This is a House of Commons Committee Special report.
The Health and Social Care Committee published its First Report of Session 2023–24, Prevention in health and social care: healthy places (HC 484), on 19 January 2024. The Government response was received on 19 April 2024 and is appended below.
FOREWORD
I am pleased to submit the Government’s response to the Committee’s report on Prevention in health and social care: healthy places, published on 19th January 2024.
I welcome the Inquiry’s focus on this important topic as part of approaches to preventing ill health and addressing unacceptable variations in health outcomes. As set out in the report, the communities and places where people live, work, grow and play have a direct impact on health and can also make healthier choices easier or harder.
We have carefully considered all the recommendations in the report, providing a response to each below. We accept some of the recommendations the Committee suggests but decline others.
Achieving the health and wellbeing benefits of improved places requires collective vision, effort and investment. That is why we are working across Government on the key social and environmental underpinnings of health and are driving forward work to deliver on our Levelling Up Missions.
Housing impacts on health, and everyone has the right to a safe and decent home. That is why we introduced the Renters (Reform) Bill which will extend the Decent Homes Standard to the private rented sector for the first time, in addition to social rented homes, ensuring decent homes for all rental tenants.
Government is also working to address health and housing hazards. We have introduced Awaab’s Law, in response to the tragic death of two-year-old Awaab Ishak. Meaning that social landlords will be newly required to address hazards such as damp and mould in social homes within a fixed time period. We have already published national guidance for social and private rented landlords on Understanding and addressing the health risks of damp and mould in the home. My department continues to work closely with the Department for Levelling Up Housing and Communities (DLUHC) to ensure the health benefits of improved housing quality are realised.
The Government is further supporting local areas and communities to shape their places and environments, taking their health into their own hands by encouraging healthy behaviours and reducing environmental hazards. The Levelling Up and Regeneration Act 2023 introduces a duty for all local councils to produce a design code to set the standard of design for a local area. DLUHC guidance highlights that the built environment has a significant impact on people’s health, and wellbeing and design codes can help to support the delivery of healthy, greener, sustainable and beautiful places. We are supporting local areas to use existing levers effectively to promote healthier choices, for example DHSC and Sport England have delivered a series of Health and Activity in Urban Design workshops, providing practical guidance on embedding health through design.
Supporting the Levelling Up health mission, our forthcoming Major Conditions Strategy will recognise the importance of working with and within local places to address disparities in health outcomes.
I thank the Committee for conducting this important inquiry and will continue to strive alongside my colleagues across Government to achieve the rightly ambitious goals on levelling up health that the Government has set.
Rt Hon Andrea Leadsom MP
Parliamentary Under Secretary of State, Department of Health and Social Care
IMMEDIATE STEPS
Housing
The Decent Homes Standard
Recommendation 1
We recommend the Government proceeds without delay in the consultation necessary to update the Decent Homes Standard for the social rented sector and in implementing a Decent Homes Standard for the private rented sector. It should set out a timetable for doing so in response to this report.
(Paragraph 17)
Accept
Everyone has the right to a safe and decent home and since 2001 the Decent Homes Standard (DHS) has played a key role in providing a minimum quality standard that social homes should meet.
The Levelling Up White Paper set out the government’s ambition to halve the number of non-decent rented homes by 2030 with the biggest improvements in the lowest performing areas, highlighting our commitment to level up the sector and ensure all renters have good quality homes.
During our consultation events preparing the Social Housing Green and White Papers, we heard that the DHS is no longer fully effective and does not meet present day concerns. We committed to reviewing the DHS in the Charter for Social Housing Residents: The Social Housing White Paper. In the Fairer Private Rented Sector White Paper we committed to extending the DHS to the private rented sector (PRS), ensuring that tenants across both tenures are secured in the knowledge that they are living in safe and decent homes.
The Renters (Reform) Bill will deliver on this commitment, bringing the PRS under the scope of a DHS for the first time. We consulted on applying the DHS to the PRS at the end of 2022 and will be publishing our response to that in due course.
