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Housing

Introduction

The intention behind this Chapter is:

  • To offer a brief overview of housing and health
  • To summarise the range of Council activities on housing
  • To direct the reader to the range of strategies that the Council has published
  • To set out in more detail issues relating to:

 

  • Housing conditions and fuel poverty
  • The people who contact the Council regarding housing issues.

 

Housing and Health

Housing and housing issues affect all members of the population in Bedford.  In broad terms there are two distinct parts to housing: Housing Places, that is the bricks and mortar that we live in, and Housing Services, that are designed to keep people living independently in their own homes.  Both of these have significant impacts on the health and wellbeing of the population in Bedford. 

There is a strong and enduring link between housing and public health.  This has been acknowledged in many health reports which state;

‘Shelter is a pre-requisite for health. However, people who are disadvantaged suffer both from a lack of housing and from poor quality housing’25

‘the health inequalities infant mortality review; this work showed that reducing child poverty, improving housing and reducing overcrowding had a direct impact on the infant mortality aspect of the health inequalities target’26        

‘Poor housing conditions have a detrimental impact on health, costing the NHS at least £600 million per year27

The World Health Organisation (WHO) have identified the most significant housing hazards associated with health effects to   include poor air quality, hydrothermal conditions (e.g. cold and damp), radon, slips trips and falls, noise, dust mites, tobacco smoke and fires1.  It is therefore widely accepted that poor housing can have a significant influence on physical and mental health with links between:

  • The poor insulation and heating leading to excess winter deaths (excess cold). Excess cold is also associated with dampness /mould and poor respiratory health including asthma6.
  • Disrepair /poor construction leading to accidents in the home including falls resulting in fractures.
  • Overcrowding which can cause poor mental health  and contribute to the spread of airborne infections, for example TB
  • Poor cooking equipment, heating appliances and inadequate ventilation leading to carbon monoxide poisoning.
  • Poor housing areas and the threat of increased crime and anti-social behaviour (ASB) leading to mental health problems including depression.

 

The Parliamentary Office of Science and Technology published a document on housing and health in January 2011 which found that there can be a negative effect on children’s education because those living in cold, damp homes cannot learn as effectively.

For the foreseeable future the great majority of the population will continue to live in stock that is already built. The evidence available to the JSNA (see the chapter on climate change) and through the Stock Condition Survey is that excess cold, fuel poverty and homes that are not energy efficient are a key issue with regard to the condition of the stock and its impact on health in Bedford Borough.  Research elsewhere supports this view. A World Health Organisation’s World Health Report 2013 noted that:

“….Better home insulation, plus energy-efficient, smoke-free heating and cooking systems and indoor ventilation, can reduce respiratory diseases, including asthma, pneumonia and tuberculosis, as well as reducing vulnerability to extremes of heat and cold. Large savings in health costs from asthma and other respiratory illness were observed in follow-up studies of home insulation in low-income homes in New Zealand. The promise of immediate health gains helped drive large-scale government investments in home improvements in New Zealand. To these short-term gains must be added the economic value of carbon savings that will be realized in future.”3

There is an increasing awareness of the impact that social isolation and tenancy failure has on a person’s health, particularly the health of older people over the age of 75 who are more likely to be living alone.  This results in more frequent access of primary care such as frequent visits to a GP where there is a limited reason for doing so.  Housing services have a significant role to play in tackling issues that arise from social isolation and are uniquely placed to do so with the networks of services available to such ones.

 The supply of housing and its condition is a fundamental wider determinant of health for the whole population. The health impacts of under-supply of housing are many and serious:

 

  • Appropriate housing is unaffordable to many households
  • Household budgets are over-stretched in order to meet housing costs
  • New households that are ready to form are unable to do so
  • People live in overcrowded conditions
  • People remain in unsuitable accommodation when their needs have changed
  • People are forced to move away from their family and support networks

 

The condition of the stock and the supply of new housing. These two elements are fundamental broader determinants of health. The key stock condition issue is hard to heat homes and fuel poverty and this has a direct bearing on health and demands on health and care services. Accessibility and suitability of homes for people whose abilities are limited is also a key issue with service use implications. The provision of new homes is important generally to healthy lifestyles; the provision of affordable housing is particularly important to people with low incomes who generally suffer from health inequalities; the provision of specialist housing is important to older people and many vulnerable groups whose use of health services is substantially affected by their access to specialist accommodation, or lack of it.

There are people within the community who need care and support services. For some this is at a particular time in their life, in other cases on a long-term basis. Housing services are well placed to provide prevention and early intervention for people with a range of short term and long term conditions, thereby reducing the demand for more acute services.  All the agencies engaged in responding to these needs have to work together to deliver effective and efficient services.

 

1.    The Council’s role in Housing

Affordable housing in Bedford Borough is provided by housing associations with the largest provider being Bedfordshire Pilgrims Housing Association (now known as bpha). Partnership working is essential both across the Local Authority departments, with Registered Providers of Social Housing, with the voluntary sector and with the different organisations within the NHS.  The Council is no longer a stock holding authority but maintains a housing function in relation housing supply, housing conditions and the housing needs of the homeless and those in need of care and support.

 In 2013/14 the Council handled more than 17,000 contacts related to housing issues. This figure reflects individual interactions across a range of services the most frequent being with Housing Benefits.

 The primary functions related to housing are listed below:

  • Housing Strategy – development of housing strategy and supporting strategies, support for new supply and affordable housing, empty homes, stock condition surveys and response including the Bedfordshire and Luton Energy Scheme
  • Housing Services – housing options, assessment of housing need, homelessness prevention, temporary accommodation, rehousing, supported housing services including special needs groups, gypsy and traveller management
  • Environmental Health – statutory interventions to address poor housing conditions, houses in multiple occupation licensing 
  • The Sustainability Team - work to promote energy efficiency and reduce fuel poverty.
  • Home Improvement Team – Disabled Facilities Grants, Home Improvement Loans and grants, Handyperson Services
  • Housing Benefits - Determination of benefit claims from applicants and administration of discretionary housing payments

 

Other Council departments also have key roles in relation to housing issues. Adult’s and Children’s Services provide a wide range of specialist accommodation and care services.  Planning Services create the planning policy framework for housing development and sustainable communities and determine planning applications

The Care Act 2014 includes housing services amongst those services which should be integrated with health services. While recognising that housing and care are distinct services the Act also recognises that housing can be part of the solution to someone with care and support needs.  This is particularly relevant when considering the wellbeing aspect of an individual’s care needs.

