Health CommitteeWritten evidence from the Chartered Institute of Housing (ETWP 61)

Summary

1.1 Many CIH members are engaged in supporting vulnerable people within communities, through the delivery of services that play a significant role in minimising or preventing the need for costly and intensive health and care interventions, and support recovery.

1.2 Over a number of years, CIH has championed the role of housing to achieving health and wellbeing, and has sought to engage health and care professionals in a greater understanding of how this can contribute to their own aims and targets.

1.3 Providing training and education on the connections between housing and health for health professionals working in the community and involved in patient discharge from hospital would strengthen the overall context to support effective medical and clinical interventions. It would ensure that housing provides part of the solution to delivering health services in the community and ensuring safe and secure environments in which to recover health and independence. Poor housing conditions lead to health problems that cost the NHS an estimated £600 million a year to treat.1 It can also make medical intervention less successful and result in wasted resources, as well as impacting negatively on the individual and households involved.

1.4 A stronger understanding of housing and its impacts would contribute greatly to a wider awareness of the social determinants of health. The importance of housing as a determinant for health inequalities was reinforced most recently by Professor Sir Michael Marmot’s report: Fair Society, Healthy Lives and one recommendation was to prioritise policies and interventions that reduce health inequalities and address climate change, including improving the energy efficiency of home.

1.5 A few of the ways in which housing can impact health, or support health and recovery are listed below:

Homelessness leads to premature deaths—47 for men and 43 for women—and increases the use of accident and emergency services, due to the inability to register with GPs.2 A study by the umbrella organisation homeless Link in 2010 estimated the costs on homelessness to the NHS at £85 million, with twice as many homeless people admitted to Accident and emergency as the general population.3

Cold and damp homes contribute to respiratory and cardiovascular problems, and are a factor in excess winter deaths. Cardiovascular disease costs £14.4 million to the NHS of which 72.1% is inpatient costs.4 Respiratory disease costs £6.6 billion to NHS and society.5

Aids and adaptations that increase the accessibility of housing increase safety and reduce the risks of accidents and falls. The report, Better Outcomes, Lower Costs compared the cost of an average adaptation, costing £6,000 with the average cost to the state of a fractured hip, of £28,665. Improved housing is a significant factor in improved mental health—significant when depression is connected with a 30% increased risk of a hip fracture in women.6 The lack of safety in the home is a key contributor to delayed discharge from hospital.

Introduction

2.1 The Chartered Institute of Housing (CIH) welcomes the opportunity to make this submission to the Health Committee in relation to their inquiry into the education, training and workforce planning of health professionals.

2.2 CIH is the professional body for people involved in housing and communities, with over 22,000 members across the UK and Asian Pacific. We are a registered charity and not-for-profit organisation. Our mission is to maximise the contribution that our members make to the well being of communities. Our vision is to be the first point of contact for—and the credible voice of—anyone involved or interested in housing.

2.3 CIH has worked in partnership with other organisations over many years to demonstrate the contribution of housing to prevention and recovery—including the Housing Learning and Improvement Network, formerly part of the Department of Health—and our most recent report covered how these connections could be made in the light of a drive towards localism from DCLG and the changes to the NHS being taken forward in the Health and Social Care Bill: Localism: delivering integration across housing health and care.

2.4 CIH also participates in the Learning for Public Health network in the West Midlands, which organises regular interdisciplinary events to focus on aspects of public health, and involves local authorities, public health professionals, environmental health officers and others with an interest in public health.

Housing’s Role in Prevention and Recovery

3.1 Many CIH members are involved in delivering support services through accommodation based schemes such as supported and sheltered housing, or through floating support to people in general needs tenancies or owner occupation. The support covers a range of client groups including people who are homeless, people with alcohol and substance misuse, mental health problems, learning disabilities and older people with varying levels of vulnerability and support requirements.

Support

3.2 Housing related support services play a significant role in reducing the need for more intensive health or care interventions, and can facilitate a quicker and more successful recovery from episodes of ill health or hospitalisation. Studies undertaken for DCLG have demonstrated how effective these are in saving money for other public services, with the health service in particular gaining from housing related support interventions. Overall, for investment of £1.55 billion, estimated savings to the public purse reached £2.77 billion including some of the highest savings among groups that make significant call on health services, such as older people. Investment in sheltered housing at a cost of £ 258.7 million saved £1,090.9 million, and for frail older people the figures were £31.4 million costs for £138.7 million savings.7

3.3 Housing with care for frail older people (extra care or very sheltered housing) has been demonstrated to enable older people to remain in their own home successfully for longer, avoiding institutional/residential care. The use of flats within such schemes can also provide a useful and natural setting for reablement and rehabilitation after hospital.

Extracare Charitable TrustEnriched Opportunities Programme (EOP)8

Extracare charitable trust developed EOP as a way of supporting older people with dementia to remain living independently for longer in their own homes, in extra care schemes, through the introduction of specialist training and support. It involved 10 schemes (including five schemes to act as placebos) in a two year study, which was independently evaluated. It demonstrated that people in the sites with the EOP:

Were 50% less likely to move into residential care.

Had a 42% decrease in hospital stays.

This has now been rolled out to the other schemes.

Housing conditions

3.4 Decent housing that is energy efficient and accessible plays a critical role in the safety and health of older and disabled people, and those suffering respiratory and cardiovascular problems.

3.5 A recent report from the Marmot Review Team into The Health Impacts of Cold Homes and Fuel Poverty has highlighted the direct impacts of cold homes including:9

The relationship between cold temperatures and both cardiovascular and respiratory diseases, which account for 40% and 33% of excess winter deaths respectively.

