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Topic on a Page - Housing & Health

Data Sources:

Public Health England: Public Health Profiles

Lincolnshire Private Sector House Condition Survey

Statutory homelessness and homelessness prevention and relief

Local Government Association (LGA):

Health and Wellbeing and Housing (LG Inform) District level toolkit and Ward level toolkit

Association for Young People's Health:

Key data on Young People 2017

Public Health England (PHE):

Health Risks of Cold Homes: Data sources

Supporting Information:

National Institute for Care and Health Excellence (NICE):

NICE Guidance: Excess winter deaths and illness and the health risks associated with cold homes [NG6] Published: March 2015

NHS Evidence:

Housing

Housing and Health

Public Health England (PHE):

Local Action on Health Inequalities: Evidence papers, Briefing no.7 Published: September 2014

Joseph Rowntree Foundation:

Housing

Social Care Institute for Excellence (SCIE):

Housing Resources and Services

Institute of Public Care

Strategic Housing for Older People (SHOP) resources

Housing LIN:

Health and Housing: Health Intelligence

Care and Support at Home

Local Government Association (LGA):

The impact of homelessness on health: a guide for local authorities

Housing

Healthy Homes: Healthy lives Housing Briefing
Published: September 2014

HM Government Policy:

Housing

Fuel Poverty Strategy for England Published: March 2015

Laying the foundations: a housing strategy for England.Published: November 2011

Housing for older and vulnerable people

National Planning Policy Framework Published: March 2012

Housing and Local Services: A-Z

Designing Gypsy and Traveller Sites: Good Practice Guide

House of Commons Library: Secure Tenancies (Victims of Domestic Abuse) Bill 2017-19: Briefing paper

Miscellaneous:

Building Research Establishment: Wellbeing and the Built Environment

Building Research Establishment 2010: Real cost of poor housing

Housing and Health Briefing Papers

Greater Lincolnshire Enterprise Partnership: Strategic Economic Plan

Lincolnshire Homelessness Strategy 2017-2021

House of Commons Library Briefing Papers:

Discretionary Housing Payments

Disabled Facilities Grant for home adaptions

Paying for supported housing

Households in temporary accommodation (England)

Applying as homeless from an assured shorthold tenancy (England)

Housing First: tackling homelessness for those with complex needs

Rough Sleepers: access to services and support (England)

Rough Sleepers and Anti-Social Behaviour (England)

Rough Sleeping (England)

Statutory Homelessness in England

WHO:

Housing and health guide

Linked Topics:

Topic last reviewed: Jun-18

JSNA Topic: Housing & Health

Background

Housing provides people with a home in which to live that meets their basic physiological needs. When this is not provided it can have a big impact on people's health. In Maslow's hierarchy of human needs, housing is the shelter aspect. Therefore, it is not surprising being homeless, living in poor condition or unsuitable housing puts people at risk and can have a negative effect on their mental and physical health, cause injuries or even lead to death.

There are many links between housing and health. These have long been recognised by different governments. Efforts have been made to address poor housing through public health and housing acts and policies.

This topic focusses on three main aspects and the threat they can pose to vulnerable groups of people such as the homeless, older people, people with long term illnesses (including mental health) or learning and physical disabilities, and families with young children:

  • Insecure housing, where people could easily lose their home, such as through repossession or eviction), and homelessness;
  • Unsuitable homes that do not meet household needs due to size, amenities, location or affordability; and
  • Poor condition housing.

There are 338,700 households in Lincolnshire (Source: Valuation Office Agency (VOA), September 2017). 4% of private sector stock in the county is estimated to be in disrepair. Under the Housing Health and Safety Rating System, 18% of private sector stock in the county is estimated to have a serious hazard that is likely to cause illness or harm - such as being too cold or having dangerous electrical wiring. The greatest proportion is in East Lindsey (22%) and the lowest is in North Kesteven and City of Lincoln (15%).

People living in poor housing conditions is one element directly affecting the demand on our health services. The Building Research Establishment (BRE Cost of Poor Housing Briefing, 2015) suggested the cost of poor housing in England to the NHS was £2 billion per annum. This figure is based on first year treatment costs only. The local costs are not known. When compared to 30 years ago, people live longer, both nationally and locally. Also, the potential for people to live longer with poor health, disabilities and health inequalities is increasing. In the last couple of years, the overall increases in life expectancy since the Second World War nationally have flattened off, and in some cases have begun to fall.

Housing, and housing related support, has a big part to play in improving health and wellbeing in an integrated system. The Care Act (2014) requires close cooperation between health and care services to address the wider determinants of health, including housing, to deliver whole system outcomes based support to meet the needs of the individual. The intention is to reduce pressure on both the NHS and social care sector by preventing and reducing hospital admissions, length of stay, delayed discharge and readmission rates.

More integrated health, care and housing services will support all local agencies to meet any statutory obligations and reduce costs in relation to homelessness and housing adaptations. The new homelessness Duty to Refer will create formal links between agencies, with a push to improve outcomes for individuals.

It is essential people are encouraged to consider and plan for their own future housing needs, with support to adapt their existing homes to meet their changing needs. It is important the right homes are available, are accessible, in the right place, in good condition and are affordable. Much of the housing need is met through the open market. Public sector organisations (such as local authorities) can take steps to influence the market and improve the local housing offer through planning policies, supporting vulnerable people to live independently through supported housing and improving the condition of housing.

Context

National Strategies, Policies & Guidance

Homelessness Reduction Act
The Homelessness Reduction Act came into being on the 27th April 2017 and placed new legal duties on English councils with effect from 3rd April 2018. It means everyone who is homeless or at risk of homelessness will be able access to meaningful help, no matter their priority need status, as long as they are eligible for assistance. Also, all care leavers under the age of 21 will be considered as having a local connection with an area if they were looked after, accommodated or fostered there for a continuous period of at least two years. From October 2018, a new duty to refer will require a range of agencies to act as soon as they become aware an individual is homeless.

