3The link between housing and health
13.The quality of housing is a key determinant of health and wellbeing. Professor Carol Holland of the Centre for Ageing Research at Lancaster University identified three housing-related factors impacting on health: cold, the risk of falls and the location of the home.22 In this chapter, we consider each of these in turn. In chapter four, we discuss what needs to happen to ensure older people live comfortably and healthily in their mainstream home. In chapter six, we discuss the health benefits of specialist housing.
Cold and keeping warm
14.The 2017 annual fuel poverty statistics show that, since 2013, the proportion of households aged 75 and over in fuel poverty has been increasing.23 The evidence we heard supported this. Jeremy Porteus of the Housing LIN said that, for some “asset-rich but cash-poor” older people, it could be a choice of “heat or eat.”24 Sue Adams of Care and Repair pointed out that older people, particularly the “older old”, are at home longer and, therefore, need to heat it for longer. She said that, for a significant proportion of older people:
It is a question of cost. On the other side is the efficiency of the home. [ … ] you get this combining of factors, where a proportion of the older population, who are at home more, are in homes that are harder to heat and on incomes that make it more difficult to afford those heating bills.25
The impacts of living in a cold home on a person’s physical and mental health can be severe. Professor Holland explained that there was a well-evidenced link between cold homes and chronic diseases, such as respiratory and cardiovascular diseases and rheumatoid arthritis, and poor mental health.26 We also heard from Sue Adams in an earlier evidence session that cold homes were connected to acute cases, namely “heart attacks, strokes and falls”.27
15.There are various public and private initiatives, for example the Winter Fuel Allowance, the Warm Homes Discount Scheme and the Energy Company Obligation, providing heating and insulation measures to vulnerable householders in receipt of certain benefits. In addition, the Energy Saving Trust is contracted by the Department of Business, Energy and Industrial Strategy to run a telephone advice service (the Energy Saving Advice Service) offering impartial energy saving advice to householders in England and Wales. In Northern Ireland and Wales, the Affordable Warmth Scheme targets support at households most affected by fuel poverty. The scheme takes a whole house approach to home energy efficiency improvements (insulation, draughtproofing, upgrading heating systems, double-glazing windows) and works in partnership with local authorities to identify households in need of help.
16.For older people, living in a cold home can cause chronic and acute illnesses and lead to reduced mobility, falls and depression. This has resultant costs to the NHS and social care. The problem is exacerbated by the fact that older people spend longer at home and may be living on a low income in homes that harder to heat. We recommend that the national advice service should partner with and signpost older people to the Energy Saving Trust’s telephone advice line. In addition, we recommend the Government consider developing a national scheme to help older people in fuel poverty and, as part of this, it may wish to consider schemes similar to the Affordable Warmth Scheme in Northern Ireland and Wales.
Falls
17.The second housing and health related factor identified by Professor Holland was falls resulting from hazards in the home, for example, raised thresholds and loose carpet. She said that 75% of the deaths related to falls happened in the home and they represented between 10% and 25% of ambulance calls to older adults.28 Falls can also precipitate serious decline in an older person and necessitate a move into long-term nursing or residential care.29 We noted in particular Sue Adams’ evidence that “A fall tends to be the trigger point at which people start to lose capacity. It’s not just the physical impact but the psychological impact”.30 Jacquel Runnalls, Co-opted Lead on Accessibility and Inclusive Design at the Royal College of Occupational Therapists Specialist Section in Housing, said that there was “increasing recognition of falls” and, accordingly, “some local authorities or health services have falls prevention teams”.31 A recently published evidence review on home adaptations by the Centre for Ageing Better found “strong evidence that minor home adaptations are an effective and cost-effective intervention for preventing falls and injuries”.32 We discuss getting help with adaptations in paragraphs 33 to 35 and the Disabled Facilities Grant in paragraphs 40 to 45.
18.The consequences of falls at home caused by often trivial hazards (we consider how these can be prevented in the next chapter) can be catastrophic, precipitating serious decline in older people’s physical and mental health. There needs to be a national and local drive to address falls and accidents in the home. This should include provision of better advice and information about repairs, maintenance and adaptations (paragraph 11), wider access to the services of Home Improvement Agencies and handypersons to facilitate adaptations (paragraph 34) and more timely implementation of, and flexible use of, Disabled Facilities Grants (paragraph 43). In addition, integrated working on health and social care should include working with housing partners to identify homes with falls and accidents risks and intervening to remove them.