The increased incidence for children in cold homes to suffer respiratory problems compared to those in warm homes (more than twice as likely).

Mental health is negatively affected by fuel poverty and cold housing for any age group.

Indirect costs include:

Increased risks of accidents and falls.

Impacts on the educational and emotional development and resilience of children.

Sandwell MBC’s Housing for Health

Under a Housing for Health strategy, Sandwell developed a number of initiatives, including a Repairs on Prescription scheme. Housing interventions were targeted at helping people with respiratory problems, cardiovascular disease and falls, and older people admitted to hospital. The main intervention has been work on central heating and insulation.

Other repairs, such as decoration, bathroom refitting and carpeting were used for people using mental health services.

An evaluation, focused on children with asthma, reported significant improvements including:

Reduced illness.

Fewer visits to doctors and stays in hospital.

Reduced need to use medication.

Increased access to school and play.

Reduced incidence of flu and colds in the family.

Reduced financial stress.

Reduced anxiety.

Adaptations

3.6 Many reports have demonstrated the value of investment in preventative services such as adaptations, to prevent accidents and falls that involve more personal distress and injury as well as increased cost to the NHS. Two Audit Commission reports10 and the previously mentioned Better Outcomes, Lower Costs all demonstrate the savings that can accrue from investment in DFGs. Many people benefit from adaptations including older people; a group that incur significant health spending—40% of the NHS budget and two-thirds of acute beds are used by people over 65.11

3.7 However, demand for these services far exceeds availability of funding. In particular there is a risk for older people in home ownership (75% of the older population) given that no further funding for private sector housing renewal is now available; people of 75, primarily home owners are the age group most likely to live in poor housing and more than one million live in non decent homes. It is unlikely that health professionals fully understand the potential impacts for services from the increased risks of falls and ill health that could result.

Commissioning and Training

4.1 Although evidence about housing’s contribution to health and wellbeing exists, it is not sufficiently well known by health professionals. As it concentrates largely on attempts to prevent ill health and accidents, it can be difficult to model the impacts and savings in the same way as with trials for drugs or clinical interventions. The difficulty of engaging health professionals was experienced by other partners in the previous commissioning structures under the Supporting People programme. A fresh opportunity for better awareness and integration may now be offered through Health and Well being Boards, and it is important that expertise on the social aspects that influence health are incorporated into the strategies and commissioning structures locally.

4.2 The example from Blackpool below demonstrates why cross professional training on housing and environmental factors is so productive. It has shaped the culture of the public sector organisations and made a shared referral process successful. All visiting officers whether from a health or housing background, can consider the impacts for colleagues and effectively connect the individual or household into the right services. This has now been extended to include local GPs.

BlackpoolTaking Integrated Working Further

In CIH/Housing LIN’s report on Housing Health and Care in 2009, Blackpool was an early case study of integrated working across the sectors. Public services in Blackpool had developed integrated networks at chief officer, strategic and operational levels that resulted in a joint training programme for frontline workers across the sectors, based on the effect of the environment on people’s health. It also led to the development of a shared referral process.

The ongoing demand for services and the constrained financial settlement across the public sector means the partners are working together to develop services, find new funding, and increase their “reach” to more members of the community. Facilitated by its unitary status, co-location of key services, and driven by the obvious impact of poor housing conditions on health, its PCT has provided continued investment in the delivery of Affordable Warmth through the Home Improvement Agency, Care & Repair.

Working with GPs

A critical development has been to ensure that customers that are common to all the services only have to engage once, to open the door to all the services they require. Recognising that more socially isolated people are likely to engage with GP services and related community health professionals such as community matrons and district nurses etc, the HIA and public health professionals have been keen to connect to GPs to reach more people requiring affordable warmth and highlight issues of poor housing conditions.

As part of that objective, Blackpool PCT and HIA have worked hard to engage GP partners to pilot a mechanism for referrals through the GPs’ IT system, which will trigger queries about the person’s housing, when assessing cold related illness. Referrals will be directed into the HIA who will coordinate interventions using shared referral process previously developed across the partners.

The approach to GPs has been supported by local Public Health professionals, who have provided the way in to engage practice managers. Housing and PCT staff have gone prepared to give answers and demonstrate how involvement in the project will directly deliver the GP/practice’s own key objectives—addressing ongoing respiratory problems, reducing repeat visits, reducing need for medications. In the long term, by developing a system that is easy to use and that produces results, they hope to win the commissioning argument with GPs and be able to continue/increase the service.

4.3 CIH would advocate that the committee looks beyond the core elements of education and training, in particular for GPs, for health professionals working in the community and for professionals who work in hospitals on discharge arrangements. We believe this is a missing link in terms of how well people are supported to maintain their health and well being and to recovery more quickly and effectively following ill health or hospitalisation. We would be pleased to discuss this further with the Committee or with appropriate officers of the Department of Health.

December 2011

1 M Davison et al (2010). The Real Cost of Poor Housing, BRE.

2 Crisis/ Sheffield University (2011). Homelessness: A silent killer

3 Homeless link/ Inside Housing, 12/11/2010.

4 NICE, Preventing cardiovascular disease: costing report, p4.

5 British Thoracic Society (2006). Burden of Lung Disease

6 Frances Heywood and Lynn Turner (2007). Better Outcomes, Lower Costs.

7 Cap Gemini (2008). Research into the financial benefits of the Supporting People programme

8 More about this scheme can be found at UKHA 2007

9 Marmot Review Team (2011). The Health Impacts of Cold Homes and Fuel Poverty, executive summary.

10 Audit Commission, Fully Equipped 2000 and 2002.

11 Care and Repair England (2011). Health, housing, social care and ageing: the golden link.

Prepared 22nd May 2012