Supported Housing Allowance to LAs
In October 2017, the government launched a consultation into the funding of supported housing and extra care housing in England. The government proposes to ring fence the grant and pass the money to upper tier and unitary authorities. The consultation closed on 23rd January 2018. The government response to the consultation is due to be published in the summer of 2018.

Care Act 2014
The Care Act 2014 was a major reform of the social care system. It puts in place law requiring greater integration of health and social care services. It also requires councils to provide more information on housing options. Also, it will expect them to help shape local housing markets to meet newly emerging needs.

Housing and Planning Act 2016
The Housing and Planning Act 2016 introduced a range of measures. The greatest impacts on the supply of affordable and safe housing are:

  • The affordable housing element of new housing developments will now be starter homes for sale, rather than rented units;
  • Extension of the right to buy for social housing tenants;
  • Sale of higher value vacant local authority homes.

National Planning Policy Framework
The National Planning Policy Framework sets out Government planning policies for England and how these are expected to be applied. There is a presumption in favour of councils approving planning applications for sustainable housing growth set out in the Framework. A sustainable development means building new homes to house a rising population that is living longer and wants to make new choices; whilst ensuring that better lives now doesn’t mean worse lives for future generations.

Memorandum of Understanding (national and local)
In 2014, a national Memorandum of Understanding (MoU) was launched by the Chartered Institute of Housing (CIH). A wide range of national organisations signed up to the MoU. It sets out:

  • A shared commitment for joint action across government, health, social care and housing sectors, in England;
  • The principles for joint working in delivering better health and wellbeing outcomes and to reduce health inequalities;
  • The context and framework for cross-sector partnerships, nationally and locally, to design and deliver:
    • healthy homes, communities and neighbourhoods;
    • integrated and effective services that meet individuals’, their carer’s/carers’ and their family’s needs;
  • A shared action plan to deliver these aims.

The MoU was refreshed during 2018 and over 25 stakeholders gave a renewed commitment to joint action across government, health, social care and housing sectors to improve health through the home.

The Quick Guide: Health and Housing provides guidance to CCGs on the role housing can have to support improving health’s system and patient outcomes. It focuses on three key areas:

  • How housing can help prevent people from being admitted to hospital;
  • How housing can help people be discharged from hospital;
  • How housing can support people to remain independent in the community.

Homes for health - These resources from the government can help local authorities, health and social care commissioners and decision makers make plans to improve health and wellbeing through the places people live. The resources include strategies, plans, advice, and guidance about the relationship between health and the home. The Government is helping local councils and developers work with local communities to plan and build better places to live for everyone. This includes building affordable housing, improving the quality of rented housing, helping more people to buy a home, and providing housing support for vulnerable people.

The Housing LIN has a wide range of resources. It is recognised by government and the housing with care sector as a leading ‘knowledge hub’ on specialist housing, our online and regional networked activities. Amongst its aims is to connect people, ideas and resources to inform and improve the range of housing choices that enable older and disabled people live independently.

Local Strategies & Plans

Lincolnshire does not have a countywide housing strategy. District Councils produce and progress housing strategies to address the housing needs they have identified within their local authority area and wider housing market areas. For further information refer to individual district council websites:

The Homelessness Act 2002 requires all Local Authorities to review homelessness in their districts and publish a strategy based on the findings of the review. There is a county wide Lincolnshire Homelessness Strategy dealing with homelessness prevention. It has a particular focus on addressing the needs of people with complex and mental health needs. A refreshed strategy for 2018-2023 launches in June 2018.

Lincolnshire Joint Health and Wellbeing Strategy
The updated Joint Health and Wellbeing Strategy will continue to highlight the importance of housing as a priority that people have access to good quality, energy efficient housing that is affordable and meets their needs.

Extra Care Housing
Lincolnshire County Council produced the Adult Care Capital Strategy that introduced a vision and plan for the provision of Extra Care Housing (ECH) now and in the future. Evidence suggests local people wish to remain and grow old in the communities they are familiar with and therefore, in response to their needs, Lincolnshire County Council is aiming to provide a number of schemes across the county so people don't have to move far, if at all, to access ECH. The strategy was recently refreshed. The strategic objectives for ECH in Lincolnshire are to:

  • Provide choices for housing, support and care services, to meet future demand;
  • Design and develop schemes that provide options in lifestyle, accommodation size, location, tenure and services;
  • Work in partnership with health, district councils, independent housing providers and voluntary groups;
  • Encourage older people's participation in the design and implementation of new schemes.

Youth Housing Strategy
The Lincolnshire Youth Housing Strategy 2013 – 2018 is being refreshed. The strategy outlines how agencies will work together to create a co- ordinated approach to meeting the needs of young people who experience difficulties with housing.

Transforming Care Plan
The Transforming Care Plan looks at how Lincolnshire will change the way care and support is provided to individuals with a range of conditions such as learning disabilities.

The aim of the plan is to maximise the opportunity for care focused on keeping individuals healthy, well and supported at home in the community.

Remodelling of Housing Related Support in Lincolnshire
In Lincolnshire, housing related support services are provided for single individuals who have a support need and are homeless, or at risk of becoming homeless. The number of people being referred for services has increased since 2015, and their needs are becoming increasingly complex. It is likely the way the services are provided will need to be looked at and maybe adjusted to make sure they continue to meet the needs and outcomes of the client group.

What is the picture in Lincolnshire?

What the data is telling us

Lincolnshire Housing Market

  • Lincolnshire has a total of 338,700 households across the county (VOA, September 2017);
  • Homeownership is the dominant tenure in the county (69.7%);
  • Over 52,000 (16.3%) households now live in private rented housing;
  • At 44,200 (14.0%), social housing households are over 7,000 less than private rented (see 'Poor Condition Housing' section below for rationale on how this is a risk to health).

The indicator of affordability (the ratio of lower quartile house prices to lower quartile earnings) in 2017 ranges from 5.80 in West Lindsey to 8.73 in South Kesteven (the lower ratio being an indication homes are more affordable). Homes were more affordable in Lincoln and East Lindsey, than Boston Borough, South Holland and North and South Kesteven (Source: ONS, 2017).

