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Housing JSNA

Abstract

This is the JSNA chapter on housing. Theme chapters summarises implications for commissioning, who is at risk and why, the level of need in the population, service provision and use, unmet needs, what works in terms of evidence, community views and priorities, any related equality impact assessments, unmet service needs/gaps and recommendations for further needs assessment work. 

Introduction

Housing is a key determinant of health.  The Dahlgren and Whitehead model  illustrates the main factors determining health, of which housing is one.

Source: G Dahlgren and M Whitehead, Policies and strategies to promote social equity in health, Institute of Futures Studies, Stockholm, 1991.

The relationship between housing and health is complex.  There are a number of housing attributes that can affect health outcomes. Cold, damp and mouldy housing conditions pose the highest risk to health. Other factors such as overcrowding, homelessness, quality of neighbourhood and hazards defined under HHSRS can also have a negative effect on health and wellbeing.  People living in poor condition housing often suffer from a number of other deprivation factors such as low income, high levels of unemployment and social isolation.

The Marmot Review  concludes that reducing health inequalities will require action on policy objectives such as ensuring healthy standard of living for all, creating and developing healthy and sustainable places and communities, and strengthening the role and impact of ill health prevention.  The Department of Health White Paper  took this link between housing and health further by setting out how the two disciplines should become more integrated, along with Adult Social Care, in delivery of preventative services.  This is reinforced in the Public Health Outcomes Framework , which highlights the influence that the quality of a place has on maintaining good health.

Implications for Commissioning

• Support the delivery of Bolton’s Housing Strategy and its strategic priorities which prioritises improving health, wellbeing, and quality of life.
• Support the delivery of the Affordable Warmth Strategy.
• Support interventions aimed at improving decency standards in Bolton’s housing stock, particularly in relation to combating cold homes and for vulnerable households.
• Support the delivery of new housing development, particularly those specifically aimed at vulnerable groups.
• Support the development of Bolton Care and Repair and its role in improving access to universal services for elderly and disabled people to prevent or delay dependence on expensive support services.
• Support improved integration between housing, health and adult social care.

Who's at Risk and Why?

There are several key at-risk groups regarding housing in Bolton.
 
Vulnerable Households
Vulnerable households are those in receipt of at least one of the principal means tested or disability benefits.  They are more likely to suffer additional health problems as a result of poor housing conditions.  The 2011 Stock Condition Study reported that 38% of vulnerable people in the private sector live in non-decent accommodation.

Older People
The number of older people in Bolton is increasing and projected to continue to do so.  Declining health and an increase in support needs are closely associated with old age.  Living in inappropriate or unsuitable accommodation can aggravate these problems, potentially create others and have a negative impact upon physical and mental health and wellbeing .

Disabled People
Disabled people may require adaptations to their home to be able to live comfortably, safely and independently.  The level of assistance available from government and the local authority falls short of what would be necessary to meet all identified need, resulting in long waiting times and unmet need.

Households Living in Poor Condition Housing
Poor housing conditions can cause falls, excess cold and can exacerbate existing medical conditions. There can also be a significant impact on a residents wellbeing, mental health and quality of life.  The 2011 Private Sector Stock Condition Study found that 24% of dwellings in the private sector were identified as having a recordable hazard.  Households living in social rented housing stock benefit from their homes being brought up to Decent Homes Standard, meaning that it is warm, weatherproof and has reasonably modern facilities.

Households in Fuel Poverty
A cold environment is linked to many health problems including respiratory complaints and strain on the heart.  People in cold homes are at a significantly greater risk illness and of winter mortality than those living in warm homes.  Poor energy efficiency and lack of ventilation are linked with the presence of damp and mould growth, which in turn can worsen bronchial problems particularly in children.  This can have an impact on education attainment through  absence from school due to sickness and not having appropriate home conditions to work in.  The increase in the number of people dying from respiratory and circulatory diseases during the winter months is referred to as ‘excess winter mortality’.  Indications are that people living in poorly heated dwellings are at a significantly greater risk of winter mortality than people in warm homes.

