First Report - Prevention in health and social care: healthy places

The places where people live—homes, communities and neighbourhoods—affect their health and wellbeing substantially. Place, health inequalities and the likelihood of developing preventable health conditions are inextricably linked. People from less well-off groups, and those who live in less well-off neighbourhoods, have a much higher likelihood of developing life-limiting health conditions and associated comorbidities, and of dying prematurely from the effects of those conditions. Although much of this ill-health is preventable, it is also often not within the power of individuals to control.

The evidence base on the importance of place in protecting good health is stronger than it has ever been. But as we discuss in the next chapter, we have known about the relationship between health and place for decades, if not longer. It is frustrating that more progress has not been made already. A determined focus on developing “healthy places” that can prevent ill-health amongst those most at risk is now vital in easing pressures on the NHS, and building a sustainable service for generations to come. (Paragraph 8) Immediate steps

Homes in the private rented sector contribute disproportionately to both the total number of poor quality homes and the costs that poor housing causes to the NHS. The existence of a statutory minimum standard for housing in the social rented sector is not enough on its own to protect tenants and the health service from the many preventable health impacts of poor quality and unsafe housing. The Renters (Reform) Bill contains some welcome steps to further protect tenants. But recent high profile cases involving tenants in social housing have demonstrated that the health impact of poor quality housing can be catastrophic. Over three years after the Government first committed to review and then extend the Decent Homes Standard to the private rented sector, no legal minimum quality standard exists to protect tenants in private rentals.

We recommend the Government proceeds without delay in the consultation necessary to update the Decent Homes Standard for the social rented sector and in implementing a Decent Homes Standard for the private rented sector. It should set out a timetable for doing so in response to this report.

It is welcome that the Government’s has proposed measures to protect social sector tenants from the worst impacts of unhealthy homes, via the implementation of “Awaab’s law”. We recommend that the Government act quickly on the outcome of its consultation on this topic for social sector tenants. It should also consider how similar safeguards could be extended to tenants in the private rented sector who are affected by housing hazards, such as damp and mould, that can pose an immediate danger to health. (Paragraph 19) 26 Prevention in health and social care: healthy places

An absence of hazards is not enough on its own to ensure that housing protects residents’ health. Space, design and location matter, and these should not be the preserve of those who are able to afford more expensive housing. Several standards exist to support the development of housing that is more widely protective of good health. Dwellings created under Permitted Development Rights (PDR), which comprise some of the most egregious examples of housing that is bad for health that we have seen during this inquiry, are now subject to minimum safeguards on space and light. These are welcome and much-needed but they are also an exception: adherence to any kind of quality standard is voluntary for the vast majority of developments and dwellings. Building enough homes is important, but the Government must require developers to aim higher, with quality housing and development that protects residents’ health.

We recommend the Government consult on both the content of existing design and space standards as they relate to health, and on the implications of making such standards mandatory for new dwellings—both for developments requiring standard planning consent, and for both householder and change of use PDR developments.

Local authorities and councils necessarily consider a wide range of criteria in assessing planning applications. This, alongside pressures on their resources and skills, makes it difficult for them to prioritise ensuring that planning promotes health. The lack of changes to requirements relating to health in the revised National Planning Policy Framework is a disappointing missed opportunity to make promotion of health a higher priority for planning authorities.

The former Public Health England’s Healthy Places team had a clear remit to support healthy development. Following PHE’s dissolution and the division of its responsibilities, there is a lack of clarity over which part of DHSC is now responsible for this role, and a lack of formal integration between DHSC and the organisations responsible for assessing planning applications. These is, however, encouraging evidence elsewhere of Departments enabling a greater focus on health in planning: for example, Active Travel England’s statutory role assessing applications for large housing developments. There are clear opportunities to go further in this vein: for example, by clarifying and formalising OHID’s role.

We recommend that OHID be made a statutory consultee for new large housing developments, building on role already accorded to Active Travel England in supporting inclusive, effective and health-protecting development.

Frontline health and social care staff do not only deal with immediate medical needs. People also present to the health service with issues that relate to unmet social needs, which can in turn, over time, develop into medical needs. Increased use of social prescribing can both relieve pressure on clinical pathways and protect good health through enhancing people’s connections with, and ability to participate in activities in their local communities—particularly for people who often lack resources to access these activities independently. There is potential for health services to make much greater use of this approach amongst groups that are currently underserved by social prescribing, such as young people. Many GPs, however, do not feel as confident working with social prescription pathways as they do with the clinical Prevention in health and social care: healthy places 27 pathways that their training focuses on. Building confidence amongst frontline providers in recommending social provision will be key to both protecting and improving individuals’ health, and promoting more cohesive, health-enhancing communities.

We recommend DHSC work with NHS England and existing networks and providers to develop a national strategy for social prescribing. This should aim to improve understanding amongst frontline clinical practitioners of the benefits of social prescribing and to improve their confidence in offering social and community-based solutions to unmet social needs, and to increase use of social prescriptions for young people across all referral routes, including hospitals, schools and other educational and community settings. It should include resources, guidance and case studies, and should focus in particular on groups that are currently underserved, where the greatest long-term preventative impacts may be accrued. (Paragraph 48) Building healthy places for the future

Integrated Care Systems aim to enable a stronger focus on prevention, and on the specific approaches needed in different communities to help ensure that they are “healthy places”. But this is a long-term agenda. The mixed longer-term outcomes of initiatives such as Healthy New Towns demonstrate that building communities that protect good health is not something that can be accomplished through isolated programmes over a few years. The immediate pressures on health services are numerous and compelling, and there is already evidence that these are crowding out longer-term strategies including prevention. Because the numerous costs of “unhealthy places” fall so heavily on the health service, it is essential that the right systems, people and funding are in place for the long term to maintain a focus on prevention and protecting population health.

We have previously recommended that all ICBs should include a public health representative, such as a public health director, and that DHSC considers making this a mandatory requirement. In response, the Department said it agreed that prevention needs to be a priority, but emphasised the importance of protecting ICS autonomy. The evidence that we have heard in this inquiry reaffirms our view that having the right people in place is crucial to ensuring the prevention agenda is not crowded out. Given what we have heard about impact that these individuals can have in ensuring a longer-term focus, we recommend that DHSC reconsiders the case for mandating representatives in this role.

Healthy places are vital to protecting people’s physical and mental health from both direct and indirect consequences and in turn, to building a sustainable health service. “Healthy places” include both the built environment—homes, communities and neighbourhoods—and wider environmental factors, such as air quality and emission levels. The benefits of building healthier places go far beyond DHSC and the health service, and achieving these benefits requires buy-in from a range of Government Departments. In turn, the benefits of healthy places are crucial to a range of wider priorities, including building a stronger, more productive economy and protecting the environment in which we live. The problems caused by “unhealthy places” are 28 Prevention in health and social care: healthy places whole-society problems. Tackling them will require long-term thinking and whole- Government solutions, including commitment, leadership and co-ordination from the very top. (Paragraph 59) Prevention in health and social care: healthy places 29