Nottingham Insight

This chapter considers the impact of housing on health, in particular physical housing conditions and the relationship between cold homes and cold related mortality and illness among vulnerable people. This joint strategic needs assessment (JSNA) identifies the strategic, policy and commissioning needs that will reduce the impact of poor quality homes on negative health outcomes including excess winter deaths (EWDs) and cold-related harms in Nottingham. Homelessness is considered as a separate topic in the Homelessness JSNA chapter.

Housing is a key determinant of health and poor quality or unsuitable homes can directly affect people’s physical and mental wellbeing, creating or exacerbating health issues. Those who are already vulnerable through disability, existing/chronic ill-health, age and/or low income, are most at risk of deprivation including poor quality homes and neighbourhood environments. There is clear evidence that links poor health with poor housing, for example: increased risk of high blood pressure or circulatory problems in elderly occupiers in poorly heated accommodation; raised levels of asthma and other respiratory conditions in children living in damp housing with high levels of mould growth.

The most serious impact of cold or poorly heated homes is, of course, the death of the occupant, with cold and damp homes being a risk factor for vulnerable people and cause of excess winter deaths; most in relation to cardiovascular disease though in rare cases, hypothermia. A higher excess winter mortality rate has been observed in the UK than in many other European countries that experience colder winters, and health problems associated with cold homes are experienced in “normal” winters as well an extremely or unusually cold weather. An increase in death rates can happen when temperatures drop below about 6°C. (NICE, 2015).

EWDs is a measure that describes the additional number of people who die in winter compared with the spring, summer and autumn months. The Excess Winter Death Index (EWDI) explains EWDs as a proportion of the expected deaths based on the number of non-winter deaths (commonly expressed as a percentage). Out of the total population of 330,734 in Nottingham, an average of 3,000 people died per year between 2007/8 and 2017/18. Of those, an average of 158 were EWDs. (ONS Public Health Mortality Files, 2019)

The greatest overlap of financial vulnerability and poor housing conditions is in the private rented sector, which has seen the largest sector growth over the past decade and now comprises over a third of Nottingham’s housing offer. The Building Research Establishment (BRE) estimated that 21%, of private rented homes contained a Category 1 Health and Housing Safety Rating System (HHSRS) hazard - defined as risks of harm to the health, safety or wellbeing of an occupant that arise from deficiencies within a dwelling on which a Local Authority has a duty to take a prescribed form of action. (BRE, 2016)

The Council Plan 2015-19 committed to the delivery of 2,500 new homes that Nottingham people could afford to rent or buy, the implementation of selective licensing for the majority of the city’s private rented stock, and to tackling fuel poverty. The Council Plan 2019-23 makes a further commitment to deliver 1,000 new social owned homes and further reduce fuel poverty for older people. As the Local Planning Authority, Nottingham City Council also has a vital role in ensuring that new homes are built to applicable building standards, on sites that protect against environmental pollution and are treated for any prior industrial use.

Improving Health and Care through the home: A National Memorandum of Understanding was established between government departments and main agencies (NHS England, Public Health England and Homes and Community Agencies) and signed by various agencies in 2015, with a new version published in 2018.

Nottingham City signed its Memorandum of Understanding to Support Joint Action in Improving Health through the Home in 2016, with the following long-term objectives:

• Integrating health, social care and housing services
• Maximising the impact from housing as part of the ‘wider health workforce’
• Maximising the housing contribution to reducing health inequalities between areas and social and cultural groups
• Further developing the housing sector’s role in reducing the demand for health and social care services
• Communities and citizens playing their part in contributing to healthier lives strategies and activities

Unmet need and gaps

• There remains a shortage of quality and affordable housing, as demonstrated by the housing register and a continued lack of security in the private rented sector, as well as sufficient evidence regarding poor quality in the private rented sector for Nottingham being granted approval, by central government, to implement a selective licensing scheme.
• There is insufficient turnover in the housing market to enable or encourage households to move as their needs change. There is a need to optimise existing housing, increase the flexibility and choice in the housing offer as well as deliver increased provision overall.
• The greatest coincidence of poor housing conditions and low income is in the private rented sector, with poorest energy efficiency performance being in the central wards Berridge, and Arboretum and Hyson Green.
• The link between poor housing and poor health, though recognised since Victorian times, is still lacking in robust enough datasets and case studies to justify (the funding and promotion of) housing interventions based on health outcomes. Housing-led or based projects have minimal monitoring of health outcomes and clinical recording and recognition of housing as a source of ill health is majority absent.
• In Nottingham, energy focussed housing interventions are coordinated by the Domestic Energy Efficiency and Fuel Poverty (DEEFP) sub-group of the Health and Wellbeing Board. However, there is a lack of joined up working between organisations and an absence of coordination of other interventions to improve conditions and outcomes in private sector housing.
• EWDs index analysis data showed comparably worse outcomes in two specific Primary Care Network areas in the city - Bulwell and Sherwood, and Bestwood and Top Valley.
• Immunisation rates for influenza for the over-65s and for at-risk individuals are lower in Nottingham City than nationally. Influenza is a key risk factor for EWDs and cold-related harm.
• Smoking-related long-term conditions continue to be a key contributory factor to EWDs, especially when combined with poorly insulated housing.
• There are too few referrals to energy efficiency services of vulnerable householders from frontline health and social care staff and a lack of data to determine whether practitioners are adequately equipped to make every contact count (MECC)

Recommendations for consideration by commissioners:

Ceri Davies, Nottingham City Council

ceridavies@nottinghamcity.gov.uk

Ellen Cooper Tydeman, Nottingham City Council

Ellen.coopertydeman@nottinghamcity.gov.uk