This presentation is for the UK Association of Directors of Public Health policy workshop 2016 and looks at how Public Health can support and lead health approaches to Housing strategy and delivery. It takes a number of examples and case studies and identifies 7 key policy and strategy principles

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Housing and Health:
making the case
Association of Directors of Public Health
Policy Workshop 26 May 2016
Teresa Heritage
Executive Member, Public Health, Localism and Libraries, Hertfordshire
City Councillor, St Albans City and District Council
Jim McManus
Director of Public Health, Hertfordshire County Council
Jim.mcmanus@hertfordshire.gov.uk

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My Thanks to
• Watford Borough Council
• Welwyn Hatfield Borough Council
• Hertfordshire Heads of Housing
• Alan Gough
• James Barber,
• Bethan Clemence,

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Housing as a Public Health Challenge
• Significant History
• DsPH in many cities often led large housing
programmes (Birmingham, 1840s, 1870s,
1930s)
• Growing evidence base

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Recent Policy Work
• BRE Housing Costs
Calculator, funded by
Public Health for all
districts
• Kings Fund Report on
District Councils –
used as a lever to
whole County

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2 Reports for Hertfordshire

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The Big Ticket Issues
1. Identifying the challenge
2. Making it real for all stakeholders
3. Making it bite for members
4. Finding a common language and terms
5. Identifying the possible
6. Taking a programme/portfolio approach
7. The dangers of getting so interested in detail
you forget delivery!

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The language of the National Audit
Office 2010 not on course!

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Elements of a Strategy on Housing
Housing Quality and
affordability
The Lives people lead The Environment and
amenities
•Decency standards
•Thermal efficiency
•Fuel Poverty
•Financial Exclusion
•Issues for social care
and health care
supported by housing
(independence, falls
prevention, telecare)
•Quality of Education
•Life skills
•Self-Efficacy
•Accessibility
•Social Isolation
•Social Inclusion
•Green
Clean
Safe
•Environmental cues
for healthy living

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A joined up vision
Healthier
Population
through shift to
prevention
Economic Growth across
population
(keyworkers as much as
science)
Housing and
Infrastructure
Growth over 20
years to meet this
Keyworker
Housing

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The Concept
2. One Shared
devolution plan with a
role for every agency
3. The Rainbow
Each agency
does its bit for the plan
4. The Outcomes
Healthier and Wealthier
Hertfordshire
1. One
virtual pot
of resource
5. One pot
of Money
comes in

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Programme and Governance
• Programme Approach
• Owned by all Public
Sector CEOs and
several Boards
• Public Health
recruiting to a post to
co-ordinate

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Programme workstreams at present
What Aim Who
Housing Quality and
Condition
Improve, reduce cost
to system
Public Health Board and
Districts
Housing Supply/
Accommmodation
Meeting new needs Health and Wellbeing
Board, Strategic
Accommodation Board
Excess Winter Deaths Reducing deaths Districts, Public Health,
Herts Help
Mental Health Crisis Reducing admissions Crisis Care Condordat
Group

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New workstreams
What Aim Who
Growth New Housing Devolution, Districts
Impact of Homelessness
on
admissions/attendances/dis
charges
Sensible system,
shared data
NHS Acutes, Public
Health, CCGs
Safe and Well Checks Reduce fires, falls
and admissions
Fire Service, Public
Health, NHS
Ongoing workstreams
What Aim Who
Hoarding and Mental
Health
Reduce
misadventure and
nuisance and get
people into services
Welwyn Hatfield Council
, Public Health, Police,
NHS

