Director of Public Health Annual Report 2018: Healthy places

The ability to stay healthy, access and maintain education, training and employment and contribute to community life is reliant on having a safe and stable place to live.

Living in an affordable good quality home is fundamental to people’s physical and mental health, helps them maintain independence for as long as possible, recover from illness and reduces demand on the NHS and social care. A sufficient supply of good quality affordable housing is also vital to the economic and social success of an area.

High quality, warm and energy efficient housing improves physical and mental health and reduces deaths. Conversely poor housing conditions are linked to poor health, accidents and excess winter deaths. A home is considered decent if it: meets the current statutory minimum standard for housing; is in a reasonable state of repair; has reasonably modern facilities and services; and provides a reasonable degree of thermal comfort. Across England in 2016, one in five owner occupied homes (19.7%) is considered to be ‘non-decent’.

A higher proportion of privately rented homes (26.8%) are considered non-decent whilst a lower proportion of socially rented homes are considered non-decent (12.6%).

Poor quality homes cost the NHS in England at least £1.4bn per year and wider society over £18.6bn. Children and older people or those with long term conditions are particularly vulnerable to poor housing conditions.

Excess cold experienced in the winter months can exacerbate a range of health problems, including respiratory and circulatory conditions, mental health problems and accidental injury for all age groups. A major factor contributing to living in a cold home is fuel poverty, where the required fuel cost is above average and if a household were to spend that amount to heat the home, the amount of money they would be left with would put them below the poverty line. Factors making households susceptible to living in fuel poverty are low household income, the energy efficiency of a home and the cost of heating.

Children and young people living in cold homes are more than twice as likely to have a respiratory condition and five times more likely to suffer from mental health problems. Hospital admissions are also higher among children living in colder homes. The long term impact of living in cold homes includes poorer educational attainment and lower emotional resilience. Adults living in cold homes have increased risk of respiratory disease, rheumatism and arthritis, mental health problems and increased risk of winter deaths from cardiovascular and respiratory disease.

It is estimated that 10% of excess winter deaths are due to fuel poverty. In addition, households living in fuel poverty are not only more likely to live in a cold home, but also more likely to have less disposable income, meaning household members may be less able to eat healthily, afford other essentials and take part in social activities.

Poor indoor air quality from materials used in the home has been linked to a range of problems including cardiovascular and respiratory disease and some cancers. Damp and mould are more likely in colder homes and can trigger exacerbations of asthma and make people more prone to respiratory infections. Children living in damp homes with mould are between 1.5 and 3 times more likely to have coughing and wheezing symptoms compared to children living in damp-free housing.

Across England, it is estimated that more than one in 25 homes has a damp problem. Damp is more common in privately rented accommodation (8.2%) and lowest in owner occupied accommodation (2.7%).

There are more injuries sustained in the home than anywhere else, resulting in approximately 6000 deaths per year nationally. Children under five and older people aged over 65 years are most likely to sustain an injury in their home. Injuries sustained in and around the home are the leading cause of avoidable death in children aged under 5 years. Each year, the cost of injuries sustained in the home is estimated to cost society over £45bn.

Falls are the most common accident in the home in all ages. The majority of these are due to trip hazards resulting from factors such as poor design or disrepair. Older people are most at risk of suffering a fall and within this age group, a fall is more likely to result in a fracture and subsequent loss of independence. In England, it is estimated that there are 1.3m households with people aged 55 and over who live in a home with a serious hazard.

Home improvements have been shown to improve health outcomes particularly for older people and those living with long term conditions on lower incomes. Housing refurbishment including damp-proofing, reroofing and new window installation is associated with improvements in general health outcomes. Home improvements have also been shown to reduce risk of falls and improve social outcomes.

The affordability of housing is increasingly becoming a problem as house price increases are consistently higher than wage increases. Housing affordability has worsened in the last two decades, with working people now expecting to pay around 7.6 times their annual earnings on average to purchase a home in England and Wales in 2016. This is up from 3.6 times earnings in 1997.

A lack of affordable housing can lead to financial hardship and stress, overcrowding and in the most severe cases homelessness. Families living in overcrowded conditions experienced a range of health related problems such as poor and irregular sleep patterns, depression and anxiety, strained family relationships and break-ups. Children and young people living in overcrowded conditions experience particular difficulties including health problems such as respiratory and infectious diseases, difficulties studying, emotional problems and developmental delays. More than 80% of families living in overcrowded homes identified lack of space as a major contribution to anxiety, stress and depression.

One impact caused by difficulty finding affordable housing is that people may turn to Houses in Multiple Occupation (HMO) in order to find somewhere to live. Poorly managed HMOs can pose a risk to physical and mental health with increased risks associated with sharing facilities with others (e.g. personal hygiene, food preparation, fire safety).

