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South East Regional Public Health Group Information Series 2 Health and Homes: A Basis South East Regional Public Health Group Information Series 2 Health and Homes: A Basis for Wider Collaboration Produced with the endorsement of CIEH – Chartered Institute of Environmental Health This information series has been compiled by the Regional Public Health Group based in the Government Office of the South East. They aim to summarise key public health issues based upon evidence, in order to facilitate good practice and improve health at local and regional levels. They are NOT policy documents. Vision Creating healthy, sustainable and live communities; decent, safer, warmer homes and ensuring the housing needs of all are met. Audience All those able to influence health by improving homes for people, including: Health and Public Health, Social Services, Environmental Health, Local Authority Housing and Planning, Housing Associations, Private Architects and Planners, Local Strategic Partnerships. Health and Homes- the three domains: The Built Environment The Home PROTOTYPE - AUGUST 2006 PROTOTYPE- AUGUST 2006 The Individual

Why it’s Important Housing - the forgotten public health agenda? The recognition of poor Why it’s Important Housing - the forgotten public health agenda? The recognition of poor health and poor housing was the main focus of earlier public health reformers. Influencing the design of earlier houses, improvements were made in ventilation, lighting, heating and overcrowding, which made a major contribution to the decline of infectious diseases. Today’s legislation now ensures basic structural and sanitary conditions. However, since the separation of Medical Officers of Health from Local Authorities in the 1970 s, housing has become a relatively marginal public health issue. The following highlights the important role that housing still has in improving health and reducing inequalities. Additionally, there are wider aspects of Housing which affect health in the long-term via the impact of housing on Climate Change. Maximising the use of active transport, insulation to reduce heat loss, and ensuring maximum use of renewable energy sources all contribute to a sustainable future, where quality of life is placed as a central value in the development of economic and housing growth. Housing- a fundamental need: ‘Maslow’s hierarchy of needs’ places housing as central to achieving health and well-being, with basic physiological needs and safety as fundamental needs placed at the base of the pyramid. Current Situation Unsafe communities, poor housing conditions, lack of infrastructure and appropriate provision compared to need affects health negatively in a number of ways: § § Physical health: Cold and damp, indoor pollutants; design quality, injury and safety hazards; ease and safety of active transport (walking, cycling) lead to excess winter deaths, obesity and heart disease, asthma and respiratory disease; Social and Mental Well-Being: Affected by noise, over-crowding, unstable housing tenure/ homelessness; poor neighbourhood quality and community safety; infrastructure deprivation, access to services, open spaces and transport. PROTOTYPE - AUGUST 2006

Percentage of households living in fuel poverty by ward, South East England Source: Centre Percentage of households living in fuel poverty by ward, South East England Source: Centre for Sustainable Energy. A Profile of Fuel Poverty in the South East Region, 2004 What Works The following is summarised from evidence of effective approaches (see References and Resources on last page for further details). 1. The Built Environment: Aspect of the Built Environment Impact upon Health Promoting Active Transport: § Safe Roads – reduced traffic and speed § Cycle paths with priority for cyclists § Safe paths § Safe parks § Good access to public transport § Better air quality Promotion of Activity: § Reduction in traffic injuries § Reduces obesity § Improved Coronary Heart ‘fitness’ § Activity in elderly reduces risk of falls and improves physical and mental well-being § Reductions in respiratory disease Community Safety: § Street lighting § Good visibility ensured in urban design § CCTV § Community and Park Wardens Reduces risk of harm and fear of crime: § Increases participation in activity, including after dark, especially by women and elder people. § Reduces social isolation and enhances social cohesion § Promotes mental well-being Social Capital: § Aesthetic and clean environment § Shops and services § Schools and Education § Community centres § Health centres Reduces inequalities in health: § Improvements in Mental Well-being § Increased social capital benefits social and mental well-being § Local access to fruit and vegetables § Improved access to services PROTOTYPE -Promotes local active transport § AUGUST 2006