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Theme: Preventing harm from
hazards in the home
Hazards in the home (such as excess cold,
trip hazards , fire risks etc.) are associated
with a number of negative health outcomes
relevant to the Public Health, NHS and
Adult Social Care Outcomes Frameworks
Theme: Providing suitable
housing for people with
disabilities/older people
The provision of suitable accommodation
can promote health & wellbeing and prevent
the need for more intensive support
Theme: Addressing the impact of
homelessness and supporting
access to accommodation
There are negative health outcomes associated
with the absence of secure accommodation.
Homeless people are more likely to have poor
health, and place a disproportionate burden on
health providersa) Private rented housing
enforcement and regulation
Stakeholders: Public Health, District &
Borough Councils, Community Protection,
NHS
a) The development of specialist
housing
Stakeholders: Public Health, District &
Borough Councils , Health & Community
Services, NHS
b) Reducing the impact of hazards in
the homes of vulnerable people
Stakeholders: Public Health, District &
Borough Councils, Community Protection,
Health & Community Services, Housing
Associations, NHS
b) Home adaptions and alterations
Stakeholders: District & Borough Councils
, Community Protection, Health &
Community Services, Housing
Associations, NHS
c) Provision of home-based health
and social care services
Stakeholders: Health and Community
Services, Housing Associations, NHS,
District & Borough Councils
a) Homeless prevention and support to
access accommodation
Stakeholders: Public Health, District &
Borough Councils, Housing Associations, NHS
b) Housing services for adults with
complex needs
Stakeholders Public Health, District & Borough
Councils, Health & Community Services,
Housing Associations, NHS
Housing and Health on a Page (First Iteration)
An overview of the main themes and sub-themes identified around housing and
health, including the key stakeholders, potential tasks and forums for partnership
working.
Potential Tasks
• Develop JSNA and housing intelligence
• Increase referrals into existing home
improvement services
• Encourage partnership working on the
development of Safe and Well Visits
• Explore business case for developing
home improvement services (such as
around thermal efficiency)
Potential Tasks
• Formalise structure between housing
providers, health and social care
• Build on existing projects and
partnerships
• Develop strategic approach to planning
and development
• Develop community networks/leadership
• Commission innovative accommodation
services
Potential Tasks
• Improve hospital discharge coordination
for patients needing housing support
• Develop multi-agency support for adults
with complex needs
• Improve access to emergency night shelter
• Explore the business cases for protecting
or expanding existing homeless prevention
services
Potential forums for partnership
working
1. Public Health Board
2. Health & Wellbeing Board
3. Herts Heads of Housing Group
4. Housing Associations Chief Execs
Potential forums for partnership
working
1. Public Health Board
2. Health & Wellbeing Board
3. Herts Heads of Housing Group
Potential forums for partnership
working
1. Dual District Accommodation Boards
2. Housing Associations Chief Execs

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Housing Quality
• Evidence of poor quality housing
Local services:
• District & Borough Council housing
enforcement
• Herts Healthy Homes
• Fire Home Safety Visits/ Safe and
Well visits
Issues
• Resources
• Referrals/data sharing
Map: Hazardous housing in Welwyn-
Hatfield

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Cost Benefits
Housing Energy Efficiency in England
In just the East of England 438,000 Dwellings have an ‘F’ and ‘G’ rating
Costing the NHS £23,360,000 per annum
(in relation to the harms associated with excess cold in these house types)

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Housing Availability
• Rise in levels of homelessness in
Herts since 2010/11
• Hospital discharge
• Adults with complex needs
• Access to emergency night shelter

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From a property
January 2016
England EWM index is 12.9,
South East is 26.7
(i.e. 27% more winter deaths
than summer)
How do we reduce the number of winter
deaths in Herts?

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Following an Excess Winter Deaths spike in Watford and
an above average EW Mortality for the region the project
was commissioned by HCC to identify the trends and
triggers for Hertfordshire
The project was delivered through the Herts
Healthy Homes Project
(formerly Keep Warm, Stay Well)
team delivers an on the ground projectThe HHH
co-ordinated with the Herts Help call centre;
Helping to address features of the Health, Adult
Care and NHS care agendas

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EWD – Figures
• England - One of the highest excess winter death rates in Northern Europe
• England has the oldest housing stock in Europe
• An estimated 43,900 excess winter deaths occurred in England
and Wales in 2014/15
• EWD contribute to 1 in 20 of all deaths per year
Direct effects of winter weather include an increase in incidence of:
heart attack influenza falls and injuries
hypothermia stroke respiratory disease
England EWM index is 12.9, South East is 26.7
(i.e. 27% more winter deaths than summer)
Excess Winter Mortality Index is EWM/average non
winter months x 100