 

The implementation of the Care Act 2014 is being addressed by Adult Services. Housing Services, which sits within Adult Services, is an integral part of this process. The engagement of the broader housing functions of the Council will be supported by the following steps:

 

  • providing a broader vision of health and housing within the JSNA
  • recommending an implementation group to follow up on the chapter
  • supporting the development of a Care and Support Accommodation Strategy

 

What do we know?

Housing Base Data

Base data on the population of Bedford is available on the Borough Council website:                 http://www.bedford.gov.uk/council_and_democracy/statistics_and_census.aspx

 

Poor housing conditions are often linked to other factors creating multiple deprivation in particular areas. Information of the Index of Multiple Deprivation and areas within Bedford is available on the Council’s website:

http://www.bedford.gov.uk/council_and_democracy/statistics_and_census/indices_of_deprivation_2015.aspx

 

Base data on housing in Bedford including projections of requirements for future housing supply is available within the Strategic Housing Market Assessment:

Available at: http://www.bedford.gov.uk/housing.aspx

 

Council Housing Strategies

The Bedford Borough Council Corporate Plan 2012-16 set the following strategic objective.

To deliver a balanced supply of homes through an integrated housing system through more effective partnerships with statutory and non-statutory services, shaped by an effective housing strategy, to meet the needs of our growing and increasingly ageing population; To ensure that regeneration is complementary to the Borough’s built environment.

 The Council has adopted the Bedford Housing Strategy to 2020. The Housing Strategy sets out objectives and an action plan.

The level of need, the dwelling types required and the tenures that will best meet those needs are considered through the Strategic Housing Market Assessment which provides an evidence base for both Planning Policy and the Housing Strategy.

Available at: http://www.bedford.gov.uk/housing.aspx   

The Local Plan 2002 set out plans for an increase in the housing stock of Bedford by 19,000 dwellings by 2021. This was reflected in the current planning framework. A new Local Plan to 2035 is in preparation which will include further increases in the planned number of dwellings in Bedford Borough. Further information is available on the Council website

     http://www.bedford.gov.uk/environment_and_planning/planning_town_and_country/planning_policy__its_purpose/local_plan_2035.aspx

 

The Strategic Housing Market Assessment led to a revision to this target in the Housing Strategy Review to 256 dwellings per year.

 

The Homelessness Strategy has been revised to take into account changes in legislation, welfare reform and best practice. This was based on a review which includes an examination of levels and trends in homelessness together with a review of the existing provision of support and other services for those facing homelessness in the Borough.

Available at:  http://www.bedford.gov.uk/housing.aspx

 

The Tenancy Strategy 2014-2017 is generally focussed on supporting affordable and social rented tenants in remaining in their homes while making best use of large properties and properties with adaptations. The strategy seeks to ensure that tenants have the support they need where a move needs to be considered because the property no longer conforms to their requirements. Decisions about individual cases will be taken by the housing association that is the landlord in accordance with its Tenancy Policy – not by the Council.

Available at:  http://www.bedford.gov.uk/housing.aspx

 

The Empty Homes Strategy 2013-2017 is designed to limit the waste of this critical resource and to prevent neighbourhoods being blighted by empty properties with the risks associated with disrepair, crime and vandalism. It identifies that there is a significant issue in Bedford with long-term empty homes and a range of strategies for tackling this problem.

Available at:  http://www.bedford.gov.uk/housing.aspx

 

The Affordable Warmth Strategy (2013-16) is aimed to tackle fuel poverty and included initiatives to help reduce households’ energy costs (including help accessing national schemes), increase households’ income and raise awareness of other help which was available. This strategy is currently under review and in the process of being amalgamated with other similar strategies to form one comprehensive approach to energy efficiency and fuel poverty.

Available at: http://www.bedford.gov.uk/environment_and_planning/sustainability/keeping_warm_at_home.aspx

 

The Care and Support Accommodation Strategy will consider the needs of a range of groups, specifically

  • People with Learning Disabilities - The Council has consulted on a draft Learning Disabilities Accommodation Strategy and is working towards adopting this document.
  • People with Mental Health issues - A Mental Health Accommodation Strategy is in preparation with a view to consultation and adoption in 2017/18
  • Older People - The Older Persons Accommodation Strategy 2011-16 requires updating which will be commenced in 2017/18 and completed in 2018/19
  • People with Physical Disabilities – A Physical Disabilities Accommodation Strategy will be commenced in 2017/18 and completed in 2018/19

 

The Supporting People Strategy 2012 – 2017 identified a need to remodel the provision of housing related support services within Bedford Borough Council to achieve the following vision: “To provide accessible high quality and cost effective housing-related support for vulnerable people that promotes independence, social inclusion and complements other services. Working in partnership with stakeholders and in consultation with service users, we will ensure services respond to local need, are accessible, equitable, flexible and provide the best possible outcomes for those who use them.”

The objectives included:

  • Effectively procure, and where appropriate, amalgamate services to deliver improved economies of scale and greater efficiencies including the procurement of larger accommodation based services to deliver better economies of scale
  • Develop a Complex Needs provision (a hostel scheme with high levels of support for rough sleepers and others with complex needs who cannot sustain tenancies and face exclusion from hostels)
  • Change the delivery of older persons services to transition the service to a more community based provision with less emphasis on sheltered accommodation
  • Change the delivery of accommodation based services to those with a Learning Disability with a focus towards those with semi-independence or those who can be helped towards independence
  • Jointly develop provision for early invention with Children’s services, such as the Independent Domestic Abuse Programme and ensure that existing provision is complimenting the aims and objectives of Children’s services

 

Available at: http://www.bedford.gov.uk/health_and_social_care/help_for_adults/supporting_people_information/info_for_providers_and_agencie.aspx 

 

Housing conditions

 

The Decent Homes Standard is a government policy that states that everyone should have the opportunity of living in a decent home which means that four broad criteria have to be satisfied:

  • Above the legal standard for housing and free from category 1 hazards.
  • Being in a reasonable state of repair.
  • Having reasonable modern facilities including kitchens and bathrooms.
  • Having a reasonable degree of thermal comfort (effective insulation and heating)

 

The highest rates of non-decency are in converted flats at 85% with older properties, pre 1919, having the highest prevalence at 43.1%.  Geographically the inner area of Bedford exhibited the highest rates of failure at 31.4% compared to Bedford North, Kempston and Bedford South and Bedford Rural.  In the centre of Bedford the highest rates of failure were found in Caudwell and Harpur Wards (40%+)8.  

 

In the UK the Housing Act 2004 (the Act) introduced the Housing Health and Safety Rating System (HHSRS) which defines 29 types of hazard found in dwellings ranging from asbestos through to fire safety.  The hazards are grouped into four categories:

 

  • Physiological requirements (e.g. damp, mould and excess cold).
  • Psychological requirements (e.g. crowding, space and entry by intruders).
  • Protection against infection (e.g. domestic & personal hygiene and food safety).
  • Protection against accidents (e.g. falls on the level, on the stairs and steps between levels).

