It’s often said that it’s the wider determinants of health, outside the reach of the NHS, that have the greatest impact on a person’s health. With that in mind, one London ICB is laser-focused on the issue of housing. CEO of South East London ICB, Andrew Bland, talked through the work so far with Victoria Vaughan.
Victoria Vaughan (VV): Why did you decide to make housing a focus of your work?
Andrew Bland (AB): When we looked at the biggest impact on people’s wellbeing across South London, and particularly South East London, what came up was employment and housing.
The Building Research Establishment was telling us that poor housing costs the NHS about £1.4 billion per annum.
A bit over half of that – about £850 million – is associated with people entering the health service, essentially, because the fabric of their house leaves them overexposed to the cold. And in winter, that exacerbates other illnesses.
And the second biggest cause was repairs and hazards. For example, people falling in their house because the stairs are not as they should be.
Then there’s the mental health side of things; overcrowding has a mental health impact. Some social prescribing interactions were about kids who couldn’t find anywhere to do their homework, or three or four family members in the same room for a prolonged time because they’re waiting for suitable housing.
The population of London has gone up by about 8% [in a decade] according to the 2021 census. In the same period, the housing stocks went up by about 4.5%. So, we do the maths – there’s less housing per population.
The competition for rentals is high and rents are rising faster than ever before. