Liverpool Healthy Homes programme: delivering NICE Guideline NG6 'Excess winter deaths and morbidity and the health risks associated with cold homes'

Liverpool’s Healthy Homes programme (HHP) aims to deliver significant sustainable health and housing improvements; to reduce the burden on NHS secondary care by targeting housing deficiencies that cause or exacerbate preventable chronic disease and premature death. Aimed principally at the private rented sector (including Registered Social Landlords), the programme is targeting some of the most vulnerable residents in Liverpool.

The project aims to prevent 100 deaths in homes across Liverpool and 1000 GP referrals.

The HHP is directly aligned to the strategic goals of Liverpool’s Sustainable Communities Strategy 2024, A Thriving International City and the targets set out in the Local Area Agreement.

The Programmes objectives are:

•           to tackle health inequalities, caused by poor quality housing conditions,

•           remove health and safety hazards from homes including excess cold,

•           engage residents on their doorstep and in their own homes, identify and support those most in need in our communities,

•           provide advice; promote health and awareness of the health impacts of poor housing conditions and accidents within the home.

Reflecting the steps recommended to develop an effective strategy in NICE NG6, recommendation 1 and Recommendation 4 regarding the identification of people at risk of ill health from living in a cold home, a baseline assessment was carried out. Research (see http://bit.ly/1kvtzVT ) confirmed that of 148,000 private sector properties in Liverpool: 11,100 lacked central heating; 44,100 were in fuel poverty;  19,400 presented a health and safety risk  the highest risks relate to excess cold, falls, electrical safety and fire;  19,000 homes failed the energy-efficiency requirements of the Decent Homes Standard. The private rented sector accounts for the highest rates of housing hazards (18.7%) and the highest concentration of poorest thermal efficiency.

The Health Poverty Index (HPI) tool allows groups, differentiated by geography and cultural identity, to be analysed in terms of their 'health poverty’. A group's health poverty is a combination of its present state of health together with anticipated health potential or lack of it. This shows that if we compare Liverpool’s health poverty with that of England, there are a number of areas where Liverpool suffers a considerably higher level of health poverty.

 See figure 1 in the supporting material.

With a population of 466,000 Liverpool is the sixth largest city in England and has some of the highest mortality rates and greatest health inequalities in England. The gap in average life expectancy compared to the rest of the UK was around three years (Liverpool male 74.8, UK male 77.9; Liverpool female 79.2, UK female 82). Additionally, life expectancy differs by up to 10 years between the most and least deprived wards of the city. Health statistics at the time of setting up the programme indicate that 27 of Liverpool’s 30 council wards were included in the national pentile of council wards that have the lowest life expectancy at birth and almost 1/4 of the Lower Super Output Areas nationally were to be found in Liverpool.

According to the last Liverpool Private Sector House Condition Survey, the private sector housing stock in the City of Liverpool consists of 148,000 dwellings with a population of 332,000. 

Before the Healthy Homes Programme, Liverpool had no health and housing related policies or strategies. Programmes were based around housing market renewal, area based schemes, and the introduction of The Decent Homes Standard; which lead to the housing stock transfer from the city council to Registered Social Landlords who could borrow to bring homes up to standard.

The programme targeted  those most in need first; we devised a prioritisation matrix using 3 key indicators, years of potential life lost, health deprivation, housing density- rented sector and several sub categories utilising the latest stock condition survey, Indices of Multiple Deprivation and more.

Intervention is the primary activity of the Healthy Homes Programme and the key to engaging with the most vulnerable groups of people suffering the greatest health inequalities within the most deprived households across the city.

In line with the overall target to reduce health inequalities, and to make most effective use of resources, a ‘Healthy Homes Index’ has been created from 14 data sets and when set against the Office of National Statistics Lower Super Output Areas (LSOAs) the index is able to show which of Liverpool’s 291 LSOAs are the highest priority areas.

See figure 2 in the supporting material.

In the first 18 months the worst 2,750 properties were identified and through the programme were inspected by environmental health officers. These officers utilised the Housing Health & Safety Rating Scheme (HHSRS, Housing Act 2004) to robustly enforce and secure the removal of hazardous conditions that adversely affect the health and safety of the occupant.

An Initial pilot was undertaken in the Kensington area of the city, Of the 41 buildings inspected, 82 Category 1 hazards were discovered and removed through robust enforcement action. These included 59% fire, 33% excess cold and 4% domestic hygiene, pests and refuse.

There are many agencies and organisations within the public, private and voluntary sector that exist to help vulnerable people resolve their housing, health and wellbeing issues; however, many of them operate on a reactive basis where potential clients need know who they are, how they can help, how to contact them and then make that initial contact. On this basis there is a potential for some of the people (and most likely those most in need) not to be able to make that contact. The Healthy Homes’ proactive approach helps to address this through its door-to-door survey approach and its ability to raise awareness of the help and support that is available and makes the connection. This is an effective demonstration of steps in NICE NG6 Recommendation 2 which advocates face-to-face contact in an effective referral service.

