1. Insert name of presentation on Master Slide The Case for Investing in Prevention: Housing Dr Sara Long Public Health Researcher; Policy, Research and International Development; Public Health Wales

2. Why? How? What? Outcome...

3. Questions to think about: Based on the evidence, how can we take things further in Wales? -e.g. Existing structures – where are the links/gaps?; What can we do to strengthen the relationship between housing and health? United in Improving Health How can PHW help with the agendas others are following/issues they are trying to achieve? -What/how? Do we have sufficient evidence on effectiveness and cost- effectiveness, and how can we best use this evidence? - How can this report be used?

5. “Total NHS costs for category one hazards (unsafe stairs and steps, electrical hazards, damp and mould growth, excessive cold and overcrowding): £67 million per year*”. * Thomson H et al (2009) The Health Impacts of Housing Improvement: A Systematic Review of Intervention Studies from 1887 to 2007. American Journal of Public Health, 99, 681-691.

6. Total costs to wider society (e.g. poor educational outcomes, reduced life chances): £168million per year.

7. IMTP: Strategic Priority 1: Adopting and implementing a multi agency systems approach to achieving significant improvements in our population’s health Strategic Priority 2: Working across sectors to improve the health of our children in their early years Strategic Priority 3: Developing and supporting primary care services to improve the public’s health Strategic Priority 4: Supporting the NHS to improve healthcare outcomes for patients Strategic Priority 5: Influencing policy to protect and improve health and reduce inequalities Strategic Priority 6: Protecting the public and continuously improving the quality, safety and effectiveness of the services we deliver Strategic Priority 7: Developing the organisation

8. How? Rapid review with two aims: 1) to provide a structured evidence review of the academic evidence on trials examining the impact of improvements to physical housing conditions on health outcomes; 2) to provide an overview of the academic evidence on economic analyses of housing improvement studies and health outcomes Literature search: Identified relevant government and scientific publications (e.g. Hillary Thompson et al.) Collated evidence > sent out for comments/review

9. *Davidson M et al (2011) The cost of poor housing in Wales. http://www.sheltercymru.org.uk/wp-content/uploads/2013/05/ BREEnglishColour.pdf What?

12. Importantly..... Results of studies may depend on baseline housing conditions – careful targeting Short follow-up period

14. United in Improving Health (partnership at a strategic level): Recent conference chaired by Tracey Cooper –included over 60 organisations; 150 people representing local government, housing associations, education, carers organisations, health, national agencies, commissioners and Welsh Government. Aims: To strengthen links between public services, the third sector and others to improve health and tackle health inequalities in Wales; generate and agree organisational commitments to improving health outcomes; identify and learn from good practice that achieves change in population health at scale and pace. The discussion centred on improving health and wellbeing through using all the resources of every organisation at a local and national level, with a view to enabling people and communities to make healthier choices within a better environment. https://www.youtube.com/watch?v=vsKyZIPlsf4

15. MoU: MoU being developed with Community Housing Cymru (early stages): -Articulates roles, responsibilities and requirements of partners -Establishes collaborative arrangements between PHW & CHC -Establish an agreed programme of work based on PHW and CHC strategic priorities (specific projects/operational details to measure tangible outcomes) to improve health and well- being and reduce inequalities -Dr Sumina Azam (Public Health Consultant, Policy, Research and International Development, PHW, sumina.azam@wales.nhs.uk)

16. LEPS: Demand & Variation Housing and Health Presenter: Louise Woodfine, Registered Public Health Specialist, FFPH

17. Tasks to think about: Health and Housing Toolkit o Will the toolkit be useful to housing and health professionals/practitioners? o How can the toolkit be improved? o How can we take this forward?

18. “Everyone has the right to a standard of living adequate for the health and well being of himself and of his family, including food, clothing, housing and medical care”. (The universal declaration of human rights) Housing & Health

19. History o 1842- Chadwick established link between living conditions of the poor and ill health o Most of health gains stemmed from public health measures: o Clean water o Sanitation o Improved accommodation Housing & Health

21. Social Justice o Vulnerable populations at most risk o Elderly o Very young o Chronic illness o Poor housing can cause worsened health o Provision of reasonable standard of accommodation will have health benefits for the most disadvantaged in society o Acheson Inquiry (1998) into health inequalities highlighted the correlation between housing quality and health Housing & Health

23. Housing scope o Living in Wales surveys 2004 and 2008 – 5,200 properties o 5% ‘unfit’ o 60% of those ‘unfit’ had significant damp problems, inadequate ventilation and/or heating o Housing & Health

24. Risk factors Damp, mould, ventilation and allergensAsthma and other respiratory illnesses Injury hazardsInjuries OvercrowdingTuberculosis Cold and heatPrem mortality and morbidity NoiseIschaemic heart disease + others RadonLung cancer LeadNeurological impacts Carbon monoxidePoisoning and mortality FormaldehydeRespiratory symptoms Indoor smoke from solid fuel useRespiratory symptoms Psychological impacts Housing & Health

25. Others..... Brief Intervention, MECC Falls/Injuries Cold/Heat/Ventilation Social isolation Noise Mental Health Homelessness Signposting Etc.......