The Level of Need in the Population

Vulnerable Households
In August 2012 there were 25,720 claiming Housing Benefit and 32,570 claiming Council Tax benefit; 23,790 households were claiming both.
There are approximately 24,642 private sector households in Bolton that are vulnerable.  Of these, an estimated 38% live in non-decent housing.  This equates to 9,481 households.
Significant changes are being made to the benefits and tax credit system due to the introduction of the Welfare Reform Act 2012.  The biggest impact upon vulnerable households will be the introduction of Universal Credit and the benefit cap.  Universal Credit will combine key benefits such as jobseekers allowance, housing benefit and tax credits.  The benefit cap will limit the amount of any benefit paid to households of working age to £350 per week for a single adult with no children and £500 per week for a couple or lone parent, regardless of the number of children they have.  The changes will impact on those households reliant upon benefit payments, which are likely to be the most vulnerable and low income households in the borough.  This is likely to create further problems for these households and create additional demand on services.

Older People
A key challenge for Bolton is the increasing number of older people.  Although people are living longer, those in very old age tend to suffer from greater ill health and require higher levels of support.  The increased resource demand associated with caring for an increasing elderly population means that this is a major concern for Bolton.
Furthermore, as people become more elderly there is a move away from owner occupation and into social housing or into the homes of family carers.  The potential pressure on social housing stock is obvious and there is a need to provide services that help to support older people to live independently in their own homes for longer to relieve some of this pressure and ensure that social and supported housing stock is available for the most vulnerable.
Further detail is available on older people in the JSNA Older People and Housing chapter here.

Disability
The Annual Report of the Director of Public Health for Bolton 2009/10 concentrated on the older population of Bolton and demonstrates that the number of people with mobility issues increases with old age and that there is a greater prevalence of mobility problems across BME groups and in the most deprived areas of Bolton.
The 2011 Housing Market and Needs Survey included an analysis of disability in the population of Bolton.  It found that:
• 49% of households in Bolton contain someone with a disability or long standing health issue;
• 23% of households contain someone with a long standing health condition such as cancer, diabetes or chronic heart disease (CHD);
• 17% of households contain someone with a physical impairment.
The Major adaptations (DFG/DFA) service takes on average around 1,300 enquiries per year.  This figure reduces to approximately 600 enquiries for assessment per year as applicants are offered alternatives such as minor aids or adaptations, they do not meet the criteria or are not eligible after means testing.

Households Living in Poor Condition Housing
The 2011 Private Sector Stock Condition Study reported that there are an estimated 36,091 private sector dwellings in the borough that fail to the Decent Homes Standard.  This equates to 36% of all the private sector homes.
To meet Decent Home standard in the private sector, the dwelling must:
• Meet the statutory minimum for housing;
• Be in a reasonable state of repair;
• Have reasonably modern facilities;
• Provide a reasonable degree of thermal comfort.
The average cost of making a home decent in Bolton is approximately £30,000.
Overall, 38% of vulnerable households live in private sector accommodation that fails the decent home standard.  This equates to 9,481 households.
In the social sector, all homes in Bolton met the Decent Homes Standard by the 2010 target set by government.  This continues to be the case as landlords undertake works to any properties that fall outside of this each year.  Registered providers are also undertaking energy efficiency improvements to large proportions of their stock to reduce carbon, bring down utility bills, and keep homes warmer.  This has included loft and cavity wall insulation, double glazing, and upgraded Band A heating systems.

Households in Fuel Poverty
Fuel poverty is the inability to heat your home to a comfortable, healthy standard.  When a household has to spend more than 10% of its income on heating their home, they are said to be in fuel poverty.  The main causes of fuel poverty are poor housing conditions and low income.  Bolton has 22,515 households in fuel poverty, which equates to 19.7% of households.  Further detail is available on households in fuel poverty in the JSNA Fuel Poverty chapter.

