HC 1048-III Health CommitteeWritten evidence from Northern Housing Consortium Limited (PH 160)

1. Submission from Northern Housing Consortium Limited.

1.1. The Northern Housing Consortium (NHC) represents organisations responsible for housing in the north of England.

2. In summary:

The NHC supports the creation of Public Health England and welcomes the focus on helping people live longer, healthier and more fulfilling lives, and improving the health of the poorest fastest. This is a key issue for the north where health inequalities persistent.

We support the decision to devolve public health responsibilities to local authorities but there must be some form of housing representation on Health and Wellbeing Boards (HWB) and in the development of Joint Strategic Needs Assessments (JSNA) and Joint Health and Wellbeing Strategies (JHWS). This is particularly important in two tier areas where the responsibility for housing lies at district level.

Housing organisations have a key role to play in tackling health inequalities and in supporting people to be healthy and independent. Linking housing to the HWB, JSNA and JHWS will strengthen local approaches to health and wellbeing.

We welcome the development of a public health outcomes framework and urge the inclusion of indicators which will tackle persistent health inequalities and which encompass the indicators in the national outcomes framework for Supporting People. Aligning the outcomes framework with the NHS and social care outcomes is welcomed although a better approach would have been to develop a common outcomes framework from the outset.

We welcome the ring fenced public health fund and the health premium. However housing organisations must be involved in delivering integrated approaches funded through the public health fund. To incentivise improvements in the most deprived areas the health premium must be linked to indicators of deprivation and must follow comparative progress. Unless this happens the gap in inequalities will widen and we will see many communities in the north fall further behind.

We have concerns that cuts in funding will jeopardise opportunities to tackle the wider determinants of health as set out in the Marmot report.

3. The Creation of Public Health England within the Department of Health

3.1 The NHC welcomes the Government’s decision to establish a dedicated body within the Department of Health—Public Health England—to achieve improvements in public health outcomes and oversee the local delivery of public health services. We welcome the aim to help people live longer, healthier and more fulfilling lives, and improve the health of the poorest fastest. The NHC has long argued for the need to focus on tackling health inequalities—a key issue for the north of England. In the health deprivation and disability domain of the 2010 Indices of Multiple Deprivation, 96 of the most deprived 100 LSOAs are in the north of England. Despite policy interventions the gap in inequalities grew steeply between 2000 and 2008 and research now shows that people are 20% more likely to die before they reach the age of 75 in the north of England than in the south of England.

3.2 The priority of the new public health agenda should be on tackling the wider determinants of health. It is important that the focus is not simply on the clinical aspects of public health but harnesses the opportunity to engage a wider range of partners and think creatively about how to do things differently.

3.3 According to research by BRE England's poorest quality housing stock could be costing the NHS £600 million a year to treat the health problems of home occupants. The overall cost to society could be as much as £1.5 billion when additional costs such as occupants' loss of earnings are taken into account. Of 2.7 million home accidents per year, about 1 million are children under 15. The estimated cost of a seriously injured home accident casualty is £45,600 and it can cost as much as £250,000 to treat one severe bath water scald. One in 20 children are disabled and more than half of disabled children live in unsuitable homes. The care costs of a seriously disabled child whose home is unsuitable are £690 per day (£0.25 million per annum). Falls often occur while waiting for adaptations. The average cost of a fractured hip is £29,665, five times the cost of an average adaptation and 100 times the cost of fitting hand and grab rails.

3.4 People living in poorer neighbourhoods are more likely to suffer a life limiting illness or disability, and this is likely to develop 13 years earlier than in richer neighbourhoods. People with long-term conditions are the most frequent users of healthcare services. Those with long-term conditions account for 29% of the population, but use 50% of all GP appointments and 70% of all in patient bed days.

3.5 The Northern Housing Consortium believes that the housing sector has a strengthened and more visible role to play in health improvement, reducing the burden on health and social care services and making savings costs to the public purse. Research shows that investment of £1.6 billion in housing related support generated savings of £3.41 billion to the public purse including £315 million of savings to health service in a year. Investment in specialist housing results in savings to the public purse of £639 million pa, which includes an estimated saving of £11,751 per person to health services for people with mental health problems. Housing organisations also play a key role in supporting community activity to increase awareness of healthy lifestyle options—including healthy eating campaigns, teenage pregnancy, walking clubs, promoting health to children and young people.

