How to tackle poor housing standards and improve health

Environmental health officer Aidan Kelly describes Liverpool’s flagship housing and health programme Healthy Homes in a nutshell: “I like to think that as the number of hazards we deal with goes up, someone’s figures in the primary care trust, in serious burns or cardio-pulmonary disease, go down.” 

We’re looking realistically at the likelihood of occupants suffering ill health from housing conditions

Mr Kelly belongs to a nine-strong environmental health team applying the housing health and safety rating system in the biggest push to remove health hazards the city’s private rented sector has ever seen. Devised, managed and run by EHOs, the £4.5m programme, funded by NHS Liverpool and delivered by Liverpool City Council, aims to engage the city’s most vulnerable tenants by sending advocates to 15,000 homes.

Liverpool EHOs say the system, which replaced the fitness standard in 2006, has allowed them to partner their primary care trust in a way they could previously only have imagined. 

Healthy Homes programme manager Phil Hatcher explains: “The main difference between the [rating system] and the fitness standard is that this is evidence based on health outcomes rather than physical property conditions. The [rating system] has been fundamental to setting up the programme and fundamental to the programme itself.”

Programme co-ordinator and system lead Ian Watson and fellow EHO Llinos Griffiths initiated Healthy Homes in 2007, during their Housing Market Renewal work in the Kensington New Deal for Communities area. Under the pilot, EHOs visited 230 homes, identifying the most serious hazards and working with landlords to remove them. It led to an estimated £240,000 of investment in rented accommodation through enforcement action, but also helped identify a wider need.

The team wanted to roll the project out and find out more about the condition of private sector rented homes in Liverpool’s poorest areas. They showed colleagues at the PCT housing health statistics gathered before and after interventions and they discovered they were talking the same language.

“We’re looking realistically at the likelihood of occupants suffering ill health from housing conditions to a degree that they require medical treatment, and how severe that harm is,” he says.

Use of advocates

Impressed, the PCT encouraged the council to bid for PCT funding. The team showed how it would use advocates to assess health and wellbeing needs and in cases of high need, use the housing health rating system. Their bid was successful and the Healthy Homes programme began in April 2009.

Initially, areas were selected using statistics for health deprivation, density of private rented accommodation and the number of potential years of life lost. The team now also considers crime rates, decency standard, hospital admissions and housing benefit rates, but there are no rigid geographical boundaries.

“We’ll do whatever we need to do,” says Mr Hatcher. “We need to respond to new data and different circumstances and challenges as they arise. The programme has evolved since inception and needs to dovetail with other programmes and initiatives without saying ‘this is our job or this is the way we have always done it’.”

Once areas are identified for intervention, the team contacts neighbourhood managers, community leaders and resident groups to promote their visits and identify needs and potential barriers, including vulnerable people, people with disabilities, non-English speaking households, nuisance residents or health and safety issues.

Advocates, highly trained individuals selected for their training and experience in health and social care and their interpersonal skills, then visit residents to collect information on excess cold, damp, mould, accidents in the home, residents’ level of physical activity and whether they are in employment, education or training.

Based on their assessment, advocates make referrals on the occupants’ behalf, for example to a smoking cessation specialist or Warm Front, which hands out insulation and heating improvement grants. If the referral has not progressed four weeks later, the advocacy manager works to remove any barriers.

Other partners include the empty property team; Citizens Advice Bureau; Merseyside Fire and Rescue Service; PCT health trainers; Nextstep, which offers free careers advice for over-18s; English Churches Housing Group, which provides homelessness prevention support; and children’s centres.

Every week, advocates visit four health centres in the target areas to assess patients. At one session they conducted 21 assessments and made 69 referrals, including 11 to EHOs. Environmental health’s relationship with the health service is getting stronger, says Mr Hatcher.

“Inbound referral mechanisms have been set up with a number of health centres and clinicians including GPs, the clinical respiratory team at Aintree Hospital and respiratory pharmacists who deal with chronic obstructive pulmonary disease patients to review the medication. This highlights the importance of environmental health as a partner within the health service, and recognises its contribution.”

“This is about engaging people,” he adds. “Some people don’t want to open the door but we aim to make the contacts that will open those doors, so we can offer our services to the most vulnerable.”