savings for some Cat 1 hazards Hazard Excess Cold Falling on stairs Falling on level Dampness Noise CO Fire Av remedial cost per dwelling (£) Total cost to remedy (£bn) Savings to NHS p. a. if hazard remedied (£bn) Payback (years) 4, 574 857 6. 061, 1. 159 0. 848 0. 207 7. 14 5. 60 780 0. 424 0. 127 3. 32 7, 382 1, 411 506 128, 590 0. 394 0. 008 0. 46 0. 015 0. 0018 0. 0015 0. 025 25. 27 4. 96 5. 21 18. 62

Costs to NHS of all homes with significant HHSRS hazards No dwellings % Housing Stock Cost to NHS p. a. (£) Homes with 1+ Cat 1 hazard 3, 472, 765 15. 3 1. 413 bn Homes with 1+ Cat 2 (rated >500) Hazard but no Cat 1 2, 476, 655 10. 9 428 m Homes with worse than average Hazard (<500) but no Cat 1 2, 433, 939 10. 7 160 m Homes with significant hazards (any of above) 8, 383, 359 36. 9 2. 0 bn All housing in England 22, 718, 266 100 -

Housing and other health hazards Risk Factor Total cost burden to NHS p. a. Physical inactivity £ 0. 9 -£ 1 bn Overweight/obesity £ 5. 1 -£ 5. 2 bn Smoking £ 2. 3 -£ 3. 3 bn Alcohol £ 3. 2 -£ 3. 2 bn Housing £ 1. 4 -£ 2. 5 bn Source: Nicol, Roys & Garrett The cost of poor housing to the NHS, PHE Briefing Paper

Thank You Any Questions?