3.6 However, in the current climate we are concerned about resourcing such activity and also how to demonstrate the positive impact of interventions—it is acknowledged that there can be a considerable time lag between intervention and evidenced outcomes.

3.7 Where research into health improvement identifies evidence of the benefits of commissioning certain types of intervention and service delivery, Public Health England should communicate this clearly and quickly to commissioners. Public Health England will play an important role in working with relevant stakeholders—including the NHS Commissioning Board - to provide advice and tools which support commissioners to redesign services that deliver better outcomes.

4. The Future Role of Local Government

4.1 It is right to devolve responsibility for commissioning of public health services to local authorities, working in partnership with the NHS, with communities and with the private and voluntary sectors.

4.2 However there is a risk that skills and capacity may be lost during the transition particularly in the current economic climate. The approach that local authorities take to managing the transition will be critical eg ensuring investment in the right skills and investment in data analysis, and ensuring that a wide range partners are engaged in the health and wellbeing agenda. The Director of Public Health will have an important role in this and promoting the public health agenda throughout the local authority.

4.3 The NHC believes there must be some form of housing representation on the Health and Wellbeing Board (HWB) to champion housing issues and enable more integrated solutions to be planned and delivered. In our submission to the Health and Social Care Bill Commons Committee the NHC requested amendments to the Bill to include explicitly “Director of Housing from the local authority” and, in two tier areas, to include housing leads from local housing authorities on the HWB. In addition we requested that a power be inserted for the Secretary of State to produce regulations stating such other persons as s/he considers appropriate, to bring additional local expertise to the HWB. This would allow the inclusion of such housing and other local experts, such as the Chief Executive of a local housing provider partner (ALMO or large scale voluntary transfer association) or a representative from any local housing provider fora. At the same time it will be important that local councillors provide a housing voice on the HWB, championing local housing issues, highlighting the impact of housing interventions on health and well-being and promoting integrated solutions.

4.4 In our Health and Social Care Bill Commons Committee submission we also requested an amendment to the Bill include a duty for HWB’s to encourage integrated working across health, social care and housing and for the inclusion of housing partners in the development of Joint Strategic Needs Assessments (JSNA) and Joint Health and Wellbeing strategies (JHWS). We believe that better outcomes can be delivered by working in an integrated way and HWB’s must quickly get to grips with roles, remits and responsibilities to ensure that opportunities are harnessed. For example Liverpool Healthy Homes is an innovative partnership approach between the PCT and City Council designed to make homes healthier and safer. Liverpool has one of the highest mortality rates and lowest levels of life expectancy in England and the worst rate of fuel poverty in England. Interventions are targeted at addressing health problems linked to housing and the environment. The approach is embedded into mainstream services and an independent evaluation of the first year of operations has estimated total savings to the NHS and to wider society of over £1.5 million.

4.5 Developing a Joint Strategic Needs Assessments (JSNA) is set to become one of the primary duties of Health and Wellbeing Boards and will provide a transparent, evidence based rationale on which to base all local commissioning plans and investment and disinvestment decisions across local authority boundaries whether these are GP commissioning, council commissioning or joint commissioning. The new demands on JSNA require the involvement of a wider range of local partners, sharing the ‘big picture’ analysis and an assessment of needs and, importantly assets. Positive examples of JSNA being used to commission integrated solutions involving housing partners can be found in Wakefield, Bristol and North East Lincolnshire. However national studies and our own engagement with housing organisations across the north shows that involvement of housing organisations in JSNA has been patchy. The NHC is working in partnership with JSNA colleagues to engage with housing organisations and their local partners to better understand the “housing offer” and the ideal relationship between JSNA and housing. In autumn 2011 we will publish a resource which aims to support housing organisations to engage with JSNA and build a stronger role for housing in local leadership for health and well-being. We also support housing organisations to develop effective customer profiling and deploy that intelligence to shape services.

