Community Practitioners' and Health Visitors' Association

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Response to the Green Paper on Housing - 'Quality and Choice: a decent home for all'

CPHVA members are health visitors and other community nurses who, in the course of their work, visit families and single people at home - regardless of tenure, type of property or income. They are in an excellent position to observe the profound effect on physical and mental health of the poor condition of the existing housing stock which is highlighted in this Green Paper.

Members grapple daily with the complexities of finding innovative ways of working effectively with local authority housing and environmental health departments in order to act both as an advocate for their clients and to influence local government housing policy. For this reason, the CPHVA welcomes Quality and Choice: a decent home for all. The development of Health Improvement Programmes and Primary Care Trusts presents an opportunity for partnership work and the identification of health need in formulating local housing strategies (Chapter 3). However, lack of coterminosity with local government boundaries, particularly those that are not unitary authorities, may be a barrier to effective outcomes.

This response is focussed upon the practical experience and research of members. We regret the omission of any mention of children either in the section headed The Active Management and Prevention of Homelessness (Para 9.60-9.65) or in Chapter 12, Tackling Other Forms of Housing-related Social Exclusion.

CPHVA is particularly concerned about the long term emotional and mental health effects to families with children during a period of homelessness. This is exacerbated by enforced mobility and the subsequent lack of choice in area, type or fitness of the property when a permanent offer is made. We would suggest that any audit of homelessness includes: the number and ages of children - from birth to 18 years; the number of moves made during the period of homelessness; the type of property used for placement; and the number of families with children placed in another District or Borough Council area. This would give some indication of the potential exclusion from access to pre-school play facilities, disruption of education, and severance from social support and trusted health professionals at a time when families are likely to be overwhelmed by the distress of life events beyond their control.

In relation to chapter 12, because of the nature of their work with children - from the ante-natal period, throughout infancy, childhood and school education - members of the CPHVA are concerned that preventive projects funded by other government departments - such as, Sure Start, Health Action Zones, Education Action Zones and Teenage Pregnancy - may not be effectively delivered with measurable outcomes unless there is a sensitive awareness of the housing needs of children. This includes having a settled home that meets minimum standards for habitation, designed to take account of the need for the storage of equipment and adequate space for play in the internal and external environment.

  • Members of the Special Interest Group on Homelessness Housing and Health have conducted research which illustrates the enormity of the task. For example, the findings of a survey of the health and living conditions of homeless families highlighted four issues:

  • The emotional distress of adults

  • The effects on the healthy development of children arising from a lack of safe play space

  • Matters relating to food and eating, for example, little or no facilities for the storage, preparation and cooking of food

  • The professional assessment of the interviewing health visitors that 85% of the families were living in a very unsafe and unhealthy environment. (Vickers et al 1990)

  • In a subsequent exploration of why female-headed households turn down the permanent offer of housing four themes were identified:

  • Concern about the fitness of the property

  • The design of the internal and external environment

  • Longing for a settled home after periods of enforced mobility

  • Confusion about the implementation of constantly changing allocation policies

It was found that this confusion was mirrored by the key informants, who spoke eloquently about the privations which a woman and her children may suffer at the time of allocation. The indications are that restrictions on choice and the poor condition of some of the housing stock may mean that a woman might feel compelled to accept an offer which does not meet minimum standards of fitness in an area where she does not want to live. Or she might refuse the offer and suffer any penalties imposed by a local authority as a result. (Vickers 1998)

Other research on the long term effects of homelessness and poor housing on families, and particularly on children, is well documented (for example Ambrose 1996 and Collard 1996). Vostanis et al (1998) compared homeless families to low income but domiciled families. The study found that homeless mothers had significantly higher rates of mental health problems (48%) and children were more likely (29%) to have mental health problems - including behavioural and emotional difficulties - of a severity to require referral for treatment. The children were also significantly delayed in communications skills. It is therefore a serious omission that chapter 12 does not include the prevention of family homelessness. Health visitors and school health nurses are working with a generation of children who may never have known what it is to have a settled home.