It is important that residents, landlords and technical experts can have their voices heard on what the new DHS should cover. Launching a formal consultation is an essential part of the review process. During 2023 we engaged with residents, landlords and technical experts on changes to the DHS, following which we commissioned analysis on the costs and benefits of updated DHS options.
It is critical that the DHS is introduced to all rented sectors and that it sets the right requirements on decency. We are working towards this and we intend to publish our consultation on an updated DHS soon.
Obligations to repair hazards
Recommendation 2
It is welcome that the Government’s has proposed measures to protect social sector tenants from the worst impacts of unhealthy homes, via the implementation of “Awaab’s law”.
We recommend that the Government act quickly on the outcome of its consultation on this topic for social sector tenants. It should also consider how similar safeguards could be extended to tenants in the private rented sector who are affected by housing hazards, such as damp and mould, that can pose an immediate danger to health.
(Paragraph 19)
Accept
The death of a child is always heart-breaking – the more so when it is entirely preventable. Awaab Ishak was only two years old when he died of a severe respiratory condition caused by exposure to mould in his social home. Following the Coroner’s report on Awaab’s tragic death, the Ishak family, with the support of Manchester Evening News and Shelter, launched a petition for ‘Awaab’s Law’, and the government listened.
Awaab’s Law was introduced through the landmark Social Housing (Regulation) Act 2023 and enables the Secretary of State for Levelling Up, Housing and Communities to set new requirements for social landlords to address hazards such as damp and mould in social homes within a fixed time period. Awaab’s Law implies terms into social housing tenancy agreements so that, once regulations are in force, all social landlords will have to comply with the requirements of Awaab’s Law. If they do not, residents will be able to hold their social landlords to account by taking legal action through the courts for a breach of contract.
We have consulted on the details of those proposed requirements, including the timescales, to make sure they are effective and proportionate and deliver the best long-term outcomes for social housing residents. The consultation closed on 5 March 2024, and we are now analysing responses to the consultation. Once this has been completed, we will publish a response setting out findings and will then bring forward secondary legislation to bring Awaab’s Law into force in the social rented sector as soon as practicable.
We agree that no tenant should have to live in dangerous housing conditions. We are taking steps to ensure that hazards in rented homes are dealt with promptly by landlords in both the private and social rented sector. But how we achieve this needs to take account of the differences between the two tenures.
Awaab’s Law was designed for social housing. Most social landlords manage large portfolios, and many have dedicated repairs and maintenance contracts or in-house teams, enabling them to tackle issues to specific timeframes. A different approach is needed for the PRS, in which vast majority of landlords own a small number of properties.
We are strengthening enforcement against hazards in privately rented homes through the Renters (Reform) Bill. The Bill will allow local councils to issue immediate fines of up to £5,000 if a dangerous hazard is present in a privately rented homes and the landlord has failed to take reasonably practicable steps to address it. This will provide a strong incentive for private landlords to take prompt action if tenants complain about unsafe conditions, as they may be fined if they do not.
The Renters (Reform) Bill includes other measures to ensure private rented sector tenants have safe and decent homes. It introduces a Decent Homes Standard for privately rented homes and provides local councils with enforcement powers to require private landlords to remedy failures to meet Decent Homes Standard requirements. The Bill also introduces a new PRS Ombudsman which will allow private tenants to get their standards and repair issues resolved quickly and for free if their landlord has not acted appropriately to remedy an issue within a reasonable timeframe. We expect the Ombudsman to be able to require that landlords provide a tenant with compensation.
National quality standards
Recommendation 3
We recommend the Government consult on both the content of existing design and space standards as they relate to health, and on the implications of making such standards mandatory for new dwellings—both for developments requiring standard planning consent, and for both householder and change of use PDR developments.
(Paragraph 27)
Decline
We recognise the importance and role that housing standards have in helping to maintain design quality, which is why Government introduced the Nationally Described Space Standard in March 2015, setting minimum internal sizes for a range of different homes, including houses and flats. As set out in the National Planning Policy Framework, local authorities have the option to make use of the nationally described space standard in their areas through their local plan policies to address a clear and justified need and where the impact on viability and housing supply have been considered.
