Our house

The NHS Alliance recently produced a briefing paper for the Housing Learning Improvement Network entitled Breaking Boundaries: reinventing primary care. It championed the idea that housing organisations can play important roles in delivering high quality primary care services. If they are to play those roles effectively, they need to have insights into current and emerging developments and to be invited to help shape the primary care service of the future.

These views are not based on vague ideas, but on actual examples in which housing and health are starting to work together – often with the express aim of reducing demand on GPs, out of hours care and A&E. Early evaluations are promising. A pilot scheme, in which family doctors in Sunderland prescribe double glazing, boilers and loft insulation for patients living in cold, damp homes, has reduced the number of GP and outpatient visits by a third in a six month period compared with a control group. These households are also saving £30 per month on their heating bills. However, this is not the first time GPs have prescribed home improvements insulation – Liverpool-based Dr Majeed has been doing it for some time through a version of social prescribing.

What makes these schemes work is a close working relationship with a housing organisation which actually installs the home improvements in homes. Both Gentoo Housing and Sustainability Group in the first example, and Liverpool Home Improvement Agency in the second, are not-for-profit housing organisations for whom organising this sort of home improvement is run-of-the-mill.

It is not only in addressing problems with the fabric of people’s home where housing organisations can play roles. Some examples of housing-health partnerships include:

New Charter (housing) Group and a federation of seven GP practices in Tameside who are co-creating a new way of working with people (patients) over the age of 75. New Charter staff based in each of the seven surgeries work with those who visit their GP frequently as well as visiting those who seldom present and who are therefore at risk of needing costly, emergency hospital-based treatment. They work with both groups in a holistic, person-centred way to find non-medical solutions to their difficulties. The project is being evaluated for the cost-savings to the NHS as well as improvements in people’s wellbeing.
South Yorkshire Housing Association, working with other housing providers across the north, is embarking on a new project to train volunteers to become qualified in assessing and inspecting health and care provision and shaping the future of care services. This is a three year pilot funded through the Department of Health’s Health and Social Care Volunteering Fund.
The ExtraCare Charitable Trust, which builds and manages housing schemes and villages designed for older people, employs experienced nurses as Health and Wellbeing Advisors. They perform a range of routine tests such as blood pressure, blood sugar levels, cholesterol levels, osteoporosis and diabetes checks to provide residents with information that will enable them to maximise their health and adopt an active lifestyle. Where residents consent, key data is shared with their GPs. They also have a contract with a national pharmacy through which they help to ensure that their residents are taking their medications as prescribed. Given the range of potential impacts, it is surprising that housing continues to be omitted from key national health documents, even those that are driving better ‘integration’. The Five Year Forward View talks about roles for statutory, charity and voluntary organisations but none of these adequately describe ‘housing’. The new Care Act is an exception – it explicitly recognises housing as a health-related function in the task of promoting greater integration between health and care. Hopefully, this will give a much-needed legislative prompt to organisations that are involved in work relating to the Better Care Fund and other health and care transformation programmes.

Here are some stand out facts that might help to put housing on the map in a bigger way:

For most GPs, at least one in 10 of their patients, and in some neighbourhoods as many as one in two in ten, live in a home owned by a council or housing association (which together own and manage around 4.1 million homes, or 17% of Britain’s homes).
Housing organisations have around 2.5 million contacts with their residents every week, compared with one million for GPs.
22% of Britain’s homes fail the Government’s Decent Homes Standard – the large majority being in the private sector.
People over 65 years of age spend over 80% of their time at home and more as they get older.

Many housing organisations have a close, often face-to-face relationship with their residents and other members of the community, and they are capable of promoting people’s health and wellbeing in a variety of ways, including where this is linked to the suitability of people’s homes. This is the premise on which they can support the reinvention of primary care.

The Five Year Forward View talks a lot about prevention. For decades, housing organisations have provided low level support to both their own residents and others living in private homes – just enough to enable them to live independently in their own homes. This was funded through the former Supporting People budget of £1.6 billion. After the ring-fencing of this budget was removed in 2009 there was a gradual withdrawal of these services which, in turn, will have contributed to an increase in GP attendances. Of course there has been some hand-wringing, but many have also been actively exploring ways in which they might reinvent parts of their business in order to support people in different ways – ways that are relevant and useful to health colleagues.

Medicines have their place but good physical and mental health depends on so much more than doctors can provide. As chairman of the NHS Alliance, Dr Michael Dixon said at the recent NHS Alliance Conference: “No more heroes or heroines – as GPs we must now recognise that it’s not all up to us and that it’s no longer all about us. It’s time to let go”. The current trend towards multi-practices, federations, cooperatives and super-practices should provide greater strategic capacity for developing new ways of integrating their work with local partners outside the NHS, including housing partners.

Most GPs understand that housing and housing support services are crucial to patient health but they have few mechanisms to make any difference. At the same time, there is a real danger that the principal NHS response to the Five Year Forward View is to reinvent ‘preventative’ services within the NHS without paying sufficient attention to the preventative work that is already going on, and under threat, beyond the surgery and hospital doors. Regrettably, this is already starting to happen.

Visionary CCGs will take a different approach to working with the myriad of community based partners on their doorstep. They will be keen to adopt a style of leadership that draws on, shapes and co-creates new models. When it comes to housing, this means:

Being open about the type of provider you commission from, recognising they do much more than just managing housing.
Talking to housing. Organisations in your localities about their business, their ambitions and how they can help you to deliver on your priorities.
Encouraging key housing providers to become a part of local integrated primary care teams.
Being prepared to work with them to shape a proposal, rather than making the process of commissioning highly competitive.
Not asking for cast-iron evidence before you commission, but agreeing to evaluate projects as they progress and considering offering your support in drawing up evaluation methodologies you can trust.
Encouraging groups of GP practices to talk to local housing providers to work out ways of dealing with routine housing problems faced by patients.

We have built the capacity to support local initiatives through a new type of project support called NHS Alliance Catalyst.

The NHS Alliance is happy to talk to other commissioners and providers about how you can break these boundaries and offer more comprehensive support to the people we collectively serve.

Clinical commissioners have been entrusted with leading and shaping the future of health. It is within their gift to explore the range of possibilities that housing can offer.

Merron Simpson is special advisor, health and housing, NHS Alliance.