Health in all policies. National level volume 2. Housing.

I don’t understand “housing”……(and don’t pretend to). As I say I’m a novice in this space.

See this blog as a foray into a world I don’t yet understand properly but know is important

We all talk about “determinants of health” as if there were a concept that was easy to grapple with and change. It isn’t, they aren’t.

From the outside the Heath care system may look like a big homogenous blob of doctors and nurses. From the inside it is not. Similarly “the determinants of health” are a series of systems, each belie vast complexity.

There’s something about systematically unpacking the complexity that underlies “the determinants of health”.

Mark Gamsu is in the case here re the “welfare system”. It is a determinant, and changes to it over recent years have had profound detrimental impacts on our mental and maybe physical health, at population and individual level.

I’ve had a go at transport a few times. Here – national rule, here, and here bike lanes v cancer drugs

Here’s housing

I don’t know much about housing. I know it’s important. I also know it’s vastly complex (more so than the nhs?) and fiddly. I know that homes, houses and communities are fundamental to health.

NEF and others do some excellent work around national policy in this area, especially land ownership.

My interest was recently sparked by a parliamentary all party report Building our Future Laying the Foundations for Healthy Homes and Buildings 

Accepting I’m a novice in this space, I was a little disappointed. Many statements of the obvious. Maybe reads a little like “health folk” looking in but maybe understanding full context.

Perhaps a better alternative would be those with a deep understanding of housing policy and delivery asking themselves how can we get better health outcomes out of our world – THAT is health in all policies.

Some specific points of critique

  1. Always wary when I see .,.’holistic view’ required,.,— what does that mean in reality
  2. Cost to NHS of poor housing is vast. Don’t doubt, cold, damp, noise, fall hazards etc etc….. same old. but 1) sure built on “interesting” (read heroic) assumptions and 2) the cash in the NHS is tightly locked up
  3. There’s no “clean” leadership re “housing and health” agenda. If you define “health” as “NHS” then there may never be. Both are wildly diverse and complex worlds that inhabit completely different universes and have different cultures. If you define “health” as something more broadly… it becomes much easier.I’d bet that the number of people with a deep understanding of both housing and health care delivery (and then indeed health) is vanishingly small.
  4. Devo makes it messy (no you don’t say). Messy responsibilities – across LA, CR / devo area / national.
  5. Needs a cross govt lead – easier said than done. But this could be done at city region level with devo giving the city region more housing power?
  6. APPG report prob over focused on building new stock and not existing stock. Problematic if your existing stock is causing poor health!
  7. Similarly Building standards – focus on new build. Takes energy away from existing stock…. Arguably this is where most health and well being gain is going to come from……
  8. Building standards might be set nationally, and incentivise LA and others to do the wrong thing? Whats the national and reginonal advocacy to change the rule book here. Job for PHE and others?
  9. On balance my sources tell me we don’t need new standards – need to provide better health ammo for planners to ask for lifetime homes or breeam standards. ( developers say they are too expensive…. Tough…. Its maybe a point that takes us onto economics of externalities…. Developer does on the cheap… some other part of society picks up the cost of cheap)
  10. Building standards also focus on “the home” and “the house” and even if done holistically – will not focus on the home in the context of community and sense of place.
  11. Linking building standards to the wider planning process might be problematic. In NHS parlance this will be like getting good lines of commiunication between orthopaedics and cardiology (different worlds). Maybe something to be said about purposeful approach to strategy so as we don’t inadvertently create ghettoes of old folk / dementia friendly communities….but neglect social networks across whole pops etc
  12. Research in this space is messy. Some want RCTs and the like. Will never happen. Wrong method. This is classic complex system territory.
  13. Green is missing from a lot of this report. Environment issue not “health” issue… but bluntly climate change one of the biggest health crisis of the back end of this and next century. Aka we should perhaps do our bit now to avoid etc.
  14. PRS – is the law right, have we got the regs right, have we actually got the resources to effectively implement the law. Saying we need more resources to protect private rent tenants will be met by ‘ it’s up to local areas how they spend RSG’ it’s a futile . pointless recommendation?
  15. Supported housing missing. Needs to be on your radar
  16. Same comments apply to retrofitting programmes. We can do these. We simply choose to cos it’s too hard with so many owners and tenants on any one street .
  17. Little reference to needs around aging populations and learning disability/difficulty. Maybe greater emphasis on homes suitable for all life course and known growth of elderly pops etc
  18. Think there is something missing about the importance of feeling safe and perceptions of community safety.