As the Committee noted, since April 2021 all new homes delivered under national permitted development rights must meet the nationally described space standards. This is a blanket requirement that applies to all such rights and so will apply to any new and amended permitted development rights that deliver homes. In addition, all homes delivered under permitted development rights since 2020 must provide adequate natural light in all habitable rooms. More broadly, in terms of other issues raised by the Committee, the permitted development right for the change of use of shops and offices to residential allows for local consideration of the impact on future residents from noise of commercial premises, and development in areas that are important for industry and storage or distribution. Other permitted development rights provide flexibility for householders to extend their homes to provide additional living space for growing families without the need for a planning application. These permitted development rights are subject to various conditions and limitations such as size limits to manage impacts on neighbours. We have recently consulted on changes to the householder permitted development rights and further details will be provided in due course.
As the Committee highlights, the National Model Design Code published in 2021, is part of the national planning practice guidance that supports the National Planning Policy Framework and provides tools and guidance to local councils for producing design codes. This guidance highlights that the built environment has a significant impact on people’s health and wellbeing and that, design codes provide a tool through which a local authority could set rules to ensure the design of new places include a mix of uses supporting everyday activities and an integrated mix of housing tenures and types to suit people at all stages of life. We recently consulted on whether permitted development rights that include prior approval in respect of design or external appearance should allow for consideration of local design codes where they are in place locally. This consultation closed in September 2023 and further announcements will be made in due course.
The Government is committed to ensuring the planning system creates healthier and more sustainable buildings and places. Through the Levelling Up and Regeneration Act, we have introduced a duty for all local councils to produce a design code at the spatial scale of their authority area, either as part of their local plan or as a supplementary plan, which will give design codes significant weight when planning applications are determined. Design codes set the standard of design for a local area, providing clarity about design expectations and will be prepared locally, reflect the local context and be based on effective community involvement, so that local people have a real say in the design of new homes and neighbourhoods. Design codes can help steer new development to deliver healthy, greener, sustainable, distinctive and beautiful places, with a consistent and high-quality standard of design.
We hope that this response gives some assurance to the Committee that we are already taking steps to ensure that design and space standards address health and well-being needs. Based upon this we do not believe it is necessary to consult on our design or space standards at this time.
Neighbourhoods and the Planning System
What do “healthy neighbourhoods” look like?
Recommendation 4
We recommend that OHID be made a statutory consultee for new large housing developments, building on role already accorded to Active Travel England in supporting inclusive, effective and health-protecting development.
(Paragraph 39)
Decline
We recognise that the built environment impacts directly on people’s health and can also make healthy choices easier or harder. The National Planning Policy Framework (NPPF) makes it clear that the planning system can play an important role in creating healthy and inclusive communities based on local health needs and in support of delivering local health and wellbeing strategies.
Engagement between plan-making bodies and relevant local health leaders can promote healthy and inclusive communities and support appropriate health infrastructure, including through the provision of safe, suitable, secure and sustainable homes, developments that contribute to walkable and cyclable neighbourhoods, good quality greenspace, and play areas that are near local amenities.
We recognise that it is important that new development is accompanied by the right infrastructure, including primary care infrastructure, and that this is supported by the planning system.
It is the Government’s policy that local plans are key to identify where development is needed in an area, and to the appropriate supporting infrastructure. This is so developers have a clear expectation of what infrastructure will be required both area-wide and onsite, especially large, allocated sites for residential development.
Any new statutory consultees in the planning system would need to be clearly justified, with clear evidence that their input would be effective and not slow down the application process and represent value for money to the taxpayer.
While there are some benefits to being a statutory consultee, the decision to grant or refuse a planning application ultimately rests with the local planning authority, which will take into account all relevant planning considerations, including the views of other organisations and bodies (statutory and non-statutory) and the wider community. National planning policy strongly encourages meaningful and early engagement with stakeholders.