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Cost Benefits
• Within Hertfordshire the evaluation of the 2013 HHH project showed a
cost avoidance/saving to society (including the NHS) of at least £688,485
- From 939 home visits which resulted in 4,452 direct actions
• Actions such as insulation supported vulnerable residents with £1.5
million of cost savings.
The hazard of excess cold on those aged over 65’s is considered to
cost the NHS over £35 million annually

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Behavioural factors
Housing factors
Age
Health
Homelessness
Fuel poor
Houses with mould
Energy inefficient
Population factors Age Group % EWD
0-64 9.6
65-74 9.2
75-84 27.5
85+ 53.7
Ability to heat
Not adapting
Not seeking help
Not accepting help
Not claiming
benefits
Each year billions
of pounds of
benefits go
unclaimed
Knowing where to
get help
> 80%
£
£
£
£
What affects EWD

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The EWD Report
• The projects aim was to identify the trends and triggers for Excess Winter
Deaths (EWD), following a high trend in Watford.
• 60 elderly participants were asked about their behaviours, circumstances
and perceptions in-home interviews, 12 months apart, The temperature and
humidity were tracked
• Of the 60 interviewees over the last 12 months there were 843 single
health interventions (excluding flu jabs) – including revisits to GPs and
65 emergency visits to hospital
• 96% of those questioned did not drink the recommended amount of
water increasing the likelihood of associated health consequences. The
worst performing group were those aged 75 or over
• 78% of those aged 75 or over lived alone;
- The most vulnerable people, with an average of 2.5 health
conditions, had no visits. The healthier a person was, the more likely
they had regular visitors

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A resourced working
group, project sponsored,
to deliver an EWD strategy
(in accordance with NICE QS)
The report has a number of key
recommendations:
To address these…..

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Develop a Herts EWD Strategy
NICE QS
Single
point of
contact
Support LA
resource
for
referrals
Currently Delivered through
Herts Healthy Homes with improved referral systems to
Herts Help by Health Services (embed in the culture)
Reduce
falls
Combat
loneliness
Fuel
Poverty
strategy
Hospital
discharge
presence
Assess
Before
discharge
……. ……
Community
Navigators
Vol.
Orgs

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Statement 1. Local populations who are vulnerable to the health
problems associated with a cold home are identified through year-
round planning by local health and social care commissioners and
providers.
• Herts Help - by Health Services (embed)
• Long term funding resource for HHH delivery (3 years??)
Statement 3. People who are vulnerable to the health problems associated
with a cold home receive tailored support with help from a local single-
point-of-contact health and housing referral service.
How the recommendations fit with NICE QS guidance
• Excess Winter Deaths Strategy??
• a joined up approach to data sharing…
Statement 2. Local health and social care commissioners and providers
share data to identify people who are vulnerable to the health problems
associated with a cold home.

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Statement 5. Hospitals, mental health services and social care services
identify people who are vulnerable to health problems associated with
a cold home as part of the admission process.
Statement 6. People who are vulnerable to the health problems associated
with a cold home who will be discharged to their own home from hospital, or a
mental health or social care setting have a discharge plan that includes
ensuring that their home is warm enough.
How the recommendations fit with NICE QS guidance
• Assessment at admission
• Assessment before discharge (in part)
Statement 4. People who are vulnerable to the health problems associated
with a cold home are asked at least once a year whether they have
difficulty keeping warm at home by their primary or community healthcare or
home care practitioners.
• Planned targeted annual communications

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The next Challenge
“I want public health
principles embedded
in all housing and
growth work so we
have a future of
health and
independence, not
problems” Robert Gordon, CBE
Leader of Hertfordshire
County Council

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Some surprising
and welcome alliances
• Andres Duany and
Lord Salisbury
• Principles for all
developers

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Thank You!
Copies of all documents can be obtained from
Jim.McManus@hertfordshire.gov.uk