There are many other, perhaps more local, opportunities

  • The role is social landlords in managing stock
  • Lots of interesting ideas re how housing providers might input into some NHS priorities unplanned admissions, delays around returning home etc. Basically get housing rep on some groups, maybe even just ad hoc or to answer the specific things. Definitely scope here. Its worth saying its hard enough getting social care on these things…. And that’s one culture shock for NHS folk…. …its not a bad thing… just different worlds folk inhabit and languages they speak….So lets go for broke!
  • Scope and reach of landlords with tenants. Lilkely more trusted than local authorities?
  • Asset management – role around ownership of assets sold. By public sector. Most social landlords might be far more creative and do more for social good than other stakeholders.
  • Fuel poverty MUST be included, obviously. Local and national elements to this.

Role of PH types in this space…..

I don’t understand “housing”……(and don’t pretend to). As I say I’m a novice in this space.

See this blog as a foray into a world I don’t yet understand properly but know is important

Making meaningful intervention in any space requires DEEP understanding of the system to be able to carry credibility and authority and thus to be able to effectively influence.

One might say the same of “housing”, of “education”, of “early years”, or of “planning”. And so on. Each of theses systems is vastly diverse and complex with many different cultures and sub cultures. Many different, difficult and odd incentives with people pulling in many different directions.

As a jobbing DPH, I cant be, and am not, expert in all areas. I know a bit about some of them. Definitely, an effort is needed to shift balance of “public health” away from “health” as defined as health care services. Most know my view that “health

NHS) and that “lifestlyes” might be better characterised as commercial determinants of health

Nobody knows better than housing professionals that poor housing is bad for heath….. so our other role is to HELP housing professionals with new languages etc??

If “PH” types (narrowly defined) are going to get expert in this space, we need real experts in housing funding game if it is to have real impact here, to make recc which it can quantify in health gain terms? we (PH types …. But actually that’s quite a broad church – well beyond those with “public” and “heath” in their job title) need to be more specific re the asks.

If we are doing health in all policies correctly….then it’s the housing sector that should own the agenda, not “health” or the DPH as proxy for “health”

So role of DPH in this one (and many other similar areas) is one of linking and connecting different worlds together, evidence, leadership etc…rather than operational delivery responsibility. Air quality is classic example of this – policy responsibility is DEFRA, tools to improve reside in DfT and HMT, consequences of getting it wrong is DH…who leads in this context?? Housing is, I suspect, considerably more complex than AQ

What we want to do it hardwire “health” (ie reduction of risks of bad stuff / optimisation of positive stuff) into policy, building new (standards), building homes in context of broader communities, existing housing stock, stock taking account of demographic etc etc… whole host of stuff. Health in all policies type of approach – basically how do we get more “health and well being” out of the existing commitments in the space of “housing and homes” (conscious Im using simple terms to describe complex stuff).

But “Health in All policies” is NOT …. Ahhh but we can do better if only “health” give us their cash – much as it would be nice…..

In Sheffield we are clear that PH = organisational responsibility and not a “department” or a line in the budget. This is easier said than done, there’s an element of (my) “personal” responsibility and accountability.

There’s definately a role for PHE in national capacity here – influencing the national architecture and the rules so a “health” becomes more the default of the policy area that is “housing”.

Other national bodies may have more specific expertise, but PHE has an important role – their position and expertise represents the biggest single chunk of Public Health resource for change in the country it therefore needs to be exercised.

it’s a complex and fiddly agenda. Lots to go at in terms of improvement opportunities.

Other refs

Homes for health collectio

Joint action on improving health through the home: memorandum of understanding


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