 

The role of fuel poverty

Public Health England has investigated the national pattern of excess winter deaths week-to-week over the winter months10.  Their analysis demonstrates that weekly peaks in excess deaths coincide with cold snaps and high circulating levels of respiratory viruses, i.e. influenza and respiratory syncytial virus. 

 

The effects of cold temperatures are not felt exclusively by people living in cold homes, but most of the people in the vulnerable groups (over 65s, those living with long-term conditions or disabilities) will spend the majority of their time at home.  The landmark Marmot review “Fair Society Healthy Lives”11  and the more recent King’s Fund report into health inequalities12 both identify warm homes as crucial to reducing the risk of death from cold temperatures, and specifically to reducing the social inequality in risk of death from the cold. The Stock Condition Survey 2011 identified excess cold as the key failing in the condition of the private sector stock in Bedford. This section focusses on excess cold and fuel poverty in relation to the housing stock. Please see the JSNA chapter on excess winter deaths for further information about this issue.

 

Fuel poverty describes the circumstance of a household having such high heating bills in proportion to its income, in order to keep the indoor temperature at a health-protecting level, that the household is living in poverty as a result.  Statistically it is defined as a household which:

 

  • has required fuel costs that are above average (the national median level)
  • were they to spend that amount they would be left with a residual income below the official poverty line

 

This definition is new, and is felt to be more robust that the previous definition, in which a household was in fuel poverty if more than 10% of income needed to be spent on fuel13.  Households can find themselves in fuel poverty because of a low income, poor energy efficiency, high unit energy costs or a combination of the three.  Households at particularly high risk are those living in private rented accommodation and those who are unemployed.

 

It is important to note that, like the excess winter deaths measure, fuel poverty is estimated rather than counted accurately.  Statistics are published annually and are calculated using a complex model, which is based on survey findings about the size and age structure of households, the type and tenure of their dwellings, average energy prices and self-reported income14

 

The most recent statistics available at neighbourhood level are from 2014.  Overall, 6,006 households or 9.2% of all households in Bedford Borough were estimated to be in fuel poverty.  The proportion varies substantially between areas, from over one in five households in Bedford town centre to less than one in twenty in the lightest coloured areas.  There are “coldspots” in the urban neighbourhoods with high levels of deprivation and in rural areas where the population is quite sparsely spread.

 

Figure 4: Prevalence of fuel poverty in Bedford Borough by lower super output area

Housing

 

Bedford Borough has a higher prevalence of fuel poverty than the regional average, but in 2012 had dipped below the national average (figure 2).  The decrease follows the national trend and is primarily due to increasing income rather than improvements to housing stock or home energy efficiency14.

 

Figure 2: Percentage of households in fuel poverty in Bedford Borough 2010-14 with regional and national comparators

Housing

Source: Department of Energy & Climate Change fuel poverty statistics15

 

Although fuel poverty is a recognised risk factor for excess winter deaths, comparing the map in figure 4.1 with the distribution of excess winter deaths in figure 3.2 shows that there is a similarity between the two patterns but fuel poverty is not the whole story.  Fuel poverty and other risk factors do not necessarily co-exist (figure 4.3) – the key to preventing excess winter deaths will be to solve fuel poverty first in those households where the risk is greatest.

Figure 6: Conceptualisation of risk factors contributing to prevalence excess winter deaths

 

H3 2015

The magnitude of risk increases with the number of ovals an individual falls into.  Other risk factors include being in one of the vulnerable groups (see Introduction) and behavioural factors such as wearing inappropriate clothing16 and keeping windows open in the home17.

Assessment of Housing Conditions and enforcement

Social Housing

Social housing received sustained investment to achieve the Decent Homes standard in the first decade of the 21st century. Bpha achieved the decent homes standard for all its properties in 2010. The proportion of social rented dwellings failing to meet the Decent Homes standard in England less than 1% and In Bedford was 0.  In contrast, nearly a quarter of the private rented sector dwellings (24.2% from a total of 13,540 dwellings) failed the decent homes standard. The remainder of this section on housing conditions focusses on conditions in the private sector.

 

Private sector housing

Category 1 hazards have a major impact on health in Bedford.  The most frequent category 1 hazards are excess cold (59.6% of the total of all category 1 hazards) and falls either on a level or on the stairs. This is different from the national picture where falls on the stairs are higher than excess cold.  The cost to remedy excess cold locally is estimated to be £13.7 million8.

 

Figure 7: Individual category 1 hazards as a % of all category 1 hazards

H4 2015

(Source: Private Sector House Condition Survey 2011)8

 

The following table shows a breakdown of non-decent properties by age of head of household.  Category 1 hazards and thermal comfort failure are both highest in the youngest age band (16-24) at 25.4%. The next highest rate of Category 1 hazards is found where household heads were aged 65 and over (16.5%) which also had the highest rate of disrepair (5.7%). 

 

The following table shows a breakdown of non-decent properties by age of head of household.  Category 1 hazards and thermal comfort failure are both highest in the youngest age band (16-24) at 25.4%. The next highest rate of Category 1 hazards is found where household heads were aged 65 and over (16.5%) which also had the highest rate of disrepair (5.7%). 

 

Figure 8: Non-decent properties by age of head of household

H5 2015

Category 1 hazards:

There were 65 category 1 and high category 2 hazards found in 2015/16 as part of the Housing and Environmental Health teams inspection work with 125 damp and mould complaints.

 

Figure 9: Category 1 hazards – actions and outcomes

 

Housing Action Taken

 

2011/12

2012/13

2013 /14

 

2014/15

2015/16

Category 1 and high category 2 hazards present as part of inspection work – an indicator of the condition and seriousness of housing defects following complaints or routine inspection.

115

136

66

40

65

Damp and Mould investigations

 

 

48

241

complaints

174

complaints

146

complaints

125

complaints

Resulting Enforcement Action

 

2011/12

2012/13

2013/14

2014/15

2015/16

Hazard awareness notices served

71

89

68

21

30

Informal notices served (this is the first action as part of the staged approach for enforcement).

81

111

51

38

69

Outcomes of Enforcement Action

 

2011/12

2012/13

2013/14

2014/15

2015/16

Properties where works/notices are complied with the hazards removed: Category 1 hazards

78

 

14

6

12

8

 

Housing Action Taken

 

2011/12

2012/13

2013 /14

 

2014/15

2015/16

Category 1 and high category 2 hazards present as part of inspection work – an indicator of the condition and seriousness of housing defects following complaints or routine inspection.