Despite housing being more affordable in comparison to other areas of the country, Lincolnshire has a relatively low household income. This means being able to afford a deposit can be a challenge, and mortgages can sometimes be many times the household annual income. Consequently, home ownership is out of reach to many households, including many key workers in the health and social care sectors. In certain areas, particularly the southern and south eastern borders, housing costs are driven upwards by the presence of residents who commute into higher income areas. This allows developers and landlords to command higher prices for housing in these areas. Also, low land values, sale prices and rental values can stifle development of new homes in other parts of the county as development provides little return on developer investment.

Changes to the population affect the demand for different types of housing. The growth in the number of people over 65 presents the greatest challenge and requires a range of accommodation and support solutions including different types of specialist and housing-related support (HRS). It also requires a broadening of understanding about the options which for many are either to stay where they are or to ‘go into a home’, the latter having quite negative connotations.

Across Lincolnshire, the total population aged 65 and over with a limiting long term illness whose day to day activities are limited a little and a lot is projected to increase from an estimated 84,301 in 2017 to an estimated 123,865 in 2035, which is around 47% of that population. This is slightly lower than the national rise of 49% and the regional figure of 51%. (POPPI - http://www.poppi.org.uk)

Insecure housing & homelessness

  • Across Lincolnshire there are 14,816 individuals/ households on a council house waiting list or in temporary accommodation waiting for suitable accommodation. Each district has differing eligibility criteria, which can affect the numbers on each register. The district areas with the largest waiting lists are Boston (2,399), Lincoln (2,372) and South Kesteven (2,999). There are a further 621 individuals/households in temporary accommodation across the county, 201 of which are in East Lindsey and 204 in City of Lincoln (ONS, 2016/17).
  • In Lincolnshire there are 398 families with children who are accepted as homeless and are in priority need for accommodation, with the district areas of Lincoln (101) and South Kesteven (124) seeing the highest numbers (ONS, 2016/17).
  • There are 639 households across the county who are accepted as being homeless and in priority need for accommodation. Again, the districts of Lincoln (164) and South Kesteven (197) see the highest numbers in need (ONS, 2016/17).
  • Boston has no households or families with children who are accepted as homeless who are in priority need, but has a statutory homeless rate per 1,000 population of 0.42 (ONS, 2016/17).
  • East Lindsey and Lincoln see the highest rates per 1,000 population of statutory homelessness in the county, with 3.24 and 3.95 respectively (ONS, 2016/17).
  • In 2017 there were 62 reported rough sleepers, an increase of 88% on the 33 in 2016 (Source: DCLG). The annual count leading to these statistics follows DCLG guidance (i.e. the number counted on one specified night of the year). However, outreach services come across more people who are sleeping rough at some point over a longer time period.

Unsuitable homes

  • In Lincolnshire 2.2% of households are overcrowded, below the national average of 4.5%. Boston (4.0%), Lincoln (3.6%) and South Holland (3.1%) are above the county average for overcrowding. (Source: CIEH)
  • Needing adaptations – In 2009 there was a self-reported estimate that 12,440 adaptations were required to private sector homes to meet people's needs as a result of disabilities at an estimated cost of over £39.1million (Source: Lincolnshire Private Sector House Condition Survey, 2009). Short term tenancy agreements, poor housing conditions and overcrowding can make adaptations of accommodation in this sector difficult. Up to 40% of properties may not be adaptable, making rehousing the only possibility. (Source: Foundations, 2016)

Poor condition housing

There is information available on the condition of existing private sector housing from the BRE dwelling level housing stock modelling and database for Lincolnshire (September 2017). This finds that the county has a higher percentage of private sector dwellings failing each of the key indicators on conditions compared to England – in particular for excess cold.

  • 18% of private sector stock in the county is estimated to have a serious (Category 1) hazard under the Housing Health and Safety Rating System (HHSRS). The greatest proportion is in East Lindsey (22%) and the lowest is in North Kesteven and City of Lincoln (15%).
  • 9% of private sector stock in the county is estimated to have an excess cold hazard. The highest proportions are in East Lindsey (14%) and the lowest is in City of Lincoln (2%).
  • 9% of private sector stock in the county is estimated to have a falls hazard. The highest proportions are in City of Lincoln (11%) and the lowest is in North Kesteven and South Holland (both 7%).
  • 4% of private sector stock in the county is estimated to be in disrepair. The highest proportions are in Boston, City of Lincoln, East and West Lindsey (all 5%), with the lowest in South Holland, and North and South Kesteven (all 4%).

Poor quality or inappropriate housing design is a contributing factor in individuals having a fall. Analysis of hospital episode statistics between 2011/12 and 2014/15 shows three quarters of falls occurred at the person's home in Lincolnshire.

Further detail around falls can be found in the JSNA Falls topic.

Housing conditions and energy efficiency are very important factors affecting excess seasonal deaths and fuel poverty.

  • During 2015, there were an estimated 38,964 households (12.4%) in fuel poverty in Lincolnshire (12.7% for the East Midlands) under the low income, high cost definition. This is compared to 33,204 households (10.6%) in fuel poverty in Lincolnshire (10.1% in the East Midlands) in 2014. (Department for Business, Energy and Industrial Strategy, 2017)
  • The percentage of private sector dwellings with an Energy Performance Certificate (EPC) rating below a Band E for Lincolnshire County as a whole is 11.6%. East Lindsey has the highest percentage falling below a Band E (17.5%) and City of Lincoln has the lowest (3.2%). (BRE Dwelling Level Housing Stock Modelling and Database for Lincolnshire County, 2017)

Detail on fuel poverty can be found in the JSNA Excess Winter Deaths and Fuel Poverty topic.