Lack of affordable homes is also linked to increase levels of homelessness. Someone is homeless if they have no access to accommodation either through a legal agreement (such as a tenancy) or an implied agreement (such as living with family or friends). This can potentially include people who are facing eviction, living in temporary accommodation, squatters, rough sleepers, people at risk of violence, those housed in poor quality accommodation that is a risk to their health and those who cannot afford their current accommodation. However while all these groups will be entitled to advice and assistance, currently local authorities do not have a duty to house everyone. All persons who approach the local authority for assistance are assessed on a case by case basis.

Homelessness can cause ill health, but in addition ill health can also result in loss of income or challenging behaviour and put some households at greater risk of becoming homeless. Approximately three quarters of homeless people report a physical health problem, with 41% reporting a long term condition (compared to 25% in the general population). The longer a person experiences homelessness the more likely their health and wellbeing will be at risk. The average age of death of a single homeless person who is rough sleeping is 30 years lower than the general population.

Only households assessed as being a priority need for housing, under the Housing Act, will potentially be given accommodation on an emergency and longer term basis. Groups deemed to be priority for housing generally include households with dependent children and/or households with a vulnerable member (e.g. due to medical reasons). Eligible individuals or families may be housed in temporary accommodation while their application for housing is considered or until suitable and secure accommodation is available. Temporary accommodation can include bed and breakfast, hostel, private sector or local authority/housing association stock and can be outside of the local authority where the housing application has been made.

Providing affordable housing for vulnerable people such as adults with learning disability and adult with substance misuse problems can lead to better social, behavioural and health related outcomes.

Provision of affordable housing for homeless people increases ability to engage with health care services, improves quality of life, mental health and employment.

The right home environment for people with additional needs protects and improves health and wellbeing, and enables people to live safely and independently in their own home. It also helps delay and reduce the need for health and social care, prevents hospital admissions, enables timely discharge from hospital and enables rapid recovery from periods of ill health. Good design and building quality should ensure homes can be adapted to people’s changing needs throughout life and enable people to stay in their own homes.

Older people spend a greater proportion of time in their homes and local neighbourhoods compared to other age groups. However, it is estimated that 2 million people aged 55 and over in England are not living in homes that meet their needs, and a high proportion of homes with older residents are not specifically designed for people as they get older (96%). This increases the risk of accidents and injuries as well as poorer physical and mental health. Developing age-friendly homes, neighbourhoods and towns is one of the most effective policy responses to our ageing population.

There is a shortage of well-designed, high-quality, appropriate and attractive housing in the right place for older people. More than three in every four adults aged 65 years and over in Bucks live in their own homes. However, nationally more than one in five older adults lives in a home that does not meet the decent standard. Nearly half the cost of poor housing to the NHS arises from poor housing among older people and is estimated at £624 million per year nationally.

Eight out of 10 older people say they would like to downsize, but only three out of 10 do so. Many people who do downsize move only at a time of crisis, when they are not necessarily making good decisions. Housing for older people needs to be close to shops, services and cultural facilities, and connect well to the public realm with good public transport links. The quality of the surrounding environment is also important, including access to shared, open, green spaces with well-placed benches and public toilets.

The majority of people living with a disability live in housing that is not designed to meet their needs. Home modifications for people with disabilities can help sustain independence, prevent hospital admissions and support earlier discharge from hospital as well as reduce care costs. Ensuring homes meet the needs of people with disabilities is also important for supporting people to remain safe and independent. It is estimated that 93% of homes lack access features for people with limited mobility.

Different people will have different needs necessitating a range of housing options from mainstream and accessible homes to supported and extra care housing. Extra care housing is accommodation that has been designed to meet the needs of older people who need additional support, often with varying levels of support available. Evidence shows that extra care housing can delay admission to a care home and provide a cost-effective alternative to residential care and can improve quality of life and social contact. There is also some evidence that extra care housing can reduce health costs.

The environments in which people live need to be designed to support their health throughout life.

The World Health Organisation (WHO) describes a lifetime neighbourhood as:

“…a place where a person’s age doesn’t affect their chances of having a good quality of life. The people living there are happy to bring up children and to grow older – because the services, infrastructure, housing, and public spaces are designed to meet everyone’s needs, regardless of how old they are.”

Lifetime neighbourhoods are those which offer everyone the best possible chance of health, wellbeing, and social, economic and civic engagement regardless of age. They provide the built environment, infrastructure, housing, services and shared social space for all people whether they are old or young, disabled or frail. Most features of lifetime neighbourhoods will benefit all generations.

The WHO has promoted the concepts of age- friendly cities and lifetime neighbourhoods. WHO describes an age-friendly city as one that:

“...is an inclusive and accessible urban environment that promotes active ageing … adapts its structures and services to be accessible to and inclusive of older people with varying needs and capacities.”

Urban and rural areas will present different challenges. For example, urban areas may more frequently suffer poor access to space or low social cohesion. Rural areas may have difficulty in providing access to services over more dispersed residential areas, for example, public transport and shops.

It is clear that designing neighbourhoods that work for all and particularly our growing child and older adult population is vital for the continued success of Buckinghamshire.