Physical health – key issues

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Poor housing can lead to poor health and exacerbate existing health conditions. A warm, dry and secure home is associated with better health.

The BRE in 2015 suggested that the cost to the NHS of poor housing in England was £2billion per annum (based on first year treatment costs only): an increase from the previous (2010) estimate of £600million.

The English Housing Survey has identified a higher prevalence of poor housing in the private rented sector (PRS) compared to other tenures. Home to almost 4 million households, the number of households living in this sector has nearly doubled in the past ten years. It is increasingly being used by local authorities and agencies to accommodate people who have approached them with a housing need e.g. they are homeless.

The apartments on the Thames in London, UK

In this section we consider the impact of poor housing on physical health. Outcomes of poor housing conditions such as overcrowding, damp, indoor pollutants and cold have all been shown to be associated with physical illnesses including eczema, hypothermia and heart disease. Respiratory health has been shown to be particularly affected in both adults and children. What is difficult to do at times is to separate the impact of specific hazards from other compounding factors, which in themselves may give rise to poor health outcomes.

General measures of physical housing conditions

In understanding how housing-related defects contribute to the health and safety of occupants, there is a need to consider what these defects are. There are two recognised measures for defining poor housing and dwellings which require interventions to improve or mitigate health hazards.

Housing Health and Safety Rating System (HHSRS)

The Housing Act 2004 provides for a system (not a standard) to assess housing conditions in England and Wales; the Housing Health and Safety Rating System (HHSRS). This evidence-based system is a means of identifying defects in dwellings and evaluating the potential effects of any defects on the health and safety of occupants, visitors, neighbours and passers-by. This system creates a statutory minimum requirement for housing across all tenures.

The system is used to rate the risk from 29 housing hazards relating to:

• Damp and mould, excess cold/heat
• Pollutants e.g. asbestos, carbon monoxide, lead
• Lack of space, security or lighting, or excessive noise
• Poor hygiene, sanitation, water supply
• Accidents – falls, electric shocks, fires, burns, scalds
• Collisions, explosions, structural collapse

This system enables a differentiation between minor hazards and those where there is an immediate threat of major harm – Category 1 hazards – and informs the action that can be taken to remove or minimise risks from hazards to health and safety. The Housing Act 2004 also contains a package of enforcement measures for local councils to use.

Decent Homes Standard

The Decent Homes Standard, defined by the government in 2006, formed the basis for investment and improvement in social housing.

In order to meet the Decent Homes Standard, social housing must:

•  Meet the statutory minimum standard for housing (see the HHSRS above) – homes with a Category 1 hazard are non-decent
•  Be in a reasonable state of repair
•  Have reasonably modern facilities and services
•  Provide a reasonable degree of thermal comfort

As a result of investment the English Housing Survey 2013 reported that only 14.7% of social housing did not meet the Decent Homes Standard. This compares well against the proportion of non-decent homes in the private sector: 19.4% of owner occupied homes and 29.8% of private rented homes did not meet the standard.

Inequalities in housing conditions are further exacerbated by poverty, deprivation and ethnicity.  Residents living in poverty are more likely to be exposed to poor conditions and live in the private rented sector.  Households in the most deprived areas are more likely to have a Category 1 hazard.

Physical health effects

The physical health effects of housing hazards are summarised in the table at the end of this section. The physical effects of some hazards such as childhood lead poisoning from lead-based paint, lead contaminated dust and soil and lead in drinking water is now well-established, as are the health effects of asbestos, radon and poor quality drinking water.

Overcrowding in the home is not a new phenomenon and evidence of the health effects has accrued over a long period. Data from the Office for National Statistics shows that homes with six residents are the fastest growing category of household and approximately 3 million people in the UK now live in a home with at least five other individuals. Children are most likely to live in overcrowded housing compared with working age adults and pensioners. Children living in overcrowded homes are up to 10 times more likely to contract meningitis and three times more likely to have respiratory problems. Respiratory and infectious diseases, such as tuberculosis (TB), and an increased risk of accidents impact on all age groups. Overcrowding also leads to uncomfortable or irregular sleeping arrangements leading to regularly disturbed sleep. The impact of overcrowding on children’s education will be discussed under the next section on mental health.

Excess cold experienced in the winter months can affect or exacerbate a range of health problems, including respiratory and circulatory conditions, cardiovascular disease, mental health and accidental injury for all age groups. Older people may be particularly vulnerable during cold periods leading to excess winter deaths (EWDs), the majority of deaths occurred among those aged 75 and over. Similarly, children living in cold, damp and mouldy homes have been found to be more likely to develop symptoms of asthma than children living in warm and dry homes. The estimated cost associated with asthma to the NHS, based on 2008 figures, was at least £847million per annum. Fuel poverty is driven by three main factors: household income, the current cost of energy and the energy efficiency of the home.  England’s housing stock is made up of relatively energy inefficient properties which can result in homes that are difficult or costly to heat.

There has been a decline in excess winter deaths.  Winter deaths can also be affected by and confounded by the prevalence of influenza and air pollution. The use of the HHSRS to identify excess cold as a Category 1 hazard, improvements in property insulation and Winter Warmth schemes may have contributed to this reduction.

Hazards and their physical health effects

Hazard Physical Health Effect Vulnerable Groups*
Damp and Mould Growth Increase in heart rate, Increased hygiene risk
Increased risk of accidents
Spread of contagious disease
Excess Cold Hypothermia
Respiratory conditions – bronchitis, pneumonia, influenza
Heart attacks, strokes
65 years plus
Excess heat Thermal stress
Cardiovascular strain and trauma
65 years plus
Lead Lead when ingested accumulates in the body and has toxic effects on the nervous system, cognitive development and blood production Under 3 years
Asbestos Pleural plaques
Lung cancer
Carbon Monoxide and fuel combustion products High Concentrations – unconsciousness and death
Lower Concentrations – headaches, dizziness, weakness, nausea, confusion, disorientation, fatigue
Radiation (Radon) Lung cancer  
Volatile Organic Compounds Short term irritation and allergic reactions to the eyes, nose and respiratory tract
Crowding and Space Increase in heart rate
Increased hygiene risks
Increased risk of accidents
Spread of contagious diseases
Entry by Intruders Injuries caused by intruders
Food Safety Food poisoning  
Water supply Gastro-intestinal illness
Lighting Eye strain
Noise Headaches
Sleep disturbance
Domestic Hygiene, pests and refuse Gastro-intestinal disease
Asthma and allergic reactions
Personal Hygiene, sanitation and Drainage Gastro-intestinal illness and Infections
Skin Infections
Children under 5 years