By NICE (2013)
Overview: In 2011, 6.8 million (29.8%) of the 22.8 million houses and flats in England did not meet housing standards (English housing survey 2011: homes report). One in ten (10.6%) were in substantial disrepair, 4.6% had damp, a quarter did not meet the ‘decent home’ standard (23.5%), and 15.3% had a serious health and safety hazard.
A large body of evidence suggests an association between poor housing and poor physical and mental health, but the nature of any causal links is complicated by the coexistence of poor housing with other determinants of poor health, such as unemployment and poverty. An analysis by the Health Development Agency (2005), now part of NICE, found review-level evidence that a number of housing interventions, such as housing subsidy programmes for low-income families and improving housing energy efficiency measures, improved health. However, the authors noted a number of methodological issues that might limit the validity of their findings.
Current advice: The Department for Communities and Local Government considers a house or flat ‘decent’ if it:
• poses no serious health and safety hazards, as measured by the Housing Health and Safety Rating System
• is in a reasonable state of repair
• has reasonably modern facilities and services, such as kitchens, bathrooms and boilers
• provides a reasonable degree of thermal comfort.
Social houses and flats that do not meet the Decent Homes Standard should undergo refurbishment to bring them up to or above the standard. Homes in the private rented sector do not have to meet the standard but are required to meet Housing Health and Safety Rating System standards. Private landlords whose properties contain hazards as assessed by the system, in particular landlords with tenants on means tested or disability benefits, can be compelled to improve their properties by local authorities.
New evidence: A Cochrane systematic review by Thomson et al. (2013) sought to establish whether physical improvements to housing affected health and socioeconomic outcomes. The authors searched for studies of the effects of rehousing and any physical change to housing – for example, heating installation and general refurbishment – on physical or mental health, wellbeing or quality of life. Thirty-nine quantitative and qualitative studies were identified, but meta-analysis of the data was not possible because of extreme heterogeneity among the studies.
Assessment of the studies by intervention type suggested that warmth and energy efficiency improvements to housing (19 studies) benefited respiratory health and had some positive effect on general and mental health. The studies of rehousing or retrofitting houses mostly looked at housing-led neighbourhood renewal (14 studies) and had mixed results, with only one small study reporting a significant improvement in general health. The limited evidence available on provision of basic housing in low or middle income countries (3 studies) reported unclear or small health improvements, as did the poor evidence on rehousing from slums (3 studies). Three studies reported lower levels of school absence in children after housing improvements, with 1 additionally reporting a link between housing improvements and a significantly lower number of days off work among adults.
The authors generated a model using the 9 studies with the best available data to analyse the overall effect on health of modern day improvements to housing. These studies suggested that warmth or energy efficiency improvements, which are often part of rehousing or retrofitting projects, can lead to improvements in health in high income countries. Analysis of the qualitative data identified in the search suggested that improvements in thermal comfort and affordable warmth allow residents to use more of their indoor space, which can promote improvements in diet, privacy, and household and family relationships.
Commentary: “This study strengthens the evidence of the link between improvements in housing – particularly in warmth and affordable warmth – and improved physical and mental health. It shows the key role of housing in the dynamic between poverty and poor health, and how improving housing can benefit school attendance and reduce absenteeism from work; for example, through improved respiratory health and improved relationships within the home.
“The significance of this evidence for practice is that primary care health professionals and others with a responsibility for improving health and wellbeing should focus not just on individual lifestyle factors but also on supporting improvements in the environment. Such improvements might include interventions to tackle fuel poverty and to improve the energy efficiency of homes.
“Local authorities becoming responsible for public health, improved integration of health and social care in the care of the elderly, and local authorities taking commissioning responsibility for the public health of children ages 0 to 5 years will potentially support health and social care practitioners in improving the health of their patients, clients and communities.” – Sabrina Fuller, Head of Health Improvement, NHS England
Study sponsorship: Chief Scientist Office, Health Department, Scottish Government; and Nordic Campbell Collaboration (NC2), Norway.