2. The Home Aspect of the Home Impact upon Health Structure and design: § 2. The Home Aspect of the Home Impact upon Health Structure and design: § Temperature § Damp § Ventilation § Noise § Overcrowding § Sanitation § Safety from intruders § Accessibility § Excess winter and summer deaths – related to insulation, heating and ventilation § Excess respiratory and cardiovascular diseases related to temperature and dampness § Noise levels affect sleep and mental well-being § Ventilation affects temperature, dampness, infectious diseases and radon § Over-crowding increases infectious diseases and increases stress levels § Increased security reduces fear of crime, potential injury and reduces the need for re-housing (from burglary or violent ex-partners) § Mainstreaming the accessible design of houses for disability decreases social exclusion. Interior Design: Injury Prevention § Child Safety § Fire Safety § Falls Prevention § Child friendly windows and stair gates decrease the risk of falls § Free distribution of smoke detectors shown to reduce fire related injuries § Lighting, grab rails and reducing trip hazards can reduce the risk of falls Decoration § Re-decorating housing association houses has shown a reduction in depression Home Improvements § Improved physical, mental health and reduced health services use after home improvements. 3. The Individual: Nationally approximately 15% of total households have vulnerable individuals. The housing needs of specific groups or individuals need to be adapted according to their circumstances. Addressing housing need adequately and preventing homelessness has been shown to have positive health and social benefits, especially for the following groups: § § § § PROTOTYPE § People with physical health problems People with a disability (physical or learning) Mental Health problems Older People Looked After Children / Vulnerable Young People 2006 Temporary accommodation Homeless people Victims of domestic violence Ex-prisoners Recovering substance misusers Travellers and gypsies Asylum seekers Teenage parents AUGUST BME groups

Example of what works - Preventing Homelessness: Homelessness Strategy- 2005 ‘Sustainable Communities: Settling Homes, Example of what works - Preventing Homelessness: Homelessness Strategy- 2005 ‘Sustainable Communities: Settling Homes, Changing Lives’ Homelessness levels reduced by actively preventing homelessness via mediation, sanctuary and secure housing for domestic violence, rent deposit schemes, debt counselling, fast tracking housing benefit and housing advice. The diagram below summarises good practice approaches developed nationally and in the South East to prevent homelessness. Ways Forward 1. The Built Environment § Local Development Frameworks- ensure health aspects and supported housing needs of vulnerable groups taken into account within the framework and for individual projects included within Section 106 and advocate for the inclusion of the ‘Secure by Design’ standard for housing and urban plans; § Encourage uptake of Eco- Homes Standards and Code for Sustainable Homes in planning and design. Seek opportunities to “green” the wider environment; § The Growth agenda: ensure public health engagement with Renaissance Partnership Boards and influence planning process; § LAAs: Adoption of housing targets that benefit health: LSP community strategies, LPSAs, LAAs; § Regeneration money funding community development- sustainable communities and healthy built environments- encouraging active transport; § Safer Communities: Participation in Crime and Disorder Reduction Partnerships and advocate for safer communities, including street lighting, increasing urban design to enhance visibility, CCTV, community wardens, and secure housing for victims of domestic violence; PROTOTYPE - AUGUST § Housing Associations: work in partnership to reduce social exclusion and enhance the health 2006 gains with local ‘In Business for Neighbourhoods’ campaigns.

2. The Home § Use health inequalities data to direct housing improvement schemes; § 2. The Home § Use health inequalities data to direct housing improvement schemes; § Winter Warmth: Partnership working to address fuel poverty and improve winter warmth (Environmental Health Practitioners with the HHSRS, health, HECA, VCS), see diagram; § Injury Prevention: Develop multi-agency injuries prevention approaches to address fire safety, child safety and falls prevention; § Home Improvement Agencies and Handyperson repair schemes: direct provision with assistance in small repairs, minor adaptations, odd jobs, safety checks, falls and accident prevention for low income and elderly households; § Influence Housing Process: Engagement with local authority housing partners and housing strategies to ensure health needs are taken into account. 3. The Individual § Homelessness: Contribute to Local Authority Homelessness Strategies and Groups: PCTs and LAs to improve health care access for Homeless people PCTs to develop joint protocols for homeless people admitted to acute trusts and CMHTs, to produce joint guidelines with DAATs; § Environmental Health: Raise awareness and engagement in wider public health workforce (EHPs) of opportunities of ‘Decent Homes Standards’ and Housing, Health Safety Rating System (HHSRS) (Housing Act 2004). The HHSRS considers the vulnerability of occupants as part of a hazard assessment, addressing winter warmth and falls prevention. Use public health skills to develop a strategic approach for prioritising HHSRS assessments; § Winter Warmth: develop referral pathways from health professionals concerned about individuals housing warmth for an HHSRS assessment, (see diagram); § Promote independence and address housing needs of vulnerable groups: via engagement with local Supporting People plans, Direct Payments, Mental Health LITS (Local Implementation Teams for the National Service Framework), Drug Action and Alcohol Teams, and Probation with local Housing Strategies; § Plan for demographic changes: with an increasingly ageing population with changing housing needs. Combine census data, local and regional housing surveys to predict and plan for changing housing needs to ensure that older people live in homes of decent standard, in a safe environment, with good access to services and transport, which promotes independent living and social integration. Ways Forward - Good Practice Example Partnership work to address fuel poverty and improve Winter Warmth: Older people are at particular risk of excess winter deaths associated with fuel poverty. The risk is higher for those living on low incomes, in under-occupied older houses, in privately rented or owner occupied housing. Aside from reducing excess winter deaths, improving winter warmth has wider physical, mental and social well-being benefits.