Of 338,700 homes in Lincolnshire at the time of the English Housing Survey 2015:

  • 33,500 (9.9%) homes do not have a boiler;
  • 65,700 (19.4%) fail the decent homes criteria;
  • 14,900 (4.4%) homes have a damp issue;
  • 15,900 (4.7%) have no double glazing, and
  • 12,500 (3.7%) have less than half double glazing.
    (Source: English Housing Survey, 2015)

Under the Energy Act 2011, new rules mean that from 2018 landlords must ensure that their properties meet a minimum energy efficiency standard, set at Energy Performance Certificate (EPC) Band E.

  • The percentage of Lincolnshire private rented stock with an EPC rating below Band E is 19.1%. East Lindsey has the highest percentage falling below Band E (21.3%) and North Kesteven has the lowest (15.4%). (Source: BRE Dwelling Level Housing Stock Modelling and Database for Lincolnshire County, 2017)

Trend

Between the censuses of 2001 and 2011 the proportion of housing in Lincolnshire that is owner occupied fell from 73.1% to 68.5%.

The private rental market (number of private rents) reduced in Lincolnshire between 2011/12 and 2015/16 but finished where it started at just over 12,500.

Insecure housing & homelessness

Rough sleeping in Lincolnshire has increased significantly. The number has continued to increase year on year since 2012. The overall number of people counted as rough sleeping has increased from 17 in 2012 to 62 in 2017. The increase from 2016 to 2017 across the county is 87%. (Source: Ministry of Housing, Communities & Local Government)

The number of people referred into Public Health commissioned Housing Related Support services (both accommodation and non-accommodation based services) increased from 2,590 in 2016 to 2,948 during 2017. This is an increase of 14%. The total number of referrals increased from 6,163 during 2016 to 6,871 in 2017. This is an increase of around 11.5%. In the same time period, the number of referrals accepted increased from 2,216 to 2,410, which is an increase of nearly 9%. It is important to note an individual may have multiple referrals generated from one assessment. (Source: CDPSharp "The Avenue", 2018)

The number of people both verified and not verified as rough sleeping, increased from 419 in 2016 to 793 in 2017. This is an increase of around 89%. (Source: Lincolnshire County Council Housing Related Support system, CDPSharp "The Avenue", 2018)

Unsuitable homes

Affordability
Annual trend data for housing affordability (ratio of lower quartile house prices to lower quartile workplace earnings) is available on the Lincolnshire Research Observatory (LRO) for years 2005-2013 for property ownership. This showed an overall improvement in affordability, but this does not reflect the condition of the homes with the lowest prices. Since 2013, however, the data published on the Office for National Statistics (ONS) website shows homes are again becoming less affordable in all Lincolnshire districts.

Poor condition housing

It is difficult to monitor trends in housing conditions as condition surveys are undertaken around every 5 years and the methodologies and standards change.

Between the 2009 Lincolnshire Private Sector House Condition Survey and the 2014 BRE housing stock modelling the following conclusions can be drawn:

  1. There were 65,700 private sector homes (24.1%) containing serious (Category 1) hazards in 2009 and this remained virtually the same in 2014 (24.0%). In 2018, there were 52,500 homes (18%) containing Category 1 hazards.
  2. The mean SAP (energy rating on a scale of 0 (poor) to 100 (good)) for private sector housing in 2009 was 52 in Lincolnshire, which is higher than that found nationally (49). The 2014 BRE stock modelling used a simple SAP methodology and estimated the average rating to be 51. In 2018, the average rating was estimated at 57 (nationally it was estimated to be 60).
  3. Between the censuses of 2001 and 2011 the number of households without central heating reduced from 16,376 to 6,185.

Key Inequalities

The households that find it hardest to access housing in general are those on low incomes and those with health problems and/or disabilities.

Children

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. (Source: CIEH)

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. (Source: CIEH)

Poor housing has also been found to impact on socio-emotional development, psychological distress, behavioural problems, and educational outcomes of children and young people. There is a growing base of evidence to indicating very young children under school age are very susceptible to long term mental health issues, such as anxiety and depression, if they are in substandard housing. (Source: CIEH)

There are approximately 68,000 children living in poverty across Lincolnshire after housing costs are taken into account. The district areas of Boston (24.7%), Lincoln (28.1%) and East Lindsey (31.1%) are the top three areas that see the highest proportions. (Source: endchildpoverty.org.uk, 2018)

Older people

The number of people aged 65 or more is expected to rise significantly in the next 25 years and there is likely to be an increasing number of people suffering from depression, isolation and dementia.

By 2030 it is projected 85,718 people over the age of 65 will live alone, which will be well above the 58,812 in 2014. (Source: LRO, 2014)

Older people are less likely to be homeless: only 3% of homeless people nationally were aged over 65 in 2014 (Source: DCLG P1E table 781, 2015). They are also less likely to be living in overcrowded homes but many may be living in family homes that are large and difficult to maintain. Some older people live with family members with no legal right to remain if their circumstances change. This may work well for many, but may also leave them vulnerable if the family is no longer able or willing to accommodate them.

The JSNA topic for Falls gives further details around key inequalities affecting older people.

People with mental health needs

In Lincolnshire the proportion of working age adults (WAA) in contact with secondary mental health service in stable, appropriate accommodation is 64%, above the regional average of 61.0%, and above the national average of 54.0%. There is very little difference when looking at the proportions by gender and national averages for males and females. (Source: PHOF 1.06, 2016/17)

A review of the evidence on housing and mental health found that:

  • Multi-dwelling housing is associated with adverse psychological health;
  • Overcrowding is associated with high rates of suicide;
  • People living in high-rise units seem to have more mental health problems than those living in other forms of housing;
  • Residents of single-family detached homes typically fare the best in terms of mental health;
  • Housing condition is positively correlated with psychological well-being and can impact on identity, self-esteem. In contrast poor quality can increase anxiety;
  • Poor mental wellbeing can be linked to: neighbour noise, feeling overcrowded, feeling unsafe/fear of crime, damp housing, and dissatisfaction with housing and neighbourhood comparisons.