Current Services in Relation to Need

Bolton Community Homes
Bolton Community Homes (BCH) is a wide ranging cross section partnership of local authority, registered housing providers, private landlord sector, community and voluntary sectors, services users, and developers.  It influences, contributes to, and supports corporate planning and area management strategies and designs develops and implements housing led regeneration activities.  Examples include:
• Affordable Housing Provision: Through new build schemes and bringing empty properties back into use;
• Development of Specialist Housing Schemes;
• Sustainable Communities;
• Contributing to the production and implementation of strategies.
Health and wellbeing related services provided by the BCH registered provider partners include:
• The Roots project: Personal development programme assisting groups and individuals to overcome barriers and become closer to mainstream society;
• Independent living services, including:
– telecare and mobility services which include property adaptations;
– a ‘sheltered forum’ for residents to shape local services;
– inter-scheme communications allowing residents from across the region to share experiences including playing and inter-scheme quiz;
• Financial inclusion: Assisting residents to maximise their incomes including providing representation at medical assessments;
• Community development and cohesion: Assisting local communities to prosper and address inequalities and deprivation;
• Very Philosophical: A process which facilitates group debate, thinking and awareness and can be tailored to promote the health and wellbeing agenda;
• Neighbourhood Management: Has a joint working approach across four geographical areas and already make links with Public Health partners and in some cases GPs and other health practitioners.  Health Development Officers (employed by Public Health) are located within the Neighbourhood Management Teams to provide links with health services in the area and influence development and delivery of services;
• UCAN Centres: The eight UCAN Centres across Bolton are focused in the most deprived communities.  They offer local residents access to a vast range of activities and support to identify and deal with their issues (including health issues).  Services offered through the UCAN centres include advice and support, counselling, IT classes, a mother and baby unit, and the Think Positive programme;
• Positive  Futures: Helping tenants back into work, volunteering and training;
• Clear Aims: Helping to build confidence and readiness for work and training.
BCH has also set up two community projects that further enhance the services it contributes to:
• UCAN Build a New Beginning Project: Helping those with low level mental health needs to build skills that will help them to access work, has started at Farnworth UCAN Centre and will be replicated at the other UCAN centres across Bolton;
• LASE Project: Helps to get young people leaving care into housing related apprenticeships.

Specialist accommodation schemes
Including sheltered and extra care housing schemes for older and vulnerable people and housing schemes for people with disabilities.

Housing Advice
Providing advice and assistance on all aspects of housing including private and social renting, housing benefit, land lord advice, bond board referrals and they also offer a triage service.

Homelessness Services
Homeless Welfare assists customers in the prevention of losing their accommodation and assesses and makes decisions on homeless presentations to the Council.  This can involve placing households in temporary accommodation and liaison with relevant agencies to ensure appropriate re-housing.  Temporary accommodation schemes include Nightstay and Lewis House, which support young homeless people and assist women fleeing domestic violence respectively.  Gilead House provides temporary accommodation for single homeless men and is currently being remodeled to offer an enhanced support offer.

Affordable Warmth Strategy
Bolton Council’s Affordable Warmth Strategy aims to reduce the number of people living in fuel poverty in Bolton.  Through achieving this aim we will also reduce health inequalities, increase life expectancy, improve housing conditions, and reduce CO2 emissions.

Care and Repair
Bolton Care and Repair aims to help residents who are older or disabled with the repair and maintenance of their home.  Services offered include advice and information, small home improvement grants, handyperson service, heating and insulation grants, home security, and a list of approved contractors.  Care and Repair also offers signposting and referral to other support services.

Housing Options for Disabled People
Bolton Council’s Find a Home Team runs a Disability Housing Register (DHR), which gives preference to applicants for suitably adapted properties that become available.  Adapted properties that become available will be offered to those on the DHR prior to it going to general advert.
In order to be assessed for inclusion on the DHR, applicant’s cases must be supported by a relevant professional such as occupational therapist or disability officer and include details of mobility difficulties and the type of adaptations required.  In November 2012 there were 138 applicants on the DHR and on average 2-3 allocations for adapted properties via the DHR take place each month.
The Disability Service, part of the Independent Living Service provided by Adults, carries out minor adaptations (under £1000).  Major adaptations are delivered via a Disabled Facilities Grant (DFG) or Disabled Facilities Adaptation (DFA) dependent on tenure and landlord.  Bolton Council provides funding for the mandatory Disabled Facilities Grant.  This grant helps towards the cost of adapting customer’s homes to enable independent living.  They can be used to give better freedom of movement into and around the home and/or to provide essential facilities within it.  For 2013/14 this will be £1.364m.  Bolton at Home provide funding for all DFA grants in their stock and spend £1.2m annually as set out in the transfer agreement.
BCH facilitates the development of new housing provision, with some schemes focusing on specialist accommodation for those with disabilities.  New provision for specialist housing groups is informed by the need demonstrated in the Strategic Housing Market Assessment and Housing Market and Needs Survey.