Below is a summary of good practice partnership work within the South East. National Below is a summary of good practice partnership work within the South East. National Drivers The Housing Act (2004) § The Housing Fitness Standard (HFS) has been replaced by the Housing, Health and Safety Rating System (HHSRS); § Focus on improving private sector housing with licensing landlords of Houses of Multiple Occupation (HMOs) and areas with anti-social behaviour; § Maintain availability of social housing and extend powers of the Housing Corporation to provide grants for developing new housing. The Housing, Health Safety Rating System (HHSRS) § Provides an assessment system for Environmental Health Practitioner’s (EHP’s) to identify (and act upon), dwellings that pose a threat to occupants’ health and safety, according to need (e. g. cold, damp, fire, trip hazards, noise, security, environment and sanitary hazards). Homelessness Strategy (2005) ‘Sustainable Communities: Settling Homes, Changing Lives’ § Target to ‘halve number of households in insecure temporary accommodation by 2010’ by preventing homelessness and supporting vulnerable people; PROTOTYPE - prevent homelessness (£ 130 m). § Significant funding to modernise hostels (£ 90 m) to AUGUST 2006

Supporting People § Supporting People Programme (£ 5 bn over 3 years) administered by Supporting People § Supporting People Programme (£ 5 bn over 3 years) administered by local authorities; housing related support services help people live independently in the community, e. g. people with learning disabilities, teenage parents, older people (community alarms, sheltered accommodation), support for substance misusers and low level preventative sources for people with mental health problems; § ‘Our Health, Our Care, Our Say’ (2006), emphases promoting independent living and social well being, care at home, increasing activity, individual choice and prevention. Public Service Agreements (PSA’s) Department of Communities and Local Government (DCLG) § Tackle social exclusion and deliver neighbourhood renewal, working with other departments, in particular narrowing the gap in health, education, crime, worklessness, housing and liveability outcomes between the most deprived areas and the rest of England, with measurable improvement by 2010; § By 2010 reduce the number of accidental fire- related deaths in the home by 20% and the number of deliberate fires by 10%; § By 2010 bring all social housing into a decent condition with most of this improvement taking place in deprived areas and for vulnerable households in the private sector, including families with children, increase the proportion who live in homes that are in decent condition; § Lead the delivery of cleaner, safer and greener public spaces and improvement of the quality of the built environment in deprived areas and across the country, with measurable improvement by 2008. DEFRA/ DTI/ DT: § To promote sustainable development across government and in the UK and internationally. (DEFRA); § To reduce greenhouse gas emissions to 12. 5% below 1990 levels in line with Kyoto commitment and move towards a 20% reduction in carbon dioxide emissions below 1990 levels by 2010, through measures including energy efficiency and renewables. (DTI/DT); § Enable at least 25% of household waste to be recycled or composted by 2005 -6, with further improvements by 2008 (DEFRA); § Eliminate fuel poverty in vulnerable households in England by 2010 in line with the Government’s Fuel Poverty Strategy objective (DEFRA/ DTI); § Improve air quality by meeting the Air Quality Strategy targets for carbon monoxide, lead, nitrogen dioxide, particles, sulphur dioxide, benzene and 1, 3 butadiene. (DEf. RA/ DT); § By 2010 increase the use of public transport (bus and light rail) by more than 12% in England, compared with 2000 levels (DT); § Reduce the number of people Killed or Seriously Injured (KSI) in Great Britain in road accidents by 40% and the number of children KSI by 50% by 2010, compared with 1994 -98 average, tackling the significantly higher incidence in disadvantaged communities. (DT). PROTOTYPE - AUGUST 2006