(Source: Evans G, Wells, N, Moch, A - Housing and Mental Health, 2003)

The connection between homelessness and mental health issues is complicated. People with mental health conditions may find they have fewer choices in relation to their accommodation and people living in difficult housing situations may develop poor mental health.

Mental health issues have also been found to be both a cause of long term rough sleeping, as well as a symptom of the experience of becoming and remaining homeless. An individuals’ wellbeing can be negatively affected by the experience of being homeless. There are complex associations with issues such as childhood trauma, drug and alcohol misuse, finances and debt, self-harm, domestic abuse, violence, and neglect and relationship breakdown.

70% of homeless people experience mental distress; compared to 25% of the general population. National findings from a homelessness health needs audit in 2011 found that:

  • 72% of clients said they had one or more mental health need;
  • 45% said they had one or more long-term mental health need;
  • 44% of those with a mental health problem said they self- medicate with drugs or alcohol;
  • 14% of clients stated that they self-harm, compared with 4% of the population;
  • 35% of those with a mental health need said that they would like more support with their mental health.

(Source: Homeless Link Mental Health and Wellbeing guide 2011)

Housing and homelessness related mental health needs are further explored in the JSNA Mental Health – Adult topic, the JSNA Mental Health and Emotional Wellbeing (Children and Young People) topic, the JSNA Financial Inclusion topic and the Lincolnshire Mental Health, Health Needs Assessment (HNA).

People with learning disabilities

In Lincolnshire the proportion of adults with a learning disability living in stable, appropriate accommodation (77.2%) is above the regional (75.7%) and national averages (76.2%). There is very little difference when looking at the proportions by gender and national averages for males and females. (Source: PHOF 1.06, 2016/17)

Further detail on Learning Disabilities can be found in the JSNA Learning Disabilities topic and the JSNA Special Educational Needs and Disability topic.

It is estimated that more than one in every 100 people in the UK has autism. Autism costs the UK £32 billion per year; more than the combined costs of heart disease, cancer and strokes. The number of people in Lincolnshire (all ages) predicted to have an autistic spectrum disorder between 2017 and 2030 is expected to increase from 5,904 to 6,389. There is limited specialist housing provision in Lincolnshire for those people who are autistic but have no other known conditions. (Source JSNA Autism topic)

Further detail on Autism can be found in the JSNA Autism topic.

Low income households

  • 17% of the private sector stock in the county is estimated to be occupied by low income households. The highest proportion is in City of Lincoln (24%) and the lowest is in North Kesteven (12%) (Source: BRE Dwelling Level Housing Stock Modelling and Database for Lincolnshire County, 2017)

The link between housing and health is an important consideration when looking at the recent welfare reforms introduced by the Welfare Reform Act 2012:

  • Freezing the majority of entitlements paid to working people;
  • Freezing Local Housing Allowances (the Government’s upper threshold for housing benefit for those in private rented homes);
  • Capping benefits at £20,000 in England (including Lincolnshire) and £13,400 for single adults.

The Government has said there will be no further cuts to welfare entitlements over the lifetime of this parliament, other than those already announced.

  • Around a third of homeless people on Job Seekers Allowance and nearly one in five on Employment and Support Allowance have been sanctioned by the Department for Work and Pensions (DWP), which is disproportionately higher than the general population;
  • Nearly a third of services report homeless people being sanctioned while facing poor mental health, learning difficulties or substance misuse problems;
  • The majority of services report clients experiencing debt, food poverty and survival crime;
  • Services report clients’ existing problems getting worse as a result of sanctions, with only a minority being motivated by sanctions to find employment.

(Source: Homeless Link, accessed April 2018)

Further information on the effect of low income and welfare benefit reforms can be found in the JSNA Financial Inclusion topic.

Private renters

Shelter in their report "Renters put at risk" has undertaken research looking at the rental market. The research looks at the number of rented households put at risk of eviction in England over the past year at a local, regional and national level (Source: Shelter). They have looked at the number of possession claims lodged in a court in the last twelve months (2015/16). A possession claim is the first stage of the legal process, and can result in a person or family being evicted. Not all possession claims lead to possession orders, and not all possession orders lead to the loss of the home and eviction. However, receiving a possession claim means a household is subject to a legal process where their home is at risk.

Current Activity & Services

District Councils have statutory duties, strategic responsibilities and exercise discretionary roles relating to housing advice, lettings and allocations, homeless people, planning, private sector housing conditions and new housing provision in their area.

District Councils listen to and have conversations with communities, housing providers and others in a variety of ways, including consultations on new strategies, policies and plans, e.g. the New Lincolnshire County Homelessness Strategy, Strategic Housing Market Assessment (or SHMA – a broad assessment based on national population and household projections, with many other sources of information assessing and analysing the wider housing needs for market and affordable housing in and area along with other outputs), and Private Housing Stock Condition Survey/ Stock Modelling Survey (commissioned around every 5 years to establish the condition of the stock. The information includes a profile of the housing stock, the Decent Homes standard, matters of disrepair and hazards within homes, energy efficiency and fuel poverty).

The County Council also has some roles in planning for and commissioning new housing, including specialist housing and housing- related support (HRS). Public Health currently commissions housing- related support (HRS) services comprising of emergency accommodation based support, non-emergency accommodation based support, floating support, a rough sleeper outreach service, domestic abuse accommodation and mental health crisis housing. These services work together to form one structured model of support. The current demand for housing related support is bigger than the supply of service available.

Lincolnshire County Council recognises the importance of housing and health. A sub group of the Health and Wellbeing Board called the Housing, Health and Care Delivery Group, was set up during 2017. It provides a strategic, structured approach and governance to the housing, health and care agenda.

Insecure housing & homelessness

Homelessness agencies and charitable organisations run a wide range of services in towns across the county including outreach, day centres, hostels and temporary accommodation. Some of the homelessness agencies also have specialist mental health workers working for them.

Relationships with housing related support and supported housing providers are in place to prevent homelessness. New arrangements with Children’s Services to tackle youth homelessness have been put in place. Of particular note is the placing of a previously Government funded rough sleeping (street outreach) service into Public Health commissioned services.