Housing and Public Health Unit
The Housing and Public Health Unit deals with many aspects of private sector housing.  The unit aims to tackle poor property standards through a combination of information, support and enforcement.

 

Private Sector Renewal Team
This team will implement a new approach to private sector renewal focusing on small targeted areas of the worst condition private sector properties and ensuring that the properties are brought into decency using the HHSRS.  They will also offer a range of new financial products to enable to recycling of resources.

BARLO
Assists and supports those private landlords who are delivering good property standards and tenancy management practices.  This includes information, advice and support, free products and services, and regular landlord events.

Strategic Housing Services
Responsible for the delivery of the borough’s overarching housing strategy and action plan.  The service ensures the joining up of housing related strategies and projects to deliver the priorities of the Council and its partners.

Evidence of What Works

The Chartered Institute of Environmental Health
CIEH have developed a cost calculator that aims to provide a baseline of likely numbers of incidents of harm resulting from poor housing, together with the associated health costs.  For Bolton, the calculator estimates that there are 165 incidents per annum which could be prevented through better quality housing, with an annual cost to the NHS of £80,200.
Housing and Public Health: A review of reviews of interventions for improving health - Evidence briefing :
• There is review-level evidence that anxiety and depression scores are reduced in people who are re-housed on the basis of medical need;
• There is review-level evidence that housing interventions involving improvements to energy efficiency measures, such as installation of new windows, can positively affect health outcomes;
• There is review-level evidence to suggest that home hazard modification interventions that seek to remove and repair safety hazards are effective in reducing falls in older people. This effect was strongest for people with a history of falling prior to intervention and men aged over 75 years.

Good Housing, Good Health
Interviews with Housing and Health professionals found :
• Both sets of professionals identified cold and damp conditions particularly in relation to the problem of excess winter deaths, housing design/safety issues in relation to falls in the elderly at home, and escape routes for fires;
• Professionals also recognised more indirect links to health through, for example, feelings about and satisfaction with the home and perceptions and feelings of safety both within the home and the neighbourhood;
• While physical housing conditions were a determinant of health, the wider context of the neighbourhood – unemployment, educational attainment, the level of antisocial behaviour, crime, fear of crime and drug-use – was also emphasised.

Local Service Delivery Evidence
• There have been 1,661 instances of customers assisted to remain living independently through interventions by Care and Repair in 2012 (Jan-Dec);
• There have been 52,363 Affordable Warmth measures (loft/cavity wall insulation) installed in Bolton, up to and including 2011-12.  This equates to annual savings of approximately £9million on fuel bills for householders in Bolton;
• Housing and Public Health have carried out 385 Housing Health and Safety Rating System inspections in 2012 (Jan-Dec) resulting in the elimination of 684 hazards.

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Community Views and Priorities

Housing Strategy
The 2008 Housing Strategy included service user consultation as part of its consultation plan.  Key issues identified by customers were:
• Provide affordable housing for young people and couples;
• Address the needs of the growing elderly and disabled population in Bolton.  Older people want garden space, garages, etc. not first floor flats or bed-sits;
• Build adaptable homes, rather than adding on adaptations later;
• Provide more ‘move on’ accommodation for people in supported housing, including young people;
• Address problems of access to services for homeless people and substance misusers;
• Assist private developers to consider size and type of homes built when developing.