115

136

66

40

65

Damp and Mould investigations

 

 

48

241

complaints

174

complaints

146

complaints

125

complaints

Resulting Enforcement Action

 

2011/12

2012/13

2013/14

2014/15

2015/16

Hazard awareness notices served

71

89

68

21

30

Informal notices served (this is the first action as part of the staged approach for enforcement).

81

111

51

38

69

Outcomes of Enforcement Action

 

2011/12

2012/13

2013/14

2014/15

2015/16

Properties were works/notices are compiled with the hazards removed: Category 1 hazards

78

 

14

6

12

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Standard Assessment Procedure (SAP) ratings:      

                       

 SAP ratings measure the energy efficiency of a building and are calculated from 1 (least efficient) to 100 (most efficient) and based on the annual energy costs for space and water heating measured in Kilowatt hours (KWh).  The modelling of excess cold hazards is based on the use of an individual SAP rating for each dwelling which is scaled to give a hazard score.  Where a dwelling has a SAP rating of less than 35, this produces a category 1 hazard score.  The more modern the building the better the SAP rating with the lowest ratings in pre 1919 dwellings (mean SAP rating of 47) with the highest scoring dwellings post 1990 at 678.

 

The lowest SAP ratings were found in Bedford Rural (Mean SAP 37) and Bedford North Centre (mean SAP of 48)8.


Thermal comfort relates to effective insulation and efficient heating.  The average thermal comfort failure in Bedford relates to the Bedford inner area at nearly a quarter (24.4%).  Under 25s are the social group most likely to suffer from thermal comfort failure8.

3.21 The highest proportionate rate of fuel poverty is found in the private rented sector in Bedford at 12.7% (1500 households) compared to 10.5% (4510 households) in the owner occupied sector.  Highest rates were also found in the Bedford Inner sub-area (13.7%) closely followed by Bedford Rural sub-area (13.6%). 

 

Complaints: - Environmental Health.    

Bedford Borough Council, through its Environmental Health and Trading Standards team has the core responsibility to ensure that private rented housing complies with minimum standards for safety under the HHSRS system.

 

  The team investigate all complaints relating to private sector housing conditions including disrepair, overcrowding, dampness and mould.  A risk based inspection programme is also undertaken to tackle the properties which have the poorest standards for fire safety and management.

 

In 2015/16 Environmental Health and Trading Standards received approximately 321 complaints about private rented accommodation, in 2015/16 there were 305 complaints and enquiries about HMOs compared to 407 in 2014/15 and 556 in 2013/14. The number of complaints about landlords was 42 in 2015/16, 29 in 2014/15, 63 in 2013/14, 61 in 2012/13, 16 in 2011/12 and 36 in 2010/11.  There was also an increase in disrepair complaints with 253 in 2015/16, 249 in 2014/15 218 in 2013/14, 53 in 2012/13, 61 in 2011/12 and 43 in 2010/11.

 

The Council has also seen complaints about overcrowding increase this year with 88 in 2015/16, 71 in 2014/15, 143 in 2012/13, 135 in 2011/12 and 100 in 2010/11.

 

The team provides advice leaflets to tenants to help them manage their lifestyles to reduce preventable problems attributable to damp and mould.  They also deal with complaints about overcrowding to enable tenants to potentially increase their priorities for social housing.  However, with serious pressures on the availability of social housing locally due to high demand and a lack of vacancies  there is an increased need to grow and develop the private rented sector and improve the quality of accommodation.

 

Environmental Health Officers provide tenants of Houses in Multiple Occupation (HMO) with advice and leaflets to help them to use heating more efficiently and keep affordably warm. Landlords will be provided with advice and leaflets on energy efficiency measures and sources of funding. Bedford Borough Council, through its Environmental Health and Trading Standards team has the core responsibility to ensure that private rented housing complies with minimum standards for safety under the HHSRS system.   

 

The team investigate all complaints relating to private sector housing conditions including disrepair, overcrowding, dampness and mould.  A risk based inspection programme is also undertaken to tackle the properties which have the poorest standards for fire safety and management.

 

Houses in Multiple Occupation 

 

In May 2013 the council introduced an Additional HMO licensing scheme to improve standards in this particular sector of the private rental market as it was estimated that over 1/3rd did not comply with current fire safety and management standards.  Approximately three years after the introduction of the HMO additional licensing scheme, the number of HMOs which were broadly compliant in 2015/16 had increased from 64%, to 82.2%.  The rate of non-decency in these properties was 31.2%, substantially higher than that found in Bedford as a whole. Over the next 3 years it is estimated that there will be approximately 500-1000 HMOs within the Borough which will need to be licensed.  The Government has also consulted on a set of new proposals for extending the mandatory licensing of HMOs.

 

A public register is maintained of all of the HMOs in the Borough which have been licensed and regularly updated to ensure that it is accurate.  However, there is a very dynamic housing market in Bedford so intelligence supplied by landlords, letting agents and estate agents is important to keep the information up to date.

 

 From 160 people surveyed in January 2013, 85% agreed with the Council’s aim to improve safety standards and the management of HMOs in the Borough19.  Tenants also reported concerns with their housing generally and were particularly concerned about damp and mould, poor repair, anti-social behaviour and electrical safety.  Other concerns which tenants mentioned included: poor insulation of homes, lack of disabled facilities, uneven flooring resulting in slips and trips and the need for designated smoking areas outside of their property.  43% of tenants, leaseholders and residents were either neutral or had concerns about the way the private rented sector was being managed by landlords with 9% suggesting that there was a very poor element within the market locally. 

 

Estimated Costs to the NHS of key HHSRS Hazards

The Building Research Establishment (BRE) have developed a methodology for evaluating the health impact assessment of housing enforcement interventions to tackle category 1 hazards14.  This includes calculating the cost of removing the category 1 hazard against the cost of health care to the NHS to provide a net present value, cost benefit analysis. Table B provides a breakdown of costs for the key category 1 hazards.

A health impact assessment (HIA) can therefore be used to calculate the potential savings to NHS and society by mitigating the most common category 1 hazards.14

The costs in the table below are based on simple sums and although commonly called cost benefit are properly known as ‘cost off-set’. This is the cost to the NHS and does not include other associated costs – in particular it does not reflect care costs which are potentially very high. There are also costs to the broader economy through time off work, reduced productivity etc.