Working together, agencies in Lincolnshire received funding from DCLG to develop a social impact bond (known as ActionLincs) for an enhanced, and more effective, longer term response to support the most complex rough sleepers and those trapped in a cycle of repeat homelessness in Lincolnshire. It builds on the existing street outreach service model. The funding is to help the client group into accommodation and address their other needs, through more personalised and holistic support. It allows for the development of a localised approach addressing the current challenges specific to Lincolnshire and specific to each individual client. The funding provides a real opportunity to proactively and creatively address the challenges, costs, risk of repeat homelessness and significant impact on public services arising from entrenched rough sleeping. The project is funded to be able to support 120 individuals identified as entrenched rough sleepers. At the last cohort refresh in 2018, 251 individuals were identified as meeting the criteria for ActionLincs.

Unsuitable homes

Strategic Housing Market Assessments carried out across Lincolnshire identify the need for more homes. Greater Lincolnshire local authorities have an aspiration to deliver 100,000 new homes. New Local Plans are being prepared across Lincolnshire to set out local planning policies in light of this and the National Planning Policy Framework. It is essential that there is an appropriate supply and mix of new build homes built in the right places to ensure homeless people, those living in unhealthy and unsafe housing, unsuitable homes or precarious and insecure housing have choices. Older people looking to downsize and disabled people need access to homes of the right size that are accessible.

Extra Care Housing is housing specifically designed with the needs of older people who are becoming increasingly frail; there are varying levels of care and support available on site. People in Extra Care Housing live in their own self-contained homes, with a legal right to occupy the property.

Extra Care Housing is also known as very sheltered housing, assisted living, or simply as 'housing with care'. It can take various forms, including flats, bungalow estates and retirement villages. It is a popular choice amongst older people because it can provide an alternative to a care home.

In addition to the communal facilities often found in sheltered housing (residents' lounge, guest suite, laundry), Extra Care often includes a restaurant or dining room, health & fitness facilities, hobby rooms and computer rooms. Domestic support and personal care are available, usually provided by on-site staff. Properties can be rented, owned or part owned/part rented. There is a limited (though increasing) amount of Extra Care Housing in most areas and most providers set eligibility criteria which prospective residents have to meet. Currently, in Lincolnshire there are 8 developments totalling 288 units. There is a mixture of single occupancy units and shared houses.

Lincolnshire County Council is incentivising private developers to create up to 600 extra care properties. The plan is part of local and national drivers for more independence and choice for people with health and care needs, with the aim to encourage people with additional health needs, or those heading for older age, to think about where they want to live before their needs develop further. Extra care housing is intended to bridge the gap between domiciliary and residential care.

Disabled facilities grants (DFGs) enable district councils to provide adaptions such as stair lifts, level access showers and extensions to assist vulnerable homeowners or private sector tenants who are older, disabled or on low income to repair, improve, maintain or adapt their home. The provision of DFG is mandatory, and local authorities must consider this when assigning budgets to housing provision. There are certain factors that mitigate this demand: firstly, DFGs are subject to means testing and secondly, there needs to be an assessment by an Occupational Therapist who will consider whether an adaptation is necessary and appropriate. When means testing has been applied the total potential DFG cost reduces from overall demand for adaptations to just under £18.9million, which reflects the fact that there are residents with disabilities with average or above average incomes but before a formal assessment has been carried out.

The new Wellbeing Service (WBS) is a generic service, available to individuals aged 18 years and over across Lincolnshire. The service delivers equitable service provision to eligible residents throughout Lincolnshire. The aim of the WBS is to promote independence and support the trend towards independent living in an individual's own home through the delivery of community based support and facilitation within care and health settings. The Wellbeing Lincs website gives further information on the service.

The WBS consists of the following six components:

  • Assessment;
  • Generic support – providing up to a maximum of 12 weeks support based on the needs established in the assessment;
  • Hospital and care in-reach – a promotion function to develop the referral pathway into urgent healthcare better;
  • Small aids and Adaptations – installation of aids and adaptations that the service user purchases, based on their needs assessment;
  • Resettlement – a resettlement service which meets individual's at home post a stay in hospital or care facility, ensuring needs are assessed and planned for upon returning home;
  • Telecare Response – a 24 hour response service to telecare alerts where the individual registers and pays for the service. Has the ability to provide falls assessment, lifting, and emergency personal care where required.

Poor condition housing

Local authorities in England have legal powers to take action against owners who have properties that are in very poor condition, including owner occupiers. Each district council in Lincolnshire works closely with owners and landlords to ensure properties are fit for occupation. Proactive work includes holding forums and producing newsletters to advise landlords of changes in the law and to promote the availability of funding, etc. Some houses in multiple occupations are required to have licences, and these are issued by the local housing authority. Many of the district councils also operate accreditation schemes to encourage the best management of property.

If landlords do not heed the advice given and housing conditions remain poor then the districts councils can prosecute and fine the owner or work can be done in default and the costs reclaimed.

Boston Borough Council and City of Lincoln Council were successful in receiving Government funding to tackle rogue landlords in 2015/16. 580 inspections were carried out in Lincoln (11% of which had Category 1 hazards) and 97 in Boston – leading to Police led raids, emergency prohibitions, improvement notices and prosecutions.

There are a number of partnerships taking the housing agenda forward in Lincolnshire, some of which are listed below:

  • Health and Wellbeing Board, and the Housing, Health and Care Delivery Group;
  • District's Housing Network;
  • Home Energy Lincs Partnership (HELP) group;
  • Housing and Infrastructure Group, and its Housing sub group;
  • Lincolnshire Affordable Housing Group;
  • Lincolnshire Homelessness Strategy Group;
  • Lincolnshire Private Sector Housing Group.

Unmet Needs & Gaps

Unmet needs

The impact of extreme weather events and cold on homeless people needs more focus.

No Second Night Out (NSNO) is a national initiative, based on a London pilot which started in 2011, aiming to ensure that no-one new to the streets has to spend more than one night sleeping rough. There is currently no provision in Lincolnshire based on this initiative.

