Housing and Health Inequalities

Building Foundations for Health and Housing

02 October 2018

Martin Higgins

NHS Lothian Public Health and Health Policy

John Snow and the Broad Street pump, 1854

Booth’s poverty map, 1886-1893

As an aside: middle class, well-to-do...

Edinburgh SIMD map, 2016

Housing, place and health

Macintyre et al (MRC Glasgow): “place effects” Social Science and Medicine, 55, 2002, pp125-139“composition or context?” in Neighbourhoods and Health, 2003

Inequalities mean that we need to consider– Deprivation and disadvantage: assess impacts on

disadvantaged groups and health gaps – Distribution (or gradient) approach: compare

impacts on range of groups in the population

• Exposures and impacts differ for population sub-groups

Actions on housing to reduce health inequalitiesMeet Scotland’s requirement for new homes in a way that increases the availability of affordable homes across all tenures.

Maintain and grow a social rented sector that provides quality homes and is accessible to all those who need it.

Ensure that tenants in the private rented sector, including families, have good, secure homes.

Use available powers nationally and locally to mitigate negative impacts of welfare reform and create a tax and benefit system that prioritises people’s need for good-quality housing to support health and wellbeing.

Establish and enforce a common cross-tenure housing standard that ensures that all housing in Scotland provides good-quality, energy-efficient homes.

Develop a formal process for NHS bodies to input into local authority housing strategies, and embed the vital role of housing within the Health and Social Care Integration agenda.

Develop training/e-learning materials that enable frontline staff to take opportunities to reduce health inequalities through action on housing.

Deliver the vision of a Scotland where fuel poverty is eliminated, beginning with households that are also income poor.

Embed a planning system that delivers high-quality places for people to live, meets the needs of communities and supports sustainable and inclusive economic growth.

Empower communities to shape the place they live, including housing that meets people’s needs throughout life.

Housing and health evidenceHousing investment which improves thermal comfort in the home can lead to

health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work. While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities.

Thomson, H., et al., Housing improvements for health and associated socio-economic outcomes. Cochrane Database Syst Rev, 2013. 2: p. CD008657.

Pathways and processes linking housing and health

• Housing condition and characteristics

• Housing within a place and community

• Housing as place of care and support

• Housing and homelessness

• Housing and the economy

Housing conditions and characteristicsStrong evidence for many different links, eg:

• Overcrowding/ appropriate space

• Energy efficiency and ventilation (air quality, humidity)

• Home safety (trips, slips and falls, fires, poisonings, environmental tobacco smoke)

• Food preparation

• Affordability

• Radon

Housing conditions Risk factors Health conditions

Thermal efficiency

Weatherproofing

Heating affordability

Ventilation

Space

Food storage, preparation and

cooking facilities

Quality of work and floor

surfaces

Soft furnishings

External appearance

Neighbourhood environment

Damp, mould, cold,

humidity

Fuel poverty

Dust mites and infestations

Cleanliness

Overcrowding

Concerns about crime and

antisocial behaviour

Cardio-respiratory

disease

Digestive health

Allergies and skin

conditions

Headaches, migraine

Stress, anxiety

Depression and mental

ill-health

Source: adapted from Curl A, Kearns A. Can housing improvements cure or prevent the onset of health

conditions over time in deprived areas? BMC Public Health. 2015;15(1):1191.

Links between house condition and health

Housing, place and community

Source: Lane et al Journal of Environmental and Public Health 2013

Housing: care and support

• Aging population, dementia, obesity

• Care at home

• Lack of local estimates of need and provision

• Health and care workforce

• Housing Contribution Statements

Homelessness in Scotland 2017/18

• 34,972 homelessness applications recorded in Scotland, 1% higher than 2016/17. The increase follows eight consecutive annual decreases from a peak of 57,672 in 2008/09 to 34,570 in 2016/17.

• Applications in 2017/18 increased in 17 out of 32 local authorities in Scotland.

• 82% of applicants (28,792 assessments out of a total of 34,950 assessments) were assessed as homeless or threatened with homelessness in 2017/18.

• 27,241 cases were assessed as unintentionally homeless, and therefore entitled to settled accommodation.

• Repeat homelessness has remained at a similar level to 2016/17 and was 6.4% for 2017/18.

• The proportion of homeless assessments where the applicant had at least one support need has increased from 34% in 2012/13 to 47% in 2017/18.

Homelessness and Health

Drivers of Homelessness

• Poverty

• Lack of affordable housing

• Restrictions on access to, and levels of, social security support

• Individual and interpersonal vulnerabilities such as mental health problems or relationship breakdown

Housing and Homelessness

• Very significant (can be catastrophic) health impacts

• Complex causes

• Affordable housing stock – necessary but not sufficient

• Need for other services and supports

• Housing First

Housing and the economy: costs

• Affordability

– Housing costs – nb link to key worker housing

– Tenure and housing supply

– Tenure support and evictions

• Heat or eat

Population and household projectionsArea Projected popn

2041Projected popnchange 2016-2041

Overall number of households 2041

Projected households change 2016-2041

East Lothian 123,245 18% 56,574 26%

Edinburgh 583,135 15% 291,764 26%

Midlothian 115,697 31% 51,544 36%

West Lothian 203,121 13% 92,340 21%

Fife 379,788 3% 180,308 9%

Scottish Borders 117,318 2% 58,181 8%

Lothian 1,025,198 17% 492,222 32%

Scotland 5,693,201 5% 2,763,089 13%

• Household increase is greater than population increase• Household units are getting smaller (2.17-2.02)• Population is ageing – many of the new households will consist primarily of

older people

Who builds houses?

-

5,000

10,000

15,000

20,000

25,000

30,000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Co

mp

lete

d n

ew

dw

elli

ngs

New Housing Supply in Scotland 1996-2016

LocalAuthority

HousingAssociations2,3

PrivateSector

Housing tenure over time (SHS 2017)

61Owner Occupier

66 66

6162

22Owned outright

32 32

39 39 Buying with help of loan / mortgage

29 29

32

Social Rent23 23 22

5

Private Rent

15 15

0

10

20

30

40

50

60

70

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

% o

f h

ou

se

ho

lds

*Please note the chart excludes 'other' tenure

Housing tenure (%) and age in Scotland

2001 2007 2015 2001 2007 2015 2001 2007 2015

16-34 years 35-59 years 60 years plus

Owner occupier

53 46 32 70 70 64 62 70 73

Social rent

28 25 25 24 22 24 34 24 22

Private rent

17 27 41 4 6 11 2 3 4

Other 2 2 2 1 1 1 2 3 2