 

Figure 10: Typical health outcomes and first year treatment costs for selected HHSRS hazards. 24

 

Hazard

Class 1

Class 2

Class 3

Class 4

Damp and mould growth

N/A

Type 1 Allergy (£1,998)

 

Severe Asthma (£1,120)

Mild Asthma (£180)

Excess Cold

Heart Attack, care, death (£19,851)

Heart Attack (£22,295)

Respiratory Condition (£519)

Mild pneumonia (£84)

Falls on the level

Quadraplegic (£59,246)

Femur fracture (£25,424)

 

Wrist fracture (£745)

Treated cut or bruise (£67)

Falls on stairs and  steps

Quadraplegic (£59,246)

Femur fracture (£25,424)

 

Wrist fracture (£745)

 

Falls between levels

Quadraplegic (£59,246)

Head injury (£6,464)

 

Serious hand wound (£1,693)

Treated cut or bruise (£67)

Fire

Burn, smoke, care, death (£11,754)

Burn, smoke, care (£7,878)

Serious burn to hand (£2,188)

Burn to hand (£107)

 

Current activity & services – Housing Conditions

Home energy efficiency schemes

The Council is seeking to raise awareness and has produced a Safe, Healthy and Well leaflet which brings together information on all the existing services provided by the council and other organisations in the public and voluntary sectors.  Over 1,000 copies were printed which have been distributed at information events and presentations, and via the Council’s Customer Service Centre, libraries, GP practices,  housing associations, and through the community organisations that contributed to the leaflet, and is available to download  from the Council’s website: www.bedford.gov.uk/safehealthywell

 

The Council works in partnership with Street Energy to deliver insulation to priority groups and in deprived areas. It also has a revolving fund created through the Bedfordshire and Luton Energy Scheme (BALES) for boiler loans. Initially funded through the Regional Housing Pot, 190 boiler loans have been completed in the Borough, helping to reduce the risks of fuel poverty and reducing the health risks associated with excess cold.  The volume of loans and the rate of repayment limit the opportunity to offer new loans. This scheme is managed by the Housing Strategy Team working with the Sustainability Team.

 

The Council successfully applied to the Department of Health’s Warm Homes, Healthy People Fund in 2011/12 and 2012/13. The aim of the national fund was to support activities which would address the public health consequences of cold housing for the most vulnerable and support the Government’s Cold Weather Plan, ultimately to reduce excess winter deaths.

 

 The Council’s Adult Services department, along with local charities and voluntary organisations partners were successful with an application to the 2011/12 fund. An additional application by the Housing Strategy Team to extend the BALES programme delivered 35 boiler replacements. The Council’ Adult Services department was also successful in leading a further joint application to the 2012/13 fund but there was not comparable funding available in 2013/14.

 

 Through the fund, the partners provided keeping warm advice, warm packs (consisting of a fleece blanket or ‘Snuggie’, ‘Thinsulate’ hat and gloves set, packet soup, hot water bottle and cover, a room thermometer and documentation promoting local services and advice on keeping warm) given to vulnerable residents in the Borough, funding for community groups to put together and distribute their own warm packs, energy audits, the installation of small energy efficiency measures, the opening of the Night Café for rough sleepers on additional nights and information on how to access insulation offers and financial assistance to help with energy bills, Those benefiting from the funding were mainly older residents living in private housing who were vulnerable to the cold and were provided with all the help that was available to them through cross-promotion and cross-referrals. Unfortunately the Warm Homes, Healthy People fund was not renewed.

 

Several voluntary organisations are delivering important services:

 

Age UK Bedfordshire has secured funding from British Gas for a Warm Homes project to lift people from fuel poverty across Bedfordshire and Luton. The project aims to directly support 1,000 people by end of December 2016.   107 assessments have been carried out in Bedford Borough since the project commenced, with clients being offered an energy efficiency/affordable warmth home survey and behaviour change guidance.  Project clients have been supported with fuel payment plans, to use heating controls and systems, to switch energy suppliers, to receive Warm Homes’ discounts and other entitlements.  A further 272 older people have attended awareness raising sessions. 

 

Bedford Citizen’s Advice Bureau (CAB) provides face-to-face, telephone or web-based advice on a broad range of issues including income maximisation, debt management, and housing problems.  Unaffordable energy bills are a frequent reason for clients to seek support.  Anecdotally, enquiries are common amongst single men in their 40s and 50s, and particularly from households who pay for their power through pre-payment meters.  The CAB can support clients to switch to cheaper energy tariffs but there are practical barriers to overcome such as the best tariffs only being available to those who are able to pay by monthly direct debit. 

 

Bedfordshire Rural Communities Charity (BRCC) employs Village Agents in the rural villages to provide information and signpost clients to services for housing and social support, pensions and benefits, health and safety in the home.  The service is free and can be by home visit or over the phone.  BRCC also coordinates ‘Good Neighbour’ care schemes to offer help with household tasks and provide social contact.  Both schemes are targeted at people over the age of 50 but a large proportion of clients are considerably older, including in the 90+ category.

 

Home Improvement Loans and Grants

The Council has a very limited fund for home improvement loans, or exceptionally grants which are available for emergency boiler replacements, critical repairs and bringing empty homes back into use. These funds are managed by the Home Improvement Team which sits within Property services.

 

Disabled Facilities Grants

 

The Council facilitates the process for Disabled Facilities Grant funding, from receipt of the referral to the design of the scheme and application stage. All queries for DFG funding are subject to a referral and assessment carried out by the Occupational Therapist.

 

In 2014/15 174 people in Bedford benefitted from DFG funding with the Council spending over £1 million delivering these essential works. During the same period of 2014/15, 264 people were referred by the Occupational Therapy Team for DFG funding, which saw an increase of 125 people from the previous year 13/14. In the period of 2015 / 16 118 people received grant funding, with a further 285 people applying for funding.

 

Following the re-categorization of the Fair Access to Care in 2015, and the definitions of the four need areas (Critical, Substantial, Medium and Low) to (High, Significant and Low), the current waiting times from the point of receiving the Occupational Therapist Referral is as follows:

 

  • High: from start to finish, depending on the results of the means test, this can take up to 16 weeks to complete
  • Significant: from start to finish, depending on the results of the means test, this can take up to 16 weeks to complete
  • Low: Generally these cases are not undertaken as they are superseded by High and Significant Cases

 

The maximum grant available is £30,000 and unless the applicant is on a passporting benefit, each applicant is subject to a means test.  This statutory grant provides major adaptations to be made to an individual’s home enabling them to remain living as independently as possible in their own home.  Some examples of the types of work which can be undertaken include:

 

  • Facilitating access in and out of the dwelling by widening doors, levelling thresholds and installing ramps.
  • Facilitating access to the living room and kitchen.
  • Facilitating access to the bedroom, toilet, washbasin and bath (and/or shower) facilities; for example, by installing a stair lift or providing a downstairs bedroom and bathroom.
  • Improving or providing a heating system in the home that’s suitable for the needs of the disabled person.

 

The grant works are vital to enabling people to remain at home rather than move into residential or nursing homes which may not be appropriate to their needs and removing pressures from Adult Social Care Funding.

