Healthy Homes Programme Utilising non-traditional Public Health workers Ian Watson, Programme Co-ordinator

“ Reducing health inequalities caused by poor quality housing conditions, and improving access to health related services in Liverpool ”

 Population: 436,000  Liverpool has among highest mortality rates and lowest levels of life expectancy. (SMR 30% higher than England & Wales)  Index of Health Deprivation Over a quarter of Liverpool’s SOAs fall within the most deprived 1% in England and over a half are within the most deprived 5%.  Large health inequalities. -10 years difference in life expectancy Overall Context

Health inequalities

Health inequality - JSNA  Healthy Eating (obesity and ill-health);  Smoking (prevalence 29% vs 24% nationally);  Regular physical activity (reduces obesity, improves mental health and well-being);  Quality of housing;  Low incomes; and  Limited access to health services.

Infant mortality - interventions  Targeting vulnerable groups  Engaging residents with Children’s Centres and clinicians  Reducing child poverty  Reducing obesity  Reducing smoking  Improving housing and reducing overcrowding  Reducing sudden unexpected deaths in infancy Factors that contribute to the gap between North West and England

Health Poverty Index The indicator Home environments (labelled 'Ind.' on the bar chart below) is made up from 4 sub-indicators : 1. Living alone 2. Social support scale* 3. Polluted local environment 4. Poor quality housing

Health and housing (BRE)

Overall Context - Housing  Poor housing conditions cause up to 500 deaths and around 5,000 illnesses requiring medical attention each year in Liverpool. (BRE estimates)  5,500 rented properties contain in the region of 7,500 category 1 hazards. (2006 stock condition survey)  Liverpool has the worst overall rate of fuel poverty in the country at 7.5% - some wards approach 50%. (CSE 2003)  Rate of excess winter deaths per year (2009 NHS profile)  For each winter death, there are 8 emergency admissions (DoH)  27% of households in Liverpool lack central heating

Accidents 1 Death 63 Hospital Admissions 1043 A&E attendances 3456 Of population Accident pyramid shows ratio between different types of accidental injuries in Liverpool according to outcome/severity  6 th highest cause of death (154 in 2008)  4 th highest accident related mortality in the country - higher than in Merseyside and in the North West.  2 nd highest accident related hospital admissions in country (8033 in 07/08)  50% of accident mortality caused by falls in 2008  Accidents in the home cause 58 deaths per year in Liverpool (2005 PCT).

Accidents - falls Falls mortality for Liverpool  Hospital admissions for falls higher in most deprived areas.  90% falls mortality - people of over 65 yrs of age (522 hip fractures in older people in 2007)

Health inequalities – upstream / downstream Reducing inequalities in health may depend on reducing inequalities in life chances and life circumstances

Programme objectives  Identify 15,000+ properties targeting need (Property condition and occupier vulnerability). Focus on private rented sector.  Assess the health needs of each occupant, and prioritise 2,750+ for HHSRS inspection.  Referrals to health and well-being related services.  Home Safety promotion (particularly under 11s and over 65s).  Through the removal of hazard exposure, the programme is designed to reduce premature deaths by up to 100 when fully implemented and reduce GP consultations and hospital admissions by over 1000 cases.

 Prioritising areas for intervention  Engaging communities Programme overview  Advocates knocking on doors  Single Assessment Process  Partner referrals to improve lifestyle and well-being  Case Support allocated to most in need  Making homes healthier and safer  Health awareness and promotion campaigns

HHP Index  IMD (4 of 7 domains)  Distribution of PRS & RSL  Rates of years of potential life lost  Emergency hospital admissions  Residence for hospital admissions for falls  Residential burglary  Housing Benefit Rate  Fuel Poverty Indicator Programme of intervention

Identify areas to be surveyed Contact Neighbourhood Managers from LCC & PCT Contact community leaders, Cllrs & local resident groups to identify the needs of the area Identify barriers and potential problems/ Issues Vulnerable and hard to reach residents - language issues - health & safety issues Publicity, promotion and events Poster and leaflet campaigns Community Engagement

Advocates / Case Support

Tackling health inequalities Financial deprivation Benefit Maximisation team CAB Age concern Next Step Pension Service Active City Clinicians Liverpool Addiction Services PCT Health Trainers Morbidity Smoking Fag Ends Oral health Patient Advisory Liaison Service Infant mortality Children’s Centres Clinicians Alcohol and drug dependency Liverpool Addiction Services Mental health Clinicians Healthy eating & obesity Taste4Life PCT Health Trainers City Safe

Referrals to Partner Agencies Patient advice and Liaison Service Patient advice and Liaison Service Benefit max

Progress - April 09 to August 10  10,582 properties visited  8,045 surveys completed  10,924 referrals to partners  1,844 HHSRS inspections carried out  £2.06M Private sector leverage  51 Health promotion events Employment- 41 direct staff working on programme - estimated 30 construction jobs in private sector

The Programme has engaged with 18,508 occupiers including: Age  1480 under 5 years of age  to14 years of age  years of age and over Disabled  1616 persons with a disability Ethnicity Customer Monitoring  19.6% of service users are not white British compared with 8.1% of population from BME communities Ethnicity

Referral PartnersTotal Referral PartnersTotal EHO1,795Smoking460 Dentist1,635Doctor207 Food & Nutrition1,333Mental Well-being718 Fuel Poverty424Benefit Maximisation365 Fire Service1,208Age Concern290 Education, Employment, and Training 630Sure Start220 Lifestyle Advisor726Alcohol & Drugs76 Energy efficiency837 Total referrals10,924 Referrals to partners

Housing inspections Time / Exposure Fire (301) -inhalation of smoke/fumes (mild to fatal), burns (mild to fatal) Falls (224) -physical injury (cuts, swellings, fractures, death), deterioration in general health for elderly Electric (38) - shock mild to fatal Collision&entrapment(21) -physical injury (cuts, piercing, trapping, crushing) Falling elements (20) - Minor bruising to death CO (5) -headaches to death, damage to nervous system Overcrowding (17) psychological distress, poor hygiene, increased risk of accidents, spread of contagious disease Harm / prevalence Entry by intruders (29) – emotional stress, injuries from aggravated burglary AcuteChronicGenerational Hot surfaces (17) - burns and scalds, psychological distress Excess cold (373) - cardiovascular conditions, respiratory diseases, rheumatoid arthritis, hypothermia Damp and Mould (169) - respiratory disease, allergic symptoms, infections, depression and anxiety Hygiene (74) - gastro-intestinal disease, asthma and allergic rhinitis, emotional distress, depression and anxiety

Disadvantaged groups  19.6% of service users are not white British vs 8.1% of population from BME communities  Prioritised accommodation occupied by asylum seekers, supporting people, & HMOs  Inbound referrals  Community engagement  37% of service users receiving benefits

Partner working Developments:  £ 80K for HHP energy efficiency measures  Inbound referrals set up with 4 health centres.  Looking to use GP patient records systems to refer into programme.  Children Centres & RoSPA teaming up to deliver home safety scheme  Winter Survival programme – 100,000+ leaflets sent out with flu vaccination letters

Inbound Referrals Healthy Homes Programme PoliceSure StartShelterBenefit max Health Centres Community Mental Health Teams Asylum Link RSLs Social Services Fire ServiceGP Also member of:  Mental health and housing development group  Accident prevention strategy group  Climate Change resilience task group  Seasonal excess death working group  PCT Neighbourhood Model

Social Marketing  Deliver CO awareness programme  Run Winter Survival road shows  Run number of Healthy Homes road shows (working with CHATS)  Working with schools to deliver accident prevention programme  Support child accident prevention week  Produced tenant information pack

Fuel cost Household income Energy efficiency Fuel Poverty Targeted approach by focusing on deprived areas, and inbound referrals Tackling Fuel Poverty

Tackling health inequalities Health inequalities 2010 Wider social determinants Local needs Longer life expectancy Reduced infant mortality Strategic use of enforcement powers Improved housing environment & reduced fuel poverty. Improving lifestyle & wellbeing Improving access to health services Increasing income Reducing seasonal excess deaths

Population health Personal health Community health Leadership Innovative Stakeholder days Central hub Partnership >16 partners Customer Focus Vision Tackle health inequalities 100 premature deaths prevented Systematic Working in priority SOAs Street by street interventions Addressing inequalities gap Referral pathways Reviewed and quality check Industrial scale 15,000 visits & 2750 HHSRS 3 Community engagement 18 Advocates 2 Case Support 10 Env Health Community engagement Protocol developed identifies vulnerable & maximises effectiveness Engagement with community Personal interventions from Advocates Diverse staff Relationship with partners e.g. CHATs, NMS Target support Outreach into community Inbound referrals Health centre surgeries Vulnerable groups e.g. Asylum seekers, BME Respond e.g. Bilingual Officers Impact at population level

Sustainability  Embed programme into mainstream services: -Single Assessment Process -RSL Charter  Comprehensive – tackling many determinants of health  Increased awareness of services  Neighbourhood based – aligns with future delivery pathways  Partnership working and inbound referrals – flexible and adaptable  Using GP patient records systems to refer  Cost benefit analysis – operational and investment efficiencies

Recognition  Used as case studies for local good practice by: -Audit Commission; - LACORS; - CIH; and - Marmot Review.  Finalists in MJ Award for Tackling Health Inequalities & Public Protection Achievement, NBA Regional and National for Customer Focus, and Chief Medical Officer ’ s Public Health Award.

Contact details: Phil Hatcher Programme Manager Ian Watson Programme Co-ordinator Liverpool City Council