CPHVA members who have a special interest in housing and homelessness are working with projects in urban and rural areas throughout England. They welcome the opportunity presented by the proposals in the Green Paper to be actively involved in the development of local housing strategies. The reality is that the cultural gulf between housing enablers, providers, enforcers and health professionals is very profound. Some consideration must be given to joint education and training so that effective partnerships can be developed to enhance the possibility for everyone to live in a safe and healthy home throughout their lifetime.

In relation to Improving Housing Benefit (chapter 11), we assume that responses from others will fully cover this matter, in particular the restrictions on payment for young people. The CPHVA would welcome any proposals to improve the administration of Housing Benefit. It is unacceptable that individuals and families are evicted due to rent arrears arising from delays in payment by local authorities. In some areas this has resulted in families with children being classed as intentionally homeless, with the consequent penalties, restrictions and indignities which they then suffer in searching for a permanent home with security of tenure.

The CPHVA welcomes the additional funding for housing renewal announced in the comprehensive spending review. However, a licensing scheme for houses in multiple occupation (para 5.30) is urgently needed to address the worst conditions in the private rented sector.

In relation to Catering for a range of housing needs (para 8.6). It is rarely acknowledged that most people are ill at home and not in hospital. It is therefore not only "people with special needs who may require ..... appropriate support in order to live in it successfully" (pg 71). Changes already implemented in the NHS has meant that comprehensive packages of acute nursing care are being delivered to children and adults in their homes. This ranges from seriously ill new-born babies to children with complex, long-term health conditions and people of all ages with terminal illnesses who are dying at home. In addition to this, the expectation is that admission to hospital, even for major surgery, will be for a very short period of time. In some cases this is a matter of hours. The responsibility for continuing nursing care is then transferred to community paediatric and district nurses. Every home should be designed so that it is fit for this purpose, including consideration of the health and safety of community nurses for whom the homes where people live are their places of work.

The CPHVA looks forward to the implementation of the new fitness standard (para 5.28) which may begin to identify the need for urgent action on all aspects of health and safety in the existing housing stock.

The final matter to which members have drawn attention in relation to quality, choice and design are upper-floor flats and maisonettes without either controlled entry or lifts. These are not acceptable as suitable homes for the following reasons. Parents with small children are daily faced with the dilemma of whether to leave the baby, the toddler or the shopping at the bottom of an open stairway. People whose mobility is compromised or who suffer sensory impairment or serious debilitating illness have the same problems. Level access, turning space, wide doors and lifts are required for prams and pushchairs as well as for wheelchairs. These facilities could be incorporated into the design of flats where land space is at a premium. Consideration of these matters could potentially eliminate the need for priority rehousing on health grounds.

n conclusion, the CPHVA welcomes Quality and Choice: a decent home for all, but fears that there are potential barriers to effective action because all organisations, including health professionals, may find it safer to deal piecemeal with the issues rather than adopt an holistic approach which involves the active participation of local communities in strategic planning. Some suggestions which we consider crucial to the success of the proposals are:

Joint education and training for housing enablers and providers, environmental health officers, health and social services professionals and the voluntary sector

In order to enhance the assessment of housing need.

Consideration of the needs of children in all matters related to housing and homelessness

The design of homes, new or refurbished, which offer flexible and safe accommodation for people to be ill or healthy in throughout a lifetime.

The Community Practitioners’ and Health Visitors’ Association would be glad to be included in any further consultation about the development or implementation of policy.


AMBROSE, P (1996) ‘I mustn’t laugh too much’ Housing and Health on the Limehouse Fields and Ocean Estates in Stepney. Centre for Urban and Regional Research, Sussex University.

COLLARD, A (1996) The Resettlement Needs of Homeless Families, 2: Case Studies. Unpublished Draft.

VICKERS, M, COPLEY, J and KEEBLE, B (1990) Interim Report of an Investigation into the Health and Living Conditions of Homeless Families in Oxford City. Report to Oxford City Council Housing Committee. September 1990.

VICKERS, M (1998) Housing Allocations: Women Who Say No! Dissertation submitted in part fulfilment of the regulations for the MSc in Housing Studies. Oxford Brookes University School of Planning.

VOSTANIS, P, CUMELLA, S, GRATTON, E and WINCHESTER, C (1998) The Impact of Homelessness on the Mental Health of Children and Families. Department of Psychiatry, University of Birmingham.

02nd August 2000