 

Landlords forum & newsletter

A landlords' forum is organised at the Bedford Corn Exchange on a bi annual basis to provide advice and support about the new additional licensing scheme with updates on current issues including how to comply with the law.  It is usually well attended with over 75 landlords. Guest speakers are also invited to give specialist talks and advice on current topics for example the Green Deal, a government initiative to encourage new green technologies to be installed and paid for through energy bills.  The seventh forum took place on the 9th June 2016.

 

A newsletter is also produced with the first issue distributed in December 2013.  The newsletter is intended to sit alongside the forum and keep those landlords who cannot attend updated. http://www.bedford.gov.uk/housing/houses_in_multiple_occupation/additional_licensing_of_hmos/landlords_forum.aspx

 

Anti-social behaviour (ASB)  forum

The Environmental Health and Trading standards team work closely with the Bedford Anti Social Behaviour Forum, with members from the police and community services, mental health teams and housing associations working together to support vulnerable victims of ASB.  A key role is to work with landlords to manage any problems identified with Tenants causing ASB.

 

Housing Needs of Residents Approaching the Council

Housing Options Service

A significant number of residents approach the Council each year with a specific housing need.  Bedford Borough Council works with BPHA in maintaining a housing register and operates a choice based lettings system for social housing.  There are currently 1037 people on the housing register seeking permanent accommodation.

Some residents require assistance with securing accommodation and approach the Council for help.  The table below shows the number of face to face contacts with the Housing Needs service over the last 5 years

Figure 8: Housing Options Service Customer Contacts

 

Housing Options Service Customer Contacts

Year

11-12

12-13

13-14

14/15

15/16

Total approaches to the Housing Options Service

4121

3081

2728

2883

3274

 

Source: Bedford Borough Council Housing Needs Service

 

Of these approaches, many are down to a person being homeless or at risk of homelessness.  The table below shows the number of homelessness decisions made by the Housing Needs service over the past 5 years. 

Figure 9: Housing Options Homelessness Decisions

 

Statutory Homelessness Decisions

 11-12

12-13 

13-14 

 

14-15

15/16

- Accepted

211

242

174

164

292

- Intentional

35

31

32

40

53

- Non priority

14

15

27

37

50

- Not homeless or threatened with

75

64

51

121

130

- Ineligible

2

1

2

4

4

Total

337

353

286

366

529

 

A key function of the Housing Needs Service is to prevent homelessness where possible through the use of spend to save initiatives or assisting individuals to access properties in the private sector.  Below is a table showing the success of this over the last 5 years.

Figure 10: Homelessness Prevention

Homelessness Prevention

Year

11-12

12-13

13-14

14-15

15-16

Total number of preventions

331

207

209

230

232

Able to remain in current home

125

68

51

51

53

Assisted to secure alternative accommodation*

204

135

149

163

173

*of which were supported into a Rent Deposit Scheme tenancy

50

59

77

73

42

Homelessness relieved (following an adverse statutory decision being issued)

2

4

9

16

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source: Bedford Borough Council Housing Needs Service

 

In addition to this the House of Industry (a local charity) funds a court desk to assist with legal cases.  In 2013-14 the Court Desk prevented homelessness for an additional 97 households. 

 The Citizens Advice Bureau also assists in the prevention of homelessness.  In 2013-14 the CAB debt advice service dealt with 147 cases where homelessness was threatened.

Rough Sleeping

Rough sleeping refers to people sleeping in the open air, or in buildings or places not designed for habitation.  Using the snapshot date of the 13th of November 2014, Bedford Borough Council conducted its own annual Rough Sleeper Evaluation in partnership with Bedford based agencies and organisations that work locally with socially disadvantaged people.

The Estimate methodology requires a robust verification process which showed that 25 people were sleeping rough on that night; this compares to previous year’s estimate figures as follows:

 

Figure 11: Rough sleeper estimate

 

Year

2011

2012

2013

2014

2015

2016

Estimated Figure

17

19

26

25

51

59

Source: Bedford Borough Housing Needs Service

There has been a substantial increase in rough sleeping in Bedford in the last two years.  In 2015 Bedford was one of the ten local authorities with the largest numbers of rough sleepers. ‘No Second Night Out’ (NSNO) funding arrangements which were implemented in Bedford in May 2013.  The funding secured the Street Outreach Service and Reconnection Service provided by Noah Enterprise.  In total 153 individuals supported into housing as a result of the NSNO initiative.  57 individuals were identified who do not have a local connection to Bedford of which 35 were reconnected to their home area and others found appropriate housing solutions. The funding for the Street Outreach Service came to an end on 31st December 2014 and the Reconnection Services ended on 31st March 2015. 

 

Supported Housing 

Tenancy failure and social isolation can result in significant increases in the number of presentations to health and social care services 28.  They can also increase a person’s vulnerability to developing long term conditions particularly amongst the older population 29  With more than 75% of the older population owning their own home and 51% of the over 75’s living alone30 this is an increasing issue which has significant potential to impact on health and social care services. 

At any one time, the Council is supporting 1266 people to gain or maintain their accommodation.  In the calendar year of 2015,  1488 individuals were assisted in one of the contracted housing related support services in Bedford, the majority of which were older people.  More than £ 2.5 million is invested in these services each year by the Council.  These services are invaluable in terms of reducing social isolation, early identification and intervention preventing more acute needs arising and maintaining a person’s level of independence.

The table below shows the number of units of accommodation available for individuals with a housing related support need.


Figure 12: Accommodation with housing related support

Client Group

No of Units

Floating Support

140

Extra Care/Frail Elderly

214 

Traditional On Site Warden

103

Older Peoples Community Living with Flexible Support

530

Older Peoples Floating Support

88

Offenders

24

Physical and Sensory Impairment

64

Learning Disabilities 

54

Mental Health

27

Single Homeless and Rough Sleepers

92

Young People at Risk

55

Teenage Parents

14

Domestic Abuse

97

Total number of units

1502

 

Source: Bedford Borough Council Supporting People Service

Data is collected from individuals leaving a service, except for older persons services.  The table below gives a breakdown of the types of service and the number of clients that went into them in 2013/14.