4.6 The NHC believes that housing organisations have a vital role to play in JSNA and in JHWS not only as contributors of data/intelligence on housing needs and assets but as intermediaries. Customer scrutiny is at the heart of the best governance structures underpinning housing providers—at its best, it challenges organisations to be truly responsive to customers and communities, with tenants not only setting the terms of service standards but seeking to take on service delivery through devolved budgets, transfer of assets and development of mutual services such as the Helena Partnerships food co-operative. Housing organisations can act as a hub sitting in the heart of the community, connected to those people typically categorised as “hard to reach” by those working in health, providing valuable links given the need for greater patient empowerment. Housing organisations are also community leaders, service providers and commissioners, and for many they see their primary role as “neighbourhood investors” with the housing element being only one part. Housing organisations in the north of England work with communities facing some of the worst disadvantages. The challenges include health inequalities but also higher rates of worklessness, higher levels of people categorised as NEET’s, a less stable enterprise culture and lower levels of educational attainment. The Government believes that social norms and the creation of an enabling environment will go a considerable way to providing people with the stimulus they require to make healthy choices. Housing organisations can also act as an innovator being creative and collaborative, shaping environments that provide opportunities for people to improve the quality of their lives and encouraging social connectedness. The NHC is embarking on a project to explore how connections are changing within our communities, how this is impacting on relationships with customers, the value of community connections in improving quality of life and the opportunities this presents for improving the way we deliver services in the housing sector.

5. Public Health Outcomes

5.1 The NHC welcomes the development of a public health outcomes framework which champions the wider determinants of health. In our consultation response we urged the prioritisation of indicators which will tackle health inequalities. We would like to see the inclusion of indicators on the “proportion of people with long-term care needs feeling supported to manage their condition” and “the proportion of people with long-term care needs who say they are confident that they can manage their own health.” We would also like to see the inclusion of indicators in the Supporting People National Outcomes Framework.

5.2 We hope that inclusion of these indicators in the final outcomes framework will encourage integrated working and will increase our understanding of the costs and benefits of this type of approach and the development of local gain share models which enable the costs as well as benefits to be shared.

5.3 Housing organisations can contribute to indicators across most of the domains, supporting commissioners to deliver more integrated services, helping to improve outcomes and deliver value of money. Many housing organisations provide assisted living solutions such as telehealthcare which can improve public health outcomes for people with long term conditions such as Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF) and diabetes and improve service efficiency. Studies internationally have shown that following the introduction of telehealthcare has seen an average reduction of admissions to hospital per year for patients with COPD of 54% and with heart failure of 38%. By helping a patient manage their condition from home, telehealthcare can empower individuals to better understand their own health needs, give them greater confidence in managing their own conditions and help to improve patient experience.

5.4 Whilst we welcome the intention to align the Framework with the NHS and social care outcomes frameworks, we feel that a common outcomes framework would have supported greater and more effective integrated working especially for people who have complex or long-term care needs and who often need access to social care and NHS services. We have concerns around how the alignment will work in practice. Given that the NHS Outcomes Framework is focused on clinical outcomes there is a risk that the NHS and GP’s may have little motivation to engage in public health.

6. Public Health Funding and Commissioning

6.1 The NHC welcomes the proposal to allocate a ring-fenced public health budget. We think that that the Health and Wellbeing Board could be the appropriate place to bring together ring-fenced public health funding with other budgets such as housing. Having housing representation on the HWB will help to ensure that public health funding is aligned with housing investment and housing related support funding and is informed by a comprehensive understanding of needs and assets in the community.

6.2 There must however be effective scrutiny in the new commissioning and delivery arrangements to ensure that funding it is being spent on genuine public health issues and delivering outcomes. There is a risk of costs being shifted within local authorities and between local authorities and the NHS, and this could be compounded with the interim formation of the cluster PCT’s over a much larger geographical area. Getting the right relationship between the HWB and the overview and scrutiny arrangements will be crucial.

6.3 The allocation of an incentive payment, or “health premium” is welcomed although the payments of the premium should be weighted to the level of health inequalities and the comparative progress made with disadvantaged areas seeing a greater premium if they make progress, recognising that they face the greatest challenges. The NHC feels that this is the most challenging issue. Ensuring areas with the greatest health inequalities do not fall further behind means that the indicators most closely linked to deprivation must be incentivised.

7. Government response to the Marmot Review

7.1 Despite policy interventions on health inequalities in the last decade the gap in health inequalities has widened. Significant economic pressures, persistent inequalities and rising demand for services will require a more comprehensive and inclusive approach of all partners providing services in a local area. As the Marmot report concluded, tackling medical determinants of health is insufficient alone and “success is more likely to come from the cumulative impact of a range of complementary programmes…..and from more effective, coherent delivery systems and accountability mechanisms.”

7.2 The abrupt termination of Housing Market Renewal pathfinder funding and front loaded cuts has had a disproportionate impact on the north of England. The NHC has concerns that in the current economic climate, with many government departments and local authorities facing significant cuts, their commitment to investing in these types of priorities may be diminished.

June 2011

Prepared 28th November 2011