Knowsley Healthy Homes Initiative

The overall aim of the initiative is to take a proactive and preventative approach to tackling housing and health related issues within the borough. By facilitating access to existing support services for those currently not engaged, the initiative will encourage residents to be healthier, more financially secure, able to work, and to look after themselves and their properties. In the long term this is intended to lower demand for more reactive council and wider public services including environmental health, social care, healthcare, the police and fire service.

• The initiative aims to make improvements in the following areas:
• Housing condition (including excess cold, damp, mould, pests).
• Energy efficiency and fuel poverty.
• Income maximisation and employment advice (inc. employment, training and skills, benefits, pensions, debt advice).
• Home safety (including preventing falls, trips, fire hazard, CO poisoning, child and elderly safety e.g. dementia patients).
• Access to health care (including doctors, dentists, community health services, management of long term conditions).
• Access to lifestyle services (including smoking cessation, drug/alcohol treatment services, healthy eating advice, exercise, mental wellbeing).
• Early help (inc. children's centres, support for older people).
• Safeguarding (including child and adult safeguarding, risk of homelessness and domestic abuse).

The initiative will be area-based and will visit up to 50% of households in the borough. The team will visit all properties regardless of tenure; however, referral pathways may differ depending on the tenure of the property visited. The team of five advocates started in September 2014 and it is anticipated that they will deliver the following outputs over the next two years:
- Number of addresses visited per year = 16,000 (32,000 in two years)
- Number of advocate surveys completed = 3,600 (7,200 in two years)
- Number of referrals generated to identified services = 4,824 (9,648 in two years).

There is an established evidence base demonstrating the links between housing and health. Hazards in the home, including excess cold, are implicated nationally in up to 50,000 deaths a year and 0.5 million injuries and illnesses. Housing also provides a setting for unhealthy lifestyle choices (e.g. drug and alcohol use, smoking and poor diet); for inequality and deprivation (e.g. debt and fuel poverty) and other harms including domestic violence and social isolation.

Significant work has been ongoing within Knowsley to ensure that housing standards across all tenures are as high as possible. However, serious hazards such as excess cold are still present in 18% of Knowsley homes.

In 2012, the Public Health Team conducted an evidence review to identify Council activities most likely to have significant impact on health outcomes whilst being highly cost effective. Housing was identified as a priority area, and more specifically a co-ordinated programme to tackle housing issues including:

• Identifying vulnerable residents and introducing a signposting service
• Routine undertaking of Housing Health and Safety Rating System (Government standard used to assess risk from housing condition)
• Preventing injury in the home through home safety assessment
• Improvements in energy efficiency and affordable warmth, linking to benefits.

This approach has been advocated in a wide range of best practice resources and aligns with a number of indicators in the Public Health Outcomes Framework. Evidence from a similar initiative in Liverpool also suggests that total savings generated over 10 years was likely to exceed £50 million to the public purse and wider society. During the development of Healthy Homes and in order to target the initiative effectively, a data model was developed. This was based on a range of indicators designed to identify residents at risk from poor housing condition, those most likely to suffer ill health resulting from poor housing, and those on low incomes. The chosen indicators included private rented properties, lone parent families, elderly residents and residents in receipt of benefits. Forty five Lower Super Output Areas (LSOAs) containing 31,310 households were identified which exhibit the highest levels of need based on these indicators and the initiative is targeted primarily at these areas.

Healthy Homes operates with a budget of approximately £470,000 a year funded solely by public health. In kind contributions from Merseyside Fire and Rescue Service include a staff member seconded to the advocate team. The budget covers staff costs for the team of nine. The five advocates are managed by a neighbourhood co-ordinator with support provided by a project support assistant. Two additional posts are also funded through the initiative within the council's housing and environmental health teams in order to undertake the additional work generated through the referrals. A budget for capital items including housing improvements and home safety equipment for particularly vulnerable residents identified through the service is also included; and external funding to provide additional services and benefits for vulnerable residents is being sought in order to maximise the potential impact of the initiative.

Development of Healthy Homes took approximately 10 months. Particular challenges have involved developing relationships with partner services to ensure they have the capacity to deal with the referrals generated by the initiative. In some instances Healthy Homes has funded additional capacity in a number of services in order to deal with referrals, particularly in relation to housing condition as outlined above.

The development of a bespoke IT system for the recording of survey data and the automatic generation of referrals, in the short term has involved a large amount of work to enable it to function effectively; however, in the long term it will significantly increase the efficiency of the initiative.

Although Healthy Homes is in the early stages of delivery (the team started on site in September 2014) results so far have been promising including identification of a number of extremely vulnerable adults with acute needs, which are now being addressed.

In five different LSOAs, over 5500 properties have been contacted by advocates and a total of 327 interviews have been completed. In addition an extra 105 surveys have been completed outside the specified work schedule creating in total over 1300 referrals. The interview success rate is an average of 10% and rising. For every one survey that is undertaken, three referrals are generated.

Main referrals services have been:

• Merseyside Fire and Rescue Service: 275 referrals
• Merseyside Police: 176
• Environmental Health and Strategic Housing: 172
• Energy Efficiency Advise & Action: 167
• Community Messaging: 122
• Health Trainers: 81
• Debt advice: 71

As of February 2015, the initiative has brought in £50,000 in projected new benefits to participating residents, and helped residents deal with £28,000 of debt, mainly via debt plans and debt re-organisation. Feedback from the referral agencies, partners and residents have been positive. The wider evaluation is ongoing and will work towards qualifying outcomes in relation to all the above referrals.

A robust evaluation framework has been developed by the Council's Policy Impact and Intelligence Team to capture the outputs from the team of advocates. In addition, discussion with partners has been ongoing to enable collection of outcomes generated as a result of any referrals, including the application of 'social return on investment'-type models which will consider the potential financial gains and those in relation to social value and wellbeing.

• Ensure that all partner services are engaged, that they understand the issues and the wider context, and have the capacity to deal with estimated referrals generated. If there is no capacity, consider how this could be provided through the programme.
• Invest time in community engagement and communication with elected members and community champions to ensure that residents are aware of the programme and more likely to be receptive to the service once it arrives in a new area.
• Ensure enough time to develop and rigorously test IT systems before the programme commences, to ensure that the correct data is collected and automated referral pathways are effective.
• Undertake regular meetings with partner services and focus groups with residents to ensure the service is working as well as it can be and to inform a robust evaluation.
• In developing the team of advocates; it has been extremely beneficial having staff with a wide range of differing backgrounds, particularly regarding public services and understanding of community led services. This has made training of the team much easier and naturally removes potential barriers when they connect and engage with partners and the local community.