Sometimes the public health contracted housing-related support (HRS) services available are not appropriate for the needs of the individual. Between 2016 and 2017, the number of referrals for support declined by housing related support providers went up from 1,727 to 2,695 (a percentage increase of 56%). The number of individuals declined for support during the same time period increased from 738 to 928 (approximately 26%).

The number of referrals for support in public health contracted housing related support services declined during 2017.

The number of referrals by district council area during 2017:

  • Boston – 449
  • East Lindsey – 378
  • Lincoln – 538
  • North Kesteven – 276
  • South Holland– 301
  • South Kesteven – 272
  • West Lindsey – 250

Overall 2,695 referrals were declined during 2017.

Number of referrals and the reason they were declined during 2017:

  • 1,043 had no move on options;
  • 394 were not contactable;
  • 379 were classed as support needs too high;
  • 244 were classed as a risk to others;
  • 229 were classed as ineligible;
  • 123 were not willing to engage;
  • 95 did not have enough information;
  • 55 were classed as support needs too low;
  • 35 were classed as a risk to staff;
  • 29 were awaiting an assessment by the local area connection provider.
  • 27 had rent arrears;
  • 22 were classed as a risk to themselves;
  • 20 were at risk from others.

(Source: Lincolnshire County Council Housing Related Support Database)

  • Housing related support providers have repeatedly told commissioners during contract management meetings there is a lack of move-on accommodation in Lincolnshire for people with complex needs who need to move on from their support.
  • It is not possible to quantify the risks associated with living in poor condition housing, e.g. increases in hospital admissions or risks of respiratory illness if indoor temperature does not provide adequate thermal comfort. Neither are the potential costs to the health and care system in Lincolnshire as a result of accidents or illness that might be caused or exacerbated by poor condition housing known.
  • Park homes are not treated as housing but are nonetheless homes for people in Lincolnshire. This presents challenges in terms of adaptability, energy efficiency, poor conditions and space. Notwithstanding park homes, caravan dwellers on the East Lindsey coastal strip present a particular challenge in respect of excess seasonal death and illness or resilience during extreme weather events.
  • Improve housing support for autistic people and ensure their needs are specifically identified in local housing strategies.
  • Gypsies, travellers and other transient populations will have specific needs not covered in this topic.

Gaps in services

  • Through contract management and performance data on housing related support services it can be evidenced services are:
    • Close to capacity with providers struggling to keep up with demand;
    • Not currently meeting the needs of all entrenched rough sleepers, whether they will not engage, accept the available options or the available options are not what they want;
    • Not currently meeting the needs of service users considered high risk.
  • Access to primary care health services and mental health services for rough sleepers is problematic, with individuals often presenting at crisis point.
  • Access to mental health services if an individual has any history of drugs and alcohol abuse is problematic. Mental health services state any drug or/and alcohol abuse must be treated prior to accessing any services with them. Providers feel there is a gap in service provision for service users with a dual diagnosis. Those people who need mental health support cannot get the correct support.
  • The Rough Sleeper Outreach service is stretched and does not have the resources (within the current contract) to spend the time required (daily contact) to achieve the best possible outcomes for entrenched rough sleepers.
  • It is recognised there is a lack of a strategic approach to delivering housing, supporting a person living independently in their own home or in extra care housing.
  • Withdrawal of private sector renewal funding in 2013 has led to fewer programmes for private rented tenants or owner occupiers to improve their own home.
  • There are few schemes to provide financial help to a low income household struggling to heat their home. Schemes that do exist are not fast track to prevent an imminent admission to hospital or facilitate hospital discharge.
  • Those most in need, and targeted Government funded schemes such as to improve central heating schemes, have a very low take up as many residents suspect scams and avoid cold calls.

Local views & insights

Disclaimer: Due to the complexity of the housing topic we have tried to capture some of the conversations, but the following is not inclusive of all comments made by service users and stakeholders.

The housing expert panel told us:

  • The housing for independence work is pivotal to the challenging future housing and health role;
  • Previous funding streams (e.g. decent homes) have ceased, thereby limiting councils’ abilities to upgrade existing stock;
  • The rules of the Environment Agency are significant in determining where housing can be provided, and may create a mismatch in terms of housing need and the ability to meet this where it is most needed;
  • A feature of the majority of difficult housing issues (e.g. neighbour disputes, evictions, homelessness, rough sleeping, etc.) is the presence of mental health needs. Access to timely, appropriate support from mental health services is a significant problem.

The Learning Disability Partnership Board told us that in relation to people with a learning disability:

  • There is not enough choice of housing for people with LD in some parts of the county;
  • Accessing housing lists via the internet is a problem for some people;
  • People do not always know their rights when it comes to what landlords should be doing or how to complain;
  • People need more help to find out about the different sorts of housing available;
  • Getting housing can be complicated – fitting everything together;
  • Housing should be planned around easy access to shops and day support;
  • Housing and support are separate but need to be considered together otherwise housing does not work for some people with LD;
  • Planning ahead takes a lot of time and doesn't end for the family even when a housing package is in place.

Risks of not doing something

Poor quality and cold housing can exacerbate and lead to a range of health issues for example; falls, respiratory conditions, mental health problems, and heart conditions leading to increased visits to GPs, medication and/or hospital admissions. If action is not taken to improve the quality and availability of homes the pressures on decreasing health and social care budgets is only going to increase.

Budget pressures and cuts are not restricted to just health and social care. They are taking place across all areas of the public sector, and housing is not immune. Current housing related support in Lincolnshire is already stretched and further cuts to budgets will impact on vulnerable individuals.

One of the current housing policies from Government includes the Right to Buy. This gives tenants in social housing the opportunity to buy their house. However, the volume of social housing being built is far short of the number being/ that could be sold under the Right to Buy scheme and will lead to a shortage of social housing if not addressed. The demand for social housing is not decreasing, and the current stock is incapable of meeting the needs for all those requiring it.