Local Area Agreements: Indicators proposed guidance followed by areas to consider Children and Young Local Area Agreements: Indicators proposed guidance followed by areas to consider Children and Young People’s Block § Number of 0 -15 year olds killed or injured in road traffic accidents; § Numbers of families with children placed in temporary accommodation under the homelessness legislation/ aggregate number of days spent by families with children in temporary accommodation; § Percentage of social housing and vulnerable households in the private sector in a decent condition; § Number of low income families in fuel poverty. Suggested areas to consider developing into an LAA: § Modal share of active transport to school (incorporated into school travel plans), as a proxy for low speed limits, good urban design, decreased parental car journeys etc. Safer and Stronger Communities Block § Increase the proportion of prolific and other priority offenders judged as having sustainable and settled accommodation at the end of their contact with probation; § Measurements of ASB – environment or other criminal activity which are recorded as a crime type (usually by the police) – e. g. criminal damage, incidents of graffiti, abandoned cars and fly-tipping; § Improving the energy efficiency/ carbon performance of operational property and/or community organisations (VCS and private) and/ or housing stock; § Public access to green spaces or condition of green spaces. Suggested areas to consider developing into an LAA: § Increase the use of green gyms to increase social capital, decrease fear of crime, improve environment and facilitate cross generational social networks. Healthier Communities and Older People Block § Improved access to employment, training and housing for those in drugs treatment or leaving drugs treatment (consider other groups- alcohol misuse and offenders); § Number of people aged 75 or over admitted to hospital as a result of falls; § Proportion of older people supported to live in their own home/ adults receiving direct payments; § Reducing fuel poverty/ increase winter warmth - e. g. level of energy efficiency of housing; numbers of vulnerable households living in fuel poverty; successful referrals to Warmfront; increased take up of eligible benefits for older people. Suggested areas to consider developing into an LAA: § Housing needs actively assessed, incorporated into care pathways, outcomes recorded and audited for vulnerable groups in contact with health care services. Economic Development Block § Reduce the incidence of child poverty, contributing to the national targets of halving child poverty by 2010; § Percentage of new housing within the growth point that meets level three in the Code for Sustainable Homes; § Level of local transport congestion; § Percentage of food products used being locally produced and supplied; Suggested areas to consider developing into an LAA: § Integrate economic regeneration with environmental design to improve the built environment; consider previously neglected areas. PROTOTYPE - AUGUST Above Indicators are in LAA Guidance: http: //www. odpm. gov. uk/index. asp? id=116135 2006

References and Resources § Chartered Institute of Housing: www. cih. org § ‘Good Practice References and Resources § Chartered Institute of Housing: www. cih. org § ‘Good Practice Briefing: Health and Housing’ Issue 29, Oct 2004; Developed by Chartered Institute of Housing and DH. Email: [email protected] org) § Chartered Institute of Environmental Health: Guides to: Decent Homes Standards; Area Renewal Urban Regeneration; Health and Housing Safety Rating System (HHSRS) www. cieh. org § National Housing Federation- supports 1400 Housing Associations in England with 5 million residents. Not for profit organisation, promoting decent, affordable housing; safer, sustainable neighbourhoods; development of mixed communities to reduce social exclusion. www. housing. org. uk § ‘Healthy Sustainable Communities- What Works? ’ Ben Cave et al, Milton Keynes South Midlands Health and Social Care Group, www. mksm. nhs. uk § Thomson et al (2001) ‘Health Effects of Housing Improvement: a systematic review of intervention studies’ BMJ 323: 187 -190, www. bmj. com § ‘Housing and Public Health: a review of reviews of interventions for improving health’ Evidence Briefing Summary and Full Report, NICE 2005, www. publichealth. nice. org. uk § ‘Our Health, Our Care, Our Say’ DH, 2006, http: //tinyurl. com/c 8 ne 2 § Housing and Public Health: a review of reviews of interventions for improving health’ Evidence Briefing Summary and Full Report, NICE 2005, www. publichealth. nice. org. uk § Supporting People – www. spkweb. org. uk § Homelessness Strategy- 2005 ‘Sustainable Communities: Settling Homes, Changing Lives’ ODPM, 2005. www. odpm. gov. uk § Shelter: National organisation for homelessness, www. shelter. org. uk § Care and Repair: A national charity aimed at improving housing conditions of older and disabled people; www. careandrepair-england. org. uk § Foundations: a national co-ordinating body for Home Improvement Agencies in England: www. foundations. uk. com § Housing Learning and Improvement Network, Department of Health Change Agent team, a resource network for health, social care and housing providers on accommodation with care solutions for older and vulnerable people – www. changeagentteam. org. uk/housing § Building our Futures- Meeting the housing needs of an ageing population: - Guidance on what data to use to predict demographic and housing changes, changing housing needs with age, including estimated changes in home adaptations, when older people move, and need for sheltered and care homes. International Longevity Centre, UK, www. ilcuk. org. uk § Commission for Architecture and the Built Environment: publications and news sharing good practice in quality design which improves health and well-being, for the built environment and for health care facilities. www. cabe. org. uk For further information please contact: jo. [email protected] gsi. gov. uk For additional copies of the Information Series please visit the SE Regional Public Health Group website www. gose. gov. uk/gose/publichealth PROTOTYPE - AUGUST 2006