Published on 19 January 2015
For so long matters affecting health and wellbeing have been seen by local authorities as of Social Services interest alone. Claims of 'bed blocking', cost shunting and premature discharge have formed the currency of dialogue between health and local government. Of course, that was never a sensible understanding of the real issues. After the most recent reorganisation of the NHS in which Public Health was largely transferred to so called 'upper tier' authorities it became increasingly clear that the bulk of public health was in fact delivered rather through the environmental health, housing, development control and leisure services of District Councils and Unitary Authorities.
Often Health and Wellbeing Boards have interpreted their title as meaning "Health and Social Care". Yet, we know that the main drivers of health and health inequality are differential smoking behaviours, differential educational experience and differentials in income.
Where people live, the housing they get and the resources they are able to access are largely shaped by factors beyond their individual control: 80% of smokers are seized by their habit before it is legal to sell them a cigarette, educational performance in schools varies so remarkably that for some parents it is an act of criminal negligence to send their child to one, yet they are prosecuted if they fail to do so, and from birth one third of our children live in homes with incomes <60% of average household incomes. And, of course, such experiences of disadvantage are cumulative so while two thirds of lone parents are in rented accommodation, so a similar proportion smoke (an average of >14 cigarettes a day) with a fifth of all social benefits returning directly to the Treasury in tobacco duty.
Tobacco is itself a significant housing issue not only degrading the housing stock of tenants who smoke but causing a third of all household fires and resulting in a third of all domestic fire deaths resulting from cigarette smoking. Yet increasing constraints on smoking in public places and the workplace result in the domestic house becoming the last - and as we've seen above sadly for some the final -refuge of the smoker.
Housing's impact upon disposable income effectively determines the extent of poverty in the wider society. Mortgage repayments and rent aside (though so significant we present income data broken down "before and after housing costs") running a home is increasingly expensive with fuel prices having doubled in the last ten years and with similar increases predicted again. Private renters part, on average, with >40% of their gross income to cover housing costs. While social housing tenants tend to be poorer at least such housing is more energy efficient - while older owner occupiers experience the
coldest homes, most difficult to heat. A generally accepted estimate of the costs of ill health caused by inadequate housing is in the region of £2.5bn.
Housing impacts on the development and education of children. Shelter's work demonstrates the relationship between depression and anxiety, slower physical growth and cognitive development, a higher incidence of respiratory problems and longer term 2 disability. The Family and Children survey found 13% of children spent the last year living in inadequately heated homes with double the rate of chest and breathing problems and school absence. Children living in crowded conditions were found by Conley (2001) to complete a quarter less schooling than their peers.
Sir Michael Marmot has argued (2010): "The rights and privileges which are so unequally associated with housing tenure are associated also with health. Security in housing does has health benefits and should be equally available to all".
In my view, the housing market, spare room subsidy, housing design, insulation schemes, benefit caps and all, form a fundamental element of any public health strategy. Exhortations to improve diet and exercise, to protect against sun burn, to stop or cut down cigarette use, to moderate alcohol consumption and practice safer sex while all admirable in themselves, are not the totality of what Public Health can be. Local Authorities which, plan and license, regulate and manage the environment, set strategy for education, land use and economic development can also accept that those are the very policy arenas which can produce the kind of major improvements in health and wellbeing that the Health and Social Care Act has tasked them to deliver.
Simon Stevens, new NHS England Chief Executive, has addressed the looming financial crisis in health by repeating Derek Wanless' claim of a decade ago that only by adopting major Public Health measures, moving from pulling people out of the river downstream to stopping them ever falling in, will the NHS remain affordable.
The recent Commonwealth Fund report (2014) identified the NHS as the best performing healthcare system amongst eleven post-industrial nations. However, against one criterion alone, 'health outcomes', the UK came off worse than all but the US. Our levels of inequality, our failures in preventative social policy and "silo" management in the public sector services impose ever greater demands on a world class care system.
Perhaps we need to go back to the home and look again at what can improve our nation's well-being where we all start off - in our homes.
Bryan Stoten is Chair of UKPHR and Visiting Professor of Health Policy, Coventry University. Until recently he was also Chair of Warwickshire's Health and Wellbeing Board.