It is the unique role of the Healthy Homes Programme to find the people who need our help and support and put them in touch with the partners that can make a difference to their lives.

In addition to this, we hold regular stakeholder events where we gather our partners together to discuss better working practices and future available support. This reflects the steps suggested in Recommendation 2 of NICE NG6 regarding the development of service links between local services within an effective referral service. Furthermore, community engagement is undertaken by the Healthy Homes, Health Promotions Team and has proven to be an essential before going to a survey area.  This activity has two essential aspects, firstly it enables us to advise the relevant people, community groups and organisations that the area is about to be surveyed and raise awareness within the community and secondly it enables people and organisations to contact us with known issues and enables us to provide a much more effective service.

The Liverpool Healthy Homes Project cost around £1.3m per year in the first years but since Public Health was brought in house under the Liverpool Local Authority 2013 the programme was subject to a 50% cut, as with all departments

Progress is measured through quality assurance with residents, post survey analysis and evaluation, programme activity and health data statistics.

Outcomes are logged on a Northgate system where each case is input and followed through. Any further involvement and actions are then logged onto that properties record. This system can be interrogated and various reports and statistical analyses performed.

In terms of housing health hazards, over 6130 HHSRS inspections have been undertaken as a direct result of referrals from Healthy Homes Advocates and Inbound Referrals received from health professionals. HHSRS inspections have resulted in over 4410 category 1 hazards being identified and removed, this includes 1423 cases of Excess Cold; levering over £5.45m in investment by private sector landlords generated as a result of enforcement action being taken by dedicated Healthy Homes programme funded Environmental Health Officer. 56,202 properties have been visited resulting in 29,012 referrals and 47,248 occupants benefitting from these referrals.

See figure 3 in the supporting material.

The 4410 category 1 hazards identified and removed; this includes 1423 cases of excess cold.

See figure 4 in the supporting material.

Advocate partner referrals breakdown since beginning of the Liverpool Healthy Homes Programme to 2015.

Various unexpected results arose from the programme ranging from the level of direct investment into the improvements of properties; to the British Research Establishment (BRE) estimated cost savings of the removal of excess cold alone; to the health promotion outcomes that included the greatest number of dental registrations than all the other Public Health campaigns and sources combined.

Cost saving from the programme

A BRE Report (2010), (analysing the 3 most commonly identified Cat 1 hazards and 1/5th of the data) indicated that work carried out during the first year of the programme is estimated to save the NHS in the region of £439,405 per year, from this point onwards. Over a 10-year period these could be extrapolated to an approximate saving of £4.4m.

The wider benefits to society have also been calculated as approximately two and a half times that of the benefit to the NHS and therefore a saving of an estimated £1.1 million per year.  Over 10 years this would result in a total saving of £11 million. 

BRE carried out a re-assessment of the programme. When the full data set of the first year of the programme was analysed; it indicated a £55 million saving to the NHS and wider society over 10 years. The removal of Excess Cold hazard alone was estimated to save the NHS and wider society £42 million over a 10 year period.

In addition to the savings the programme provides to the NHS and the wider community, there are other consequential effects on the local economy. It is estimated that the improvement work done to properties made as a result of a Healthy Homes intervention is supporting at least 30 construction jobs in the City.

Liverpool’s healthy Homes Programme has been host to numerous other Local authorities who wanted to set up their own Healthy Homes, such as Knowsley, Blackpool and Bournemouth. Furthermore Liverpool Healthy Homes heads up the Healthy Homes Best Practice Group whilst traveling around the country delivering presentations on best practice and securing health funds through dissemination of business case learning.

• Invest time in generating buy in from the services that will benefit from the works, without their support and a varied financial structure; programmes are likely to fail.
• Liaise with elected members to develop relationships and promote the services and collaborative work.
• Regular communication of results to stakeholders is important along with regular meetings to check that the relevant data is being collected for those stakeholders and the correct reporting back can be achieved.
• Be adaptable and forward thinking allowing for changes in priorities and how your programmes can support these new priorities whilst meeting the communities existing needs.
• Develop staff to be able to perform multiple tasks. i.e rather than just having advocates train staff to be case support workers and energy efficiency/ fuel poverty advisors; this generates greater staff buy in to each person who doesn’t just see it as a case.
• Develop simple IT systems that can be updated utilising common Microsoft Office packages in order to limit cost of systems and reduced dependency on expert personnel in particular tailored expensive programmes with license costs and costs to upgrade or alter.