Whilst we acknowledge the Committee’s interest and argument in this area, we are not currently looking to extend the list of statutory consultees further beyond existing commitments.
Supporting Healthy Communities: Social Prescribing
Recommendation 5
We recommend DHSC work with NHS England and existing networks and providers to develop a national strategy for social prescribing.
This should aim to improve understanding amongst frontline clinical practitioners of the benefits of social prescribing and to improve their confidence in offering social and community-based solutions to unmet social needs, and to increase use of social prescriptions for young people across all referral routes, including hospitals, schools and other educational and community settings.
It should include resources, guidance and case studies, and should focus in particular on groups that are currently underserved, where the greatest long- term preventative impacts may be accrued.
(Paragraph 48)
Decline
National ambitions for the delivery of social prescribing have been set out in the NHS Long Term Plan. Thiscommitted to rolling out social prescribing across primary care networks (PCNs) in England so that over 900,000 people were referred to social prescribing by 2023/24 with 1,000 link workers in place by 2020/21. This supported a wider effort to roll out personalised care commitments. Social prescribing has grown significantly across England since 2019. There are now approximately 3,600 social prescribing link workers and have been over 2.5 million referrals to social prescribing in general practice since 2019, exceeding NHS Long Term Plan commitments.
Published Guidance on supporting high frequency users and our Delivery plan for improving access to primary care already sets out strategic direction for the integration of social prescribing within existing care pathways. Social prescribing enables GPs, PCN staff and all local agencies to refer people to link workers who can work with them to access, through personalised care and support planning, different ways of meeting their needs. Social prescribing within PCNs is a universal offer but works particularly well for people who need support with their mental health, are lonely or isolated and/or have complex social needs which affect their wellbeing. Link workers connect people to community groups, activities (such as health & wellbeing, sport and exercise and the natural environment) and agencies for practical, emotional and social support.
We recognise the potential benefits of social prescribing to different population groups. As set out in the Network Contract Directed Enhanced Service (DES) Guidance 2023/24, PCNs must provide access to a social prescribing service to all patients who could benefit, and deliver a proactive social prescribing case-finding service, typically delivered through employing social prescribing link workers either directly or through contracting arrangements with a local VCSE provider. We are now seeing social prescribing developing across other parts of the NHS and with children and young people also.
We have also piloted the delivery of social prescribing schemes exploring links between physical and mental health and the built and natural environment, including cross- government Green Social Prescribing pilots and Department for Transport (DfT) Active Travel Social Prescribing pilots. Integrated Care Systems (ICS) are also developing social prescribing in secondary and community care to support self-care and provide support to addressing the wider determinants of health.
NHSE has developed further support for the national infrastructure for social prescribing, such as an Information Standard for social prescribing and a national workforce development framework.
BUILDING HEALTY PLACES FOR THE FUTURE
System-level support for healthy placemaking
Recommendation 6
We have previously recommended that all ICBs should include a public health representative, such as a public health director, and that DHSC considers making this a mandatory requirement. In response, the Department said it agreed that prevention needs to be a priority, but emphasised the importance of protecting ICS autonomy.
The evidence that we have heard in this inquiry reaffirms our view that having the right people in place is crucial to ensuring the prevention agenda is not crowded out. Given what we have heard about impact that these individuals can have in ensuring a longer-term focus, we recommend that DHSC reconsiders the case for mandating representatives in this role.
(Paragraph 56)
Decline
We fully recognise and support the important roles played by local directors of public health and their teams, including in furthering core aims of integrated care systems to improve population health and tackle inequalities. However, we have no plans to alter the provisions of the Health and Care Act 2022 which set out mandatory membership requirements for integrated care boards (ICBs).
ICBs can exceed the legislative minimum requirements for membership to address local needs. It is for the local authority, with the ICB and other partner organisations, to determine who best represents the needs of local populations, and this can include directors of public health.
Independent of issues of ICB membership, local authorities have a duty to provide ICBs with a public health advice service as per regulations made under the NHS Act 2006. Similarly,
ICBs have a legal duty to seek appropriate advice on matters including prevention and the protection or improvement of public health.