 

Figure 13: Types of support service

 

Service Type

Number recorded

Homeless Hostel (including Mental Health hostels)

106

Rough Sleeper services

85

Domestic Violence services (refuges & IDVA service)

197

Young Person services (including Teenage Parents)

88

Floating Support (generic & specialist)

172

Offender services

12

Learning Disability services

4

Physical Disability services

1

Sensory services

12

Mental Health services

6

Source: CRF data 2013/14

Gypsies and Travellers

Gypsies and Travellers suffer some of the poorest health and education outcomes in the UK today.  From long running research undertaken by the Ormiston Trust Gypsies and Travellers have:

  • Low access to preventative health services – often due to lack of a settled address
  • Life Expectancy around 50 compared to 78 in the settled community
  • Infant mortality 7 to 12 times higher than the settled community

 

Gypsy and Traveller children are those most at risk within the education system.  OFSTED suggests that up to 10, 000 Travelling children nationally are not even registered with a school

These facts highlight some of the significant issues faced by the Gypsy and Traveller community.  Engaging with the community can be challenging due to mistrust of those in positions of authority by the Community as well as misconceptions still held by statutory providers. 

The Council owns and manages two permanent sites for members of the Gypsy and Traveller community.  These are Kempston Hardwick – 22 plots and Willow Drift – 14 plots.  The Council is one of the few in England and Wales to have used HCA funding in recent years to extend its provision of Traveller sites through the provision of six new pitches at Kempston Hardwick (bringing the total to 22) and the new site at Willow Drift. The new site is operated in conjunction with a residents association which offers the opportunity for a more meaningful engagement by the community with Health and Education services.

 There are no permanent private sites in Bedford. The Gypsy and Traveller Accommodation Assessment 2012 found that this met the need for sites in Bedford to 2021. There are periodically unauthorised encampments and unauthorised developments. A new assessment is being carried out as part of the preparation for the Local Plan to 2035. 

 

What is this telling us?

 

The Marmot Review: Fair Society, Healthy Lives 2010 states that health inequalities result from social inequalities and that action on health inequalities requires action across all the social determinants of health, including housing.  Creating a fairer society is fundamental to improving the health of the whole population and ensuring a fairer distribution of good health.  Inequalities in health arise because of inequalities in society – in the conditions in which people are born, grow, live, work, and age. So close is the link between particular social and economic features of society and the distribution of health among the population, that the magnitude of health inequalities is a good marker of progress towards creating a fairer society.

 

The Review contains objectives relating to housing and health

 

  • Develop common policies to reduce the scale and impact of climate change and health inequalities
  • Improve community capital and reduce social isolation across the social gradient.

 

Further to these objectives the review recommends prioritising policies and interventions that reduce both health inequalities and mitigate climate change, by:

 

  • Improving active travel across the social gradient
  • Improving the availability of good quality open and green spaces across the social gradient
  • Improving the food environment in local areas across the social gradient
  • Improving energy efficiency of housing across the social gradient.

 

It further recommends the full integration of planning, transport, housing, environmental and health systems to address the social determinants of health in each locality and support for locally developed and evidence based community regeneration programmes that remove barriers to community participation and action and reduce social isolation.

 

There is a need to address excess cold and fuel poverty both through the provision of improved advice and referral systems and through the provision of energy efficiency measures. The Landlords and tenants in particular may be unaware of the options available to them to improve thermal efficiency and reduce excess cold.    

 

For those over 75yrs there is an increased risk of excess winter death with a higher risk for females. Over 65yr olds are also the second highest category of age group to be more likely to have a category 1 hazard in their home which could increase the risk of hip fracture.

 

Applying the Decent Homes Standard, overall non decency rates differ little between White British heads of households (24.4%) and Black & Ethnic Minority (BME) heads of households (23.7%).  BME households had the highest levels of disrepair and thermal comfort failure whilst White British households had higher rates of category 1 hazards.

 

16-24 year olds are more likely to live in properties with thermal comfort failure (25.4%).

 

 Income inequality and housing affordability are key determinants of housing careers and consequently of the health outcomes that are linked to housing.  There is a continuing shortage of housing of all tenures and a need to address affordability. The worsening of affordability puts great pressure on household budgets and leads to households living in unsuitable housing that does not support their health and well-being.

 

There is a continuing shortage of social housing and private rented sector housing that is accessible to people on low incomes. Reductions in funding for affordable housing and changes to the planning system are reducing the supply of affordable housing.  Households dependent on Housing Benefit are struggling to secure accommodation in the Private Rented Sector. There is a reduction in the number of properties available within Local Housing Allowance rates. This invariably means that properties available to those in receipt of Benefits will be those with a lower market value and in areas of higher deprivation.

 

The impact of welfare reform has not been fully seen yet.  It is important to consider what trends may be developing due to welfare reform that may impact on a person’s independence and health.

 

Although it is early into the scheme there are approximately 1000 HMOs not yet licensed through the additional licensing scheme.

 

Landlords and tenants may leave their properties in disrepair thereby increasing the likelihood of falls.

 

There is a lack of appropriate accommodation with a high level of support for homeless people with complex needs who are unable to sustain tenancies and are in many cases excluded from hostels. It is clear that rehousing alone will not provide solutions for the majority of those who are rough sleeping and who have complex issues. The lack of a Complex Needs Housing Unit, the main aim of which will be to equip rough sleepers with the life skills for sustainable independent living and assist them with access to good quality housing, is a contributing factor to the reason we have a significant number of long term rough sleepers. This is being addressed through the development of a Complex Needs Scheme which is under construction and due for completion in December 2017.

 

 It is important to maintain the assessment and early intervention for people new to the streets to support the reduction in short term rough sleepers and the prevention of people becoming entrenched into a life style of rough sleeping. Bedford Borough Council will use the annual snapshot information to engage further with local agencies to tailor services to the individual needs of rough sleepers. The ending of the NSNO funding has had an impact on our ability to provide: 

 

  • Street Outreach Services
  • Reconnection Services
  • Assistance to access private sector tenancies

 

The funding for the Street Outreach Service came to an end on 31st December 2014 and The Reconnection Services ended on 31st March 2015. 

There is a continuing need to improve the accessibility of housing and its suitability for people with disabilities.

A range of housing related to care and support needs is required as well as improved domiciliary services.

One focus of the Care Act 2014 is information advice and advocacy services. There is a knowledge network in Bedford and ongoing work to improve that network. This includes departments within the Council, GP services and other health services organisations and voluntary organisations. There is an active proposal to develop a Lifestyle Hub. This proposal is being brought forward by the Council but will be based in the hospital. Independent advice and information is offered by Age Concern, the CAB, Carers In Bedfordshire, the Alzheimers Society, and the Tibbs Dementia Foundation.

Work is in progress to review the information and advice offered, identify gaps and possible areas for improvement. It is important that access to advice on housing and appropriate referral strategies is included within that.

There is a recognised need for a channel shift which will include improved IT and better on-line advice and information.

 

Recommendations

Develop a Mental Health Housing and Referral Pathway with the East London Foundation Trust, focusing on homelessness prevention and early intervention.