26. Working Together: Practical Example o CHARISMA (Children's Health in Asthma – Research to Improve Status though Modifying Accommodation) o Multi–agency health and housing project which aims to improve the health of asthmatic children by improving housing conditions o Estimated 40% of doctor diagnosed asthma is due to residential exposure Housing & Health

27. Target Group o Live within the Wrexham Local Authority area o Children aged between 5 and 15 o On the list of a participating general practice o Taking inhaled steroids for asthma (3 or more prescriptions over 12 month period) o Identify those children in primary and secondary care Housing & Health

28. CHARISMA: Intervention o ‘ A package of housing improvements designed to provide adequate ventilation and temperatures and reduce mould spores’ o Ventilation and (partial) Central Heating (CH) or Ventilation only o All housing types o All areas o All partners Housing & Health

29. CHARISMA: Conclusions o Significantly improved asthma specific quality of life for all functions (symptoms, treatment, worry and communication) o Significantly reduced physical problems o Psychosocial health (emotional, school and social functioning) improved (but not significantly so). o All measures improved (even those with non-significant results) so less likely to be a chance result. o Improved health and well-being of the child and (perceived) benefit siblings/household members. o Likely underestimation of impact (longer term, household members) o May reduce school absence (p = 0.053) o Value for Money/Cost effective Housing & Health

30. CHARISMA: Additional Activity o APSE Local Government Awards Winner 2009 o NHS Wales Awards 2009 runner up o Winner of Novartis and RCGP Research Paper of the Year 2011 – Children and Medicine o Publication – BJGP, WHQ, EHN o WCBC mainstreamed 2009/2012 o East Cheshire, Nottingham, Sunderland, Anglesey & Gwynedd o Challenges - housing input, health and well-being outcomes Housing & Health

31. Sources Used o Brunt, H. Poor Housing & Asthma ppt o Koreishi, S. Housing & Health ppt o Woodfine, L. Health & Housing ppt o Woodfine, L. CHARISMA ppt o Rob Atenstaedt, Associate Director of Public Health for North Wales Housing & Health

32. WCHE LOGO Carbon Monoxide Asthma & Housing Alcohol Injuries

33. Housing & Health Making Houses Healthy Snapshot Partnerships & Useful Contacts Evidence, Data & Reports Additional Information WCHE CHC

34. Housing & Health Snapshot o What is the toolkit and who is it for? The toolkit aims to train, educate and raise awareness of the links between asthma and housing and support health and housing professionals/practitioners in understanding how they can work together to improve the health and well-being of people through improving their housing. o Why is it important? A home is a central part of people’s lives. Good housing can help to improve physical and mental health and wellbeing. Poor housing, particularly damp, mould, inadequate ventilation and the presence of allergens can exacerbate asthma and other respiratory illness. o What does the toolkit do? To give housing and health professionals a better understanding of the link between housing and health and how they can be supported when working with families and individuals.

35. Housing & Health Making Houses Healthy o Who is the toolkit for? o Housing o Health o General o What resources will be available for me to use? o Training Materials & Presentations o Posters o Action & Prompt Cards o Areas of good practice

36. Housing & Health Evidence, Data & Reports o Evidence e.g. reducing exposure to damp and moulds and improving ventilation can be effective in improving overall health and quality of life and reducing asthmatic symptoms............. o Data Useful sources of asthma data can be found through The Child Profile, The GP Cluster Profile and Asthma UK o Reports o The Case for Investing in Prevention: Housing o WCHE Joint Paper o Together for Health – A Respiratory Health Delivery Plan o Measuring & Evaluating o HIA & validated questionnaires e.g. EQ5D, ACT

37. Housing & Health Partnerships and Useful Contacts o WCHE o Working together The evidence suggests that real and measurable differences can be made to improve health by working in partnership o Partners o WCHE o CHC o PHW o Housing Associations o Housing Expert Panels o Others o Useful contacts

38. Housing & Health Additional Resources and Information o Fuel Poverty (FP) and Energy Efficiency (EE) o Asthma UK o CIEH o Research

39. Tasks to think about: Health and Housing Toolkit o Will the toolkit be useful to housing and health professionals/practitioners? o How can the toolkit be improved? o How can we take this forward?