In recent years, there has been increase in the number of household repossessions, and Lincolnshire has not been immune. When individuals and families unfortunately lose their home, one of the options available to them is to get housing through the private rented sector. There is already pressure on the private rented sector due to the lack of affordable homes for first time buyers, and this adds to the pressure. A lack of suitable rented housing could mean the prevalence of poor, substandard rented accommodation may increase. Also, it could lead to an increasing acceptance of poor condition. Tenants may be too frightened to complain to landlords because they know they may be evicted for complaining, with the landlord knowing they have someone else willing to take the property.

What is coming on the horizon?

Sustainable Transformation Partnership
Implementation of the Sustainable Transformation Plan (STP) includes measures to enable referrals from healthcare professionals in to housing and housing-related support (HRS) services and effective hospital discharge planning to ensure timely discharge to a suitable home. The Prevention Plan element of the STP also recognises the need for closer integration between health, care and housing to address housing issues.

Disabled Facilities Grant (DFG)
The recent increase in central government funding for the national DFG programme, from £220m to £394m and rising to more than £500m in 2019/20 was accompanied by a change in approach by central government. The government’s intention is the DFG should be seen strategically as part of the BCF, with decisions on how the monies are spent made jointly between Health, Housing and Social Care. The objective is to ensure people remain independent in their own homes and avoid a costly admission to hospital and residential care. To aid this, local authorities are being encouraged to innovate, utilise their powers under the Regulatory Reform (Housing Assistance) Order 2012 and use the DFG fund to support strategic initiatives. In two tier local authority areas, including Lincolnshire, the monies will be passed to the County Council, but the statutory duty to deliver DFGs remains with District Councils.

Changes to Care Leavers Provision
Section 3 of the new Children & Social Work Act 2017 has introduced a new duty which requires the Local Authority to offer Personal Assistance (PA) support to all care leavers up to age 25, irrespective of whether they are engaged in education or training. This includes care leavers who return at any point after the age of 21 up to age 25 that request PA support. The Department for Education have carried out a consultation in relation to this Act, which ended 27 November 2017. The statutory guidance is expected in early 2018. This could have an impact on Public Health commissioned accommodation based housing related support services.

Homelessness Reduction Act
The Lincolnshire Homelessness Strategy (2017-21) says the Homelessness Reduction Act 2017 has the potential to considerably increase the workload of District Councils in Lincolnshire in meeting their duties to households in housing need. The Duty to Refer will apply to a range of other organisations locally. There are risks of legal challenge to authorities if resource requirements are not met and councils are unable to meet new legal duties arising from the Act. The demands of the Act will be met from a combination of existing resources, partnership working and any future funding from government.

The Energy Efficiency (Private Rented Property) (England and Wales) (Amendment) Regulations 2016
The Energy Efficiency (Private Rented Property) (England and Wales) Regulations 2015 establish a minimum level of energy efficiency for privately rented property in England and Wales. From April 2018, landlords of privately rented domestic and non-domestic property in England or Wales must ensure their properties reach at least an Energy Performance Certificate (EPC) rating of E before granting a new tenancy to new or existing tenants. These requirements will then apply to all private rented properties in England and Wales – even where there has been no change in tenancy arrangements – from 1 April 2020 for domestic properties, and from 1 April 2023 for non-domestic properties.

What should we be doing next?

  • A Lincolnshire Adult Care Peer Review was undertaken in May 2018. It looked at demand management and housing related services in Lincolnshire. A range of evidence was put before an expert panel, who brought together a range of areas to consider, along with recommendations:
    • A clear vision and strategy is required to support all partners to effectively address the various housing challenges;
    • Adoption of a ‘Lightbulb’ approach may help to further develop an integrated housing offer at the front door, including within hospitals;
    • The Council should be careful to ensure that the existing prevention and wellbeing offer is enhanced by the emerging developments within integrated approaches with the NHS and districts.
  • Develop better understanding and co-ordination between all local Clinical Commissioning Groups (CCGs), United Lincolnshire Hospitals (ULH), Lincolnshire Partnership Trust (LPfT), all District Councils and the County Council (LCC). This will improve liaison and clarify pathways between all agencies. Also, it will help to develop a co-ordinated strategy and approach to identifying accommodation needs. Particular emphasis will be on supporting those with mental health needs and improving hospital discharge processes.
  • Continue to look at discharges from ULH and LPfT and identify opportunities for improvement where there are issues for patients. Sometimes housing can be a problem resulting in a discharge being delayed.
  • Use the planning system and available funding streams to ensure enough new homes of the right type are available in the right places to meet household needs, e.g. increase move-on accommodation for people no longer needing housing-related support.
  • Model the condition and energy efficiency of the housing stock in Lincolnshire. So that this can be overlaid with health profiles and deprivation data for example to more effectively target advice and schemes.
  • Developing strategic relationships and partnerships through the Homelessness Strategic Partnership to deliver concerted action across partners to tackle homelessness.
  • Explore the opportunity for a standalone topic for JSNA for homelessness.
  • Develop a clear action plan to respond to the increase in rough sleeping.
  • Deliver the social impact bond project ACTion Lincs working with entrenched rough sleepers with complex needs.
  • Conduct a health needs assessment for single homeless people to better understand their health needs and ability access services.
  • Progress the measures in the Housing and Planning Act 2016 and recent Government consultations to tackle rogue landlords and address poor housing conditions in the private rented sector.
  • Identify funding streams for those households most in need to improve their own homes and support them to access services.
  • Consider the health needs of those residing in park homes and static caravans, including transient populations, gypsies and travellers.
  • Explore the opportunities for social prescribing to include housing advice. Some housing organisations are already involved with social prescribing. They have staff working from GP surgeries, alongside patients and help with some non-medical issues, such as housing.
  • Ensuring quicker access to mental health services for those at risk of losing tenancies due to mental health conditions.
  • Changing the perception of extra care and other housing for older people to encourage a shift to more age-appropriate accommodation.

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk

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