To assess the feasibility of a pilot healthy homes initiative in Bedford to target the most vulnerable areas and/or individuals to help prevent excess cold within 2017/18.

To develop the Care and Support Accommodation Strategy to identify opportunities for more effective services and more cost effective delivery of services as below.

  • People with Learning Disabilities – Adopt the Learning Disabilities Accommodation Strategy in 2016/17
  • People with Mental Health issues –Complete the Mental Health Accommodation Strategy which is in preparation with a view to consultation and adoption in 2017/18
  • Older People - The Older Persons Accommodation Strategy 2011-16 requires updating which will be carried out in 2017-19
  • People with Physical Disabilities – A Physical Disabilities Accommodation Strategy will be developed in 2017-19

 

To maintain co-ordination linking accommodation needs related to the provision of health and care services with the development opportunities that may be available through 2017/18

To develop an Existing Homes Housing Strategy to bring together the Council’s work on improving the condition of the existing housing stock; draft to be developed in 2017/18.

To encourage and support landlords to help their tenants become more energy efficient through holding a landlord forum in 2017/18

To participate in the Bedford 2020 process to promote better on-line advice and information, review the information and advice offered, identify gaps and possible areas for improvement.

 

References:

1.     World Health Organisation http://www.euro.who.int/en/health-topics/environment-and-health/Housing-and-health 

2.     Parliamentary Office of Science and Technology published a document on housing and health in January 2011 http://www.parliament.uk/documents/post/postpn_371-housing_health_h.pdf (Accessed 16th December 2014)

 

3.     World Health Organisation: The World Health Report – Research for Universal Health Coverage 2013 http://apps.who.int/iris/bitstream/10665/85761/2/9789240690837_eng.pdf (Accessed 16th December 2014) 

4.     Department for Communities and Local Government: Live Table 104 Dwelling Stock by tenure: England https://www.gov.uk/government/statistical-data-sets/live-tables-on-dwelling-stock-including-vacants (Accessed 16th December 2014)

5.     Bedford Borough Statistical Profile – Housing and Households June 2014

6.     Bedford Borough Council: Income and Benefits http://www.bedford.gov.uk/health_and_social_care/bedford_borough_jsna/wider_determinants/employment_and_income/income_and_benefits.aspx (Accessed 16th December 2014)

7.     Bedford Borough Council: Population Estimates and Forecasts http://www.bedford.gov.uk/council_and_democracy/statistics_and_census/population_estimates.aspx  (Accessed 16th December 2014)

8.     Bedford Borough Council, July 2011, Private Sector House Condition Survey  http://www.bedford.gov.uk/housing.aspx  (Accessed 16th December 2014)

9.     ODPM 2003 Statistical evidence to support the housing health and safety rating system volumes I.II and II ODPM London.

10.  Public Health England (2013).  Excess winter mortality report 2012 to 2013.  https://www.gov.uk/government/publications/excess-winter-mortality-2012-to-2013  Accessed 10th March 2014)

11.  The Marmot Review Team (2010).  Fair Society Healthy Lives.  Strategic review of health inequalities post-2010.  http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review  (Accessed 10th March 2014)

12.  David Buck and Sarah Gregory (2013).  Improving the public’s health.  A resource for local authorities.  http://www.kingsfund.org.uk/publications/improving-publics-health  (Accessed 10th March 2014)

 

13.  Department of Energy and Climate Change (2013).  Fuel poverty methodology handbook 2013.  https://www.gov.uk/government/publications/fuel-poverty-methodology-handbook-2013  (Accessed 11th March 2014)

14.  Department of Energy and Climate Change (2013).  The fuel poverty statistics methodology and user manual.  https://www.gov.uk/government/publications/fuel-poverty-methodology-handbook-2013 (Accessed 7th July 2014)

15.  Department of Energy and Climate Change (2014).  Annual fuel poverty statistics report, 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/319280/Fuel_Poverty_Report_Final.pdf  (Accessed 7th July 2014)

16.  Department of Energy and Climate Change.  Fuel poverty statistics.  https://www.gov.uk/government/collections/fuel-poverty-statistics#2012-statistics  (Accessed 20th October 2014)

17.  Keatinge, W.R., Donaldson, G.C., Bucher, K., Jendritsky, G. & al, e. 1997, "Cold exposure and winter mortality from ischaemic heart disease, cerebrovascular disease, respiratory disease, and all causes in warm and cold regions of Europe", The Lancet, vol. 349, no. 9062, pp. 1341-6.

18.  Department for Communities & Local Government: English Housing Survey Headline Report 2011-12. https://www.gov.uk/government/collections/english-housing-survey#2011-to-2012

19.  Bedford Borough Council, October 2012, Consultation on a new HMO (Houses in Multiple Occupation) licensing scheme in Bedford. 

20.  House of Commons Energy and Climate Change Committee: The Green Deal: watching brief (part 2) http://www.publications.parliament.uk/pa/cm201415/cmselect/cmenergy/348/348.pdf (Accessed 16th December 2014)

21.  Department for Communities & Local Government: Live Table 1008: additional affordable homes provided by local authority area https://www.gov.uk/government/statistical-data-sets/live-tables-on-affordable-housing-supply

(Accessed 17th December 2014)

 

22.  Department for Communities & Local Government: Statutory Homelessness January to March Quarter 2014 England (Revised) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/339003/Statutory_Homelessness_1st_Quarter__Jan_-_March__2014_England_20140729.pdf  (Accessed 17th December 2014)

23.  Gov.UK: Homelessness Statistics https://www.gov.uk/government/collections/homelessness-statistics (Accessed 17th December 2014)

24.  Steward J. L. Effective Strategies and interventions:  Environmental Health and the private housing sector, University of Greenwich March 2013 CIEH p36-37

25.  Independent Inquiry into Inequalities in Health Report, Sir Donald Acheson, 1996 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/265503/ih.pdf (Accessed 28th January 2015)

26.  Department of Health (2007) Implementation Plan for Reducing Health Inequalities in Infant Mortality.(Accessed 28th January 2015

27.  Quantifying the cost of poor housing, BRE. http://www.bre.co.uk/page.jsp?id=2369 (Accessed 28th January 2015)

28.  The Creativity and Aging Study: The Impact of Professionally Conducted Cultural Programs on Older Adults – Cohen 2006 http://artshealthnetwork.ca/resources/creativity-and-aging-study-impact-professionally-conducted-cultural-programs-older-adults-?page=28

(Accessed 28th January 2015)

29.  Social Relationships and Mortality Risk: A Meta-analytic Review – Holt-Lunstad 2010 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910600/ 

(Accessed 28th January 2015)

30.  Office of National Statistics  http://www.ons.gov.uk/ons/index.html   (Accessed 28th January 2015)

 

 

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