Location of the home and loneliness
19.Professor Holland explained that the location and the environment outside the home can affect physical and mental health in the following ways:
If you are in a home that is completely inaccessible to your friends or relatives, or there is no bus service, and your environment outside the home is not age friendly, you are going to be isolated. You are going to struggle to get a healthy diet because you cannot get to the shops properly. You are not going to be physically active, because it is too difficult to get out and about in your environment. Maybe there is no bench between you and the shop, when you could walk as long as there was a bench or toilet there.33
Jacquel Runnalls of the Royal College of Occupational Therapists said that being physically active was linked to independent living, general resistance to illness and good mental health, and loneliness and social isolation were associated with mortality.34 We note that the contributors to our web forum often said that they prized being near local amenities and public transport networks. We received a significant amount of evidence about the social and community aspects of living in specialist housing, where residents have communal areas in which to socialise. In 2015, the International Longevity Centre-UK surveyed residents of extra care housing on their independence, loneliness, and quality of life, finding that:
Our respondents reported lower loneliness than those in the community, giving some reason to believe that housing with extra care plays a role in reducing loneliness among its residents compared to what might be experienced if they stayed in the community.35
We look at the health and wellbeing benefits of specialist housing in paragraphs 87 to 92.
20.Social isolation can lead to poor mental and physical health. Ensuring that older people’s housing is within easy reach of local services, amenities and public transport links is therefore critical, and we consider the location of new housing for older people further in paragraph 117. Loneliness is harder to tackle. We support the recommendations of the Jo Cox Commission’s Call to Action,36 including a UK wide Strategy for Loneliness across all ages and a programme to develop the evidence around ‘what works’ in tackling loneliness, and welcome the Government’s recent appointment of a ‘Minister for Loneliness’.
The costs of poor housing
21.Poor housing clearly results in costs to the health service. Reference was often made to research by the Building Research Establishment (BRE) in 2016 which estimated the costs of poor housing to the NHS as £1.4 billion per annum.37 A further analysis of the BRE’s data by Care and Repair showed that nearly half this amount (£624 million) arose from poor housing among older people.38
22.Furthermore, poor housing can delay discharge home from hospital which is costly both to patients’ health and wellbeing and to the NHS. NHS providers’ audited accounts for 2016–17 estimated that delayed transfers of care cost providers £173 million, but, in its report on the accounts, NHS Improvement stated that the full costs were likely to be much higher.39 Gill Moy, Director of Housing and Customer Services at Nottingham City Homes, said her organisation’s Hospital to Home project found a place in an independent living scheme for a gentleman whose transfer home from hospital was delayed by 30 weeks because his home was not suitable for him to return to. She said the project was:
Partly conceived to reduce delayed transfers of care, but it spends a lot of time concentrating on early intervention/prevention. Housing has a massive role to play in that early intervention/prevention agenda, so preventing people from going into hospital in the first place, but then trying to prevent readmission.40
With regards to hospital readmissions, Jacquel Runnalls of the Royal College of Occupational Therapists explained that the risk of this was higher from a home that is unsafe, cold and poorly insulated.41
23.There is a well-evidenced link between housing and health and wellbeing, and the consequent costs of treatment by the health service. Poor quality, un-adapted, hazardous, poorly heated and insulated accommodation can lead to reduced mobility, depression, chronic and acute illness and falls and social isolation to loneliness and depression. We recommend that prevention, early intervention and promotion of health and wellbeing through housing should be a priority for the national advice service. It should refer people to where they can get practical help to improve the quality of their home and to their local authority and health service if more immediate, direct intervention is needed. In this context, we note that Karen Buck MP’s Homes (Fitness for Human Habitation and Liability for Housing Standards) Bill 2017–19, currently before the House, would help to resolve some of these issues for tenants. The Bill seeks to require that residential rented dwellings in England are fit for human habitation at the start of the tenancy and thereafter.42
Housing, health and social care
24.Health and social care integration aims to overcome organisational, legal and regulatory boundaries between the sectors to ensure that patients receive cost-effective care when and where they need it. In most cases, this involves closer working between health and social care services. The Department of Health, the then DCLG and NHS England have made various commitments to integration over the years43 and, in 2015, NHS England established 44 sustainability and transformation ‘footprints’, requiring local health bodies to draw up sustainability and transformation plans, now called partnerships (STPs), to improve services and finances over the five years to March 2021. In March 2017, it was announced that ten STPs would evolve into Accountable Care Systems (ACS) in which NHS organisations and local councils would collaborate more closely on the provision of care.44
25.Because of the public health consequences of unsuitable housing, the need to integrate housing services with health and social care services, or for these services to work together more closely, has been recognised. The care and support statutory guidance states that “The suitability of living accommodation is a core component of an individual’s wellbeing and when developing integrated services, local authorities should consider the central role of housing within integration, with associated formal arrangements with housing and other partner organisations”.45 A 2014 NHS England and Department of Health backed national Memorandum of Understanding set out a shared commitment to joint action across government, health, social care and housing to deliver better health and wellbeing outcomes and, among other things, aimed to enable “improved collaboration and integration of healthcare and housing in the planning, commissioning and delivery of homes and services”.46 However, the evidence we heard suggested that housing services were not routinely integrated with health and social care services. The Housing LIN said that housing, particularly older people’s housing, needed to be “placed firmly in the health and adult care arena to maximise the benefits from the housing sector to the wider service integration agenda”.47 Gill Moy of Nottingham City Homes said that, while Nottingham’s STP included housing, that was “not replicated across the country”.48 She went on to describe the benefits of closer working between housing, health and social care which included housing officers being able to make referrals for care and support, promote the health agenda among their tenants and facilitate hospital discharge. Our predecessor Committee considered the operation of the Disabled Facilities Grant in its inquiry on adult social care and found that its administration and operation was hampered by the split in responsibility between district and county councils.49 This tier split may also hamper closer working between health, social care and housing.