Housing Market and Needs Survey
In 2011 a postal survey of 12,000 households was conducted to examine housing needs and aspirations of local people (3,395 households responded). This survey told us that:
• 13% of respondents said that their home was not adequate for their needs; 41% of these stated it was due to the need for improvement or repairs;
• 7% of households in the borough are privately rented (8,479 homes) and the average rent paid by respondents in the private rented sector was £405 per month;
• Less than 16% of newly forming households currently have enough savings for a deposit for an entry level home in Bolton and up to 60% of newly forming households do not have the necessary income to obtain a mortgage for the same type of property;
• 21% of all family households that responded to the survey planned to move within the next three years;
• 6,057 households contain someone looking to move in the next three years;
• 13% of all the households planning to move in the next three years are considering some form of supported housing, 60% whom are looking to rent their next home from a housing association;
• 47% of all households in the private rented sector are planning to move within the next three years, this equates to 3,986 moving households;
• Bungalows are in high demand and there appears to be a shortage in both social and market housing;
• Terraced housing is in low demand.  There are high numbers of existing households looking to move on from this type of accommodation and amongst newly forming households it is overlooked in favour of semi-detached homes or flats;
• 71% of all older households are under-occupied;
• There is high demand for adaptations that will provide level access bathing and single level living, such as walk in showers and downstairs bedrooms, bathrooms and toilets.

New Openings Group
The New Openings Groups carried out a consultation exercise on housing issues and options.  This was facilitated by Strategic Housing.  Key issues identified were:
• Almost 70% felt that they had a real choice about where they lived and who they lived with;
• Respondents highlighted that feeling safe was an issue, especially when going out of the house at night;
• 45% responded that given the choice they would like to move house;
• Only 23% responded that they would contact the Housing Options Office/Housing Office for help with moving house.

Bolton Carer’s Forum
A meeting of Bolton Carer’s Forum was used to discuss the housing issues most important to group members.  The issues identified were:
• For people with disabilities to have choice over where they live and the type of property they live in;
• To have an increased offer of housing choices for people with disabilities;
• For there to be one point of contact for people with housing issues that can give advice on housing options, accommodation based support and living independently.  It should be clear where to go for this information and be well publicised;
• More focus on the housing needs of specialist groups. New build homes specifically for people with disabilities.  Would it be possible for new build homes to take into account the needs of tenants before they moved in?
• Need to be more opportunities for living with other adults with similar levels of independence.  This would provide some level of peer support and help with building confidence;
• Help to put in place strategies of care/support for when parents are no longer able to care for their disabled child.

Equality Impact Assessments

No recent local equality impact assessments have been carried out that we are aware of.  If you are aware of any such work locally please let us know at Bolton Health Matters.

Unmet Needs and Service Gaps

The large number of non-decent homes concentrated in the private sector means that it is extremely unlikely that public funding will be able to resource the necessary improvements.  The Council must develop its role in supporting householders to respond to these issues themselves.
The costs of rectifying defective housing can be too high for some low income households. The national financial situation means that there is reduced availability of credit for owner occupiers and landlords who may need to repair and improve their properties.  The amount of funding available for the Council to improve private sector housing has also dramatically reduced.  This highlights the need for affordable financial products to be developed for those living in the worst condition private sector stock so they are able to make the necessary improvements to their homes using their equity or interest free loans.
Disabled Facilities Grants and Adaptations continue to be in high demand resulting in long waiting times for non-priority cases.  The service may benefit from a more streamlined approach that would shorten waiting times and potentially mean delivery of more cases within existing budgets.
Supporting the ageing population will require considerable planning and resources.  Additional supported housing schemes in both the social and private sectors should be encouraged.
Plans are in place for the development of Bolton Care and Repair as the lead agency in assisting and advising older and disabled people with repairs, improvements, maintenance and adaptations to their home. In linking this approach with other services, the aim is to help people to maintain their independence and prevent or delay the need for social care.
Changes made under the Welfare Reform Act will impact on the most vulnerable and low income households.  This is likely to create additional demand for housing services such as homeless welfare, homeless prevention and housing advice.

Recommendations for Needs Assessment Work

Housing needs, the housing market and condition of private sector housing stock in Bolton is assessed every five years through a programme of research which produces the Housing Needs Survey, Strategic Housing Market Assessment and Private Sector Stock Condition Study.
Further assessment may be needed to further understand the housing needs and aspirations of more vulnerable groups such as older people, disabled people or households affected by the changes to the benefit system.
Further outcomes monitoring and assessment of the impacts that housing services have on health is necessary to be able to demonstrate the effects of home improvements, repairs and support services on a customer’s physical and mental health.

Key Contacts

• Michelle Horrocks – Housing Strategy Unit Manager
• Paul Philbin – Bolton Community Homes Partnership Manager

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