Local public health teams should be an integral part of multidisciplinary working across place-based partners. Guidance for ICBs on delivering a quality public health function has been published, endorsed by NHS England, the Association of Directors of Public Health, the Local Government Association and the Faculty of Public Health: NHS England » Delivering a quality public health function in integrated care boards
DHSC will continue to work closely with NHS England and ICBs to ensure that the current arrangements are working.
A cross-government approach
Recommendation 7
Healthy places are vital to protecting people’s physical and mental health from both direct and indirect consequences and in turn, to building a sustainable health service. “Healthy places” include both the built environment—homes, communities and neighbourhoods—and wider environmental factors, such as air quality and emission levels.
The benefits of building healthier places go far beyond DHSC and the health service, and achieving these benefits requires buy-in from a range of Government Departments. In turn, the benefits of healthy places are crucial to a range of wider priorities, including building a stronger, more productive economy and protecting the environment in which we live.
The problems caused by “unhealthy places” are whole-society problems. Tackling them will require long-term thinking and whole-Government solutions, including commitment, leadership and co-ordination from the very top.
(Paragraph 56)
Accept
As the committee’s report notes, much of what keeps us healthy lies outside the NHS and social care system. The quality of places where people live, work and age and children learn, grow and play is critical to our health - from good quality housing to well-designed neighbourhoods that ensure access to green spaces, and enable physical activity and healthy food choices.
Creating healthy places and ensuring good health for all is essential to Levelling Up – it’s about ensuring everyone, wherever they live, can enjoy fulfilling, healthy and productive lives. Addressing the drivers of ill health and reducing health inequalities between places is something the government remains committed to, which is why the Levelling Up White Paper set a Mission to increase healthy life expectancy and reduce disparities between areas.
As your report highlights, creating healthier places requires sustained, cross-government commitment, and this is why the mission sets a medium-term ambition stretching to 2030 and beyond. Through the framework of the Health Mission, DHSC and DLUHC facilitate cross departmental engagement on wide ranging issues relating to health, recognising that many of the factors critical to good physical and mental health are the responsibility of partners beyond DHSC and the health service.
We are exploring new and existing opportunities for cross-government action on the drivers of health to support progress on the health mission and our wider common interests. We are also working across government to act on a wide range of issues relating to health.
The role of local government in our endeavours is critical, as councils are close to their populations and have a detailed understanding of how and where to focus action to meet local health needs. That is why we are supporting local authorities to design good quality housing and places that improve access to green space and physical activity, and to create healthier food environments.
For example, DHSC is working with DLUHC and DWP on the Healthy Homes Pilot Programme, which is providing £10 million to support 40 local authorities. The project aims to build the evidence base on what contributes to successful damp and mould enforcement and improved health outcomes for tenants. DHSC continues to support DLUHC with the Renters (Reform) Bill and Social Housing (Regulation) Act.
DHSC is supporting Defra in delivery of the Government’s Environmental Improvement Plan. This includes a commitment to developing an evaluation tool to better understand the impact of outdoor interventions on health, wellbeing and disparities. Similarly, the department has collaborated with Natural England to deliver the Green Infrastructure Framework - a major new tool aimed at planners and developers to help increase the amount of green cover to 40% in urban residential areas.
DHSC is collaborating with DfT and Active Travel England to help deliver the Government’s cycling and walking plan. We jointly aim to ensure health, wellbeing and action to tackle disparities are embedded across new active travel policies and programmes. This includes improving evaluation, targeting funding to areas of higher health need, and supporting involvement in active travel work by local authority public health teams.
The Public Health England Healthy Places team, referred to in paragraph 36 of your report, transferred to the Office for Health Improvement and Disparities (OHID), within DHSC, where my officials continue their work to ensure that the design of the built and natural environment contributes to improving the public’s health and reducing health disparities. The team works across Government to support priorities such as the Levelling Up Health mission and undertakes capacity building activity with local systems to help improve health.