26.The need to integrate housing services with health and social care services has been recognised in the care and support statutory guidance and the Department of Health, Ministry of Housing, Communities and Local Government and NHS England supported 2014 Memorandum of Understanding to support joint action on improving health through the home. We believe that, given the health consequences of unsuitable housing, this should be reflected better at local level. Housing services should take equal status to health and social care services in the planning and implementation of closer working and in Sustainability and Transformation Partnerships (STPs) and Accountable Care Systems (ACSs). The Government should monitor the extent to which STPs and ACSs include plans for closer working between housing, health and social care organisations and include mechanisms to address housing issues having a direct impact on residents’ health outcomes. The Government should, where necessary, make representations to such organisations to ensure that housing is included in STPs and ASCs.
27.On the interface between housing and social care, we heard that some local authority social services teams were not routinely considering extra care housing, where onsite care and support is included, as an alternative care option to domiciliary or residential care.50 Yet it is an important option. Professor Holland said that her evaluation of extra care housing had found that people who were frail and living with dementia could be cared for appropriately in this type of scheme, highlighting that “residential care, and especially nursing care, would be far more expensive”.51 Jeremy Porteus of the Housing LIN said that “at least one third of people moving into residential or nursing care could potentially be offered either extra care or social housing”.52 Age UK said that the planned social care green paper needed to consider older people’s housing, including the need to help older people adapt their own homes and build accessible housing.53 We were pleased that the then Local Government Minister said “the social care green paper itself will look at issues around housing when it comes to older people”.54 The right kind of housing can keep people healthy, support them to live independently and reduce the need for home care or residential care. The social care green paper, planned for publication in summer 2018, must consider the range of housing for older people, from mainstream and accessible homes to supported and extra care housing, as well as access to adaptations and repairs. In particular, the social care green paper should consider the role of extra care housing in the provision of social care alongside domiciliary and residential care.
22 Q194
23 BEIS, Annual fuel poverty statistics report, 2017 (2015 data), June 2017
24 Q40
25 Q61
26 Q194
27 Q61
28 Q194
30 Q67
31 Q200
32 Centre for Ageing Better, The role of home adaptations in improving later life, November 2017
33 Q206
34 Q195
36 Jo Cox Commission on Loneliness, Combatting loneliness one conversation at a time: A call to action, undated
37 See, for example, Housing LIN and EAC [HOP 012]; Centre for Ageing Better [HOP 046]; Elders Council of Newcastle [HOP 033]; Care and Repair [HOP 013]
38 Care and Repair, Off the Radar: Housing disrepair & health impact in later life, March 2016
39 NHS Improvement, Performance of the NHS Provider Sector year ended 31 March 2017, June 2017
40 Q195
41 Q196
43 The Better Care Fund (created in 2013, requiring local health bodies and local authorities to pool existing funding and produce joint plans for integrating services), the Integrated Care and Support Pioneers Programme (2013) and the Five Year Forward View (2014).
44 NHS, Next steps on the NHS Five Year Forward View, March 2017
45 DHSC, Care and support statutory guidance, updated August 2017 (para 4.91)
46 DHSC, A Memorandum of Understanding (MoU) to support joint action on improving health through the home, December 2014
48 Q217
49 Communities and Local Government Committee, Adult social care: Ninth Report of Session 2016–17, March 2017
50 Q54
51 Q216
52 Q54
54 Q238
8 February 2018