The true cost of poor housing: illness and death

20 Jul 2018 Nick Garbutt    Last updated: 20 Jul 2018

A mud cabin in Belfast 1888. Pic: PRONI

Good health is about much more than a good health service. There are many more factors that affect our well being than that.

This week it was reported that poor housing was costing the NHS £1.4 billion per annum.

These figures echo an earlier survey in Northern Ireland which examined the linkages between poor housing and poor health.

The Cost of Poor Housing Report was commissioned by the Northern Ireland Housing Executive in 2012. It received little coverage at the time yet its findings are important, relevant, and some progress has been made in acting on them.

There is nothing revolutionary about all this – housing conditions have long been known to be critical to good health and our ancestors had a better track record of dealing with it than we do today.

The 1841 census found that two thirds of the Irish population were living in single room mud cabins with no windows. There is no question that the poor, overcrowded, insanitary living conditions in both rural areas and the cities exacerbated the effects of the Irish famine. As did, incidentally, the squalid workhouses that the destitute and starving were condemned to live in.

The authorities eventually acted. The 1866 Sanitary Act enforced the connection of all houses to a new main sewer, set definite limits for the use of cellars as living rooms and established a definition of ‘overcrowding’. The Public Health Act (Ireland) of 1878 specified a number of measures that local authorities had to adopt to improve public health, including ensuring that there was an adequate water supply, drainage and sewage disposal.

These reforms took time to have impact in Ireland – it wasn’t until the early part of the 20th century that deaths from  tuberculosis started to fall. However mortality rates from the disease were higher than Britain and most of Europe until the mid-century.

It is important to remember that connecting ill-health to poor housing is not some new revelation, but has been known for centuries and attempts to improve living conditions pre-date the establishment of the National Health Service. Today many, including policy-makers, seem locked into the notion that good health is all about treating illness, when this is clearly not the case.

The 2012 report systematically identifies the housing factors that cause ill-health. They include: dampness; living in a cold home; household accidents; noise; the fear of crime; overcrowding; and fire safety.

It is helpful to understand the scale of the problems here because the report used an identical methodology to reports into housing in England and Wales.

The good news is that the housing stock in Northern Ireland is generally in better condition than that in England and Wales, and that many of the more serious problems here are comparatively cheap to fix.

It estimates that 144,000 (20%) of Northern Ireland’s homes should be deemed ‘poor housing’. This compares with 22% in England and 29% in Wales. The most common type of hazard in Northern Ireland fits into the accidents category - the risk of falls which typically would arise from unsafe stairs in homes, steps outside them or unsafe paving outside them. Older people and small children are especially at risk from this.

Another key factor is cold. Government annually measures Excess Winter Deaths – a large proportion of which are related to cold homes. The last available figure for Northern Ireland shows that in 2015/16 there were 640 Excess Winter Deaths. The UK as a whole is the sixth worst performer amongst 30 European nations for these deaths, and as many die every year from a cold home as from prostrate cancer and breast cancer.

But the number of deaths is only part of the story. A healthy indoor temperature is around 21°C and the risk of adverse health effects begins once the temperature falls below 19°C.

The report states: “Below 16°C there is a substantially increased risk of respiratory and cardiovascular conditions, especially among the elderly. Below 10°C the risk of hypothermia becomes appreciable, especially for the elderly. Low temperatures can impair the thermoregulatory system of the elderly and the very young. Cold air streams may affect the respiratory tract and can slow the heart temporarily. These increase strain on the heart and also blood pressure. Low temperatures can also worsen the symptoms of rheumatoid arthritis, aggravate conditions like sickle cell anaemia and the related thalassaemia, and can affect the healing of leg skin ulcers.”

This throws up the issue of fuel poverty. Having a warm home is not a nice, cosy aspiration but a necessity for a healthy life.

According to the 2016 Northern Ireland House Condition survey around 160,000 households in Northern Ireland (22%) are in fuel poverty. That is alarming, but not as bad as it was back in 2012 when the figure was around double that. The improvement is largely down to a near £300 million government investment in energy efficiency, thus reducing fuel consumption. There’s no room for complacency – as fuel costs continue to rise, so too will fuel poverty, despite the new measures.

The Cost of Poor Housing Report estimated that it would take around £469 million to deal with so-called Category One health risks in Northern Ireland. This would, in turn, lead to savings elsewhere of £82 million, meaning the payback would be just five years with 40% of these savings - £33 million accruing to the health service. This looks like a good investment. It is also a rosier picture than that in England where the position appears to be slowly worsening rather than improving.

Other findings from the report are predictable but equally disturbing: poor housing is more prevalent in rural areas, as is fuel poverty, older people are most at risk as are those who live in homes built before 1919.

Yet this is only part of the picture. The Cost of Poor Housing was only able to analyse physical, not mental health because of the lack of data. More recent research suggests that the impacts on mental health of poor housing are even more severe.

A recent report from the Joseph Rowntree Foundation – The Housing and Life Experiences report found that people in poor housing are not necessarily even aware of the physical health risks: “For the most part the physical fabric of participants’ homes was not perceived to have a significantly negative impact on their own health or the health of others in the household although damp was certainly a problem in many properties.”

Instead they talked about high levels of stress and anxiety from anti-social behaviour and criminality in their communities and an intolerable level of insecurity, especially in the private sector over their tenancies: “Would the lease be renewed? Would the rent go up? Would they be able to afford a rent increase? Would they be able to find another property they could afford?”

This area awaits comprehensive research. But it seems obvious that mental ill health is also linked with poor housing and measures will also be required to ensure homes are safe and tenancies secure: putting people before profiteers.

And the bottom line for government is that improving health cannot come about from simply ring-fencing health spending, it involves all departments working together.

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