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

2. 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)

3. 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 affect mental health

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

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

6. 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)

7. 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)

8. 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

9. 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 3x more likely to demonstrate mental ill health
Moving home many times in early life affects child behaviour and mental health
(Shelter)

10. 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

11. 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

12. Cold – Direct impacts
Excess winter deaths 3x higher in coldest quarter than warmest quarter; 40% attributable to cardio-vascular disease &33% attributable to respiratory disease
Children - >2x 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)

13. 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)

14. (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 there were 8,963 cases reported (HPA)
Increase risk of accidents & unintentional injuries

15. 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)

16. 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

17. 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

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

19. 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

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

21. 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

22. Potential Housing Hazards
D - Protection Against Accidents
Collisions, Cuts and Strains
Collision & Entrapment
Explosions
Position and operability of amenities
Structural Collapse & Falling Elements
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

23. 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

24. 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

25. “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

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

27. 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

28. 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

29. Local authority action
, 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 (0.795m with any Cat 1 hazard – 0.229m 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

30. 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
No. Cat 1 hazards
Total cost of remedial action (£)
Savings to NHS p.a. (£)
Payback period
England
4,752,000
17.6bn
602m
29.3
Wales
363,433
1.5bn
67m
22.9
N. Ireland
144,458
0.4bn
33m
12.8
Scotland
458,434
58m
26.4

31. Costs and savings for some Cat 1 hazards
Av remedial cost per dwelling (£)
Total cost to remedy (£bn)
Savings to NHS p.a. if hazard remedied (£bn)
Payback (years)
Excess Cold
4,574
6.061,
0.848
7.14
Falling on stairs
857
1.159
0.207
5.60
Falling on level
780
0.424
0.127
3.32
Dampness
7,382
0.394
0.015
25.27
Noise
1,411
0.008
0.0018
4.96 CO
506
0.0015
5.21
Fire
128,590
0.46
0.025
18.62

32. 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
1.413bn
Homes with 1+ Cat 2 (rated >500) Hazard but no Cat 1
2,476,655
10.9
428m
Homes with worse than average Hazard (<500) but no Cat 1
2,433,939
10.7
160m
Homes with significant hazards (any of above)
8,383,359
36.9
2.0bn
All housing in England
22,718,266
100 -

33. Housing and other health hazards
Risk Factor
Total cost burden to NHS p.a.
Physical inactivity
£0.9-£1bn
Overweight/obesity
£5.1-£5.2bn
Smoking
£2.3-£3.3bn
Alcohol
£3.2-£3.2bn
Housing
£1.4-£2.5bn
Source: Nicol, Roys & Garrett The cost of poor housing to the NHS, PHE Briefing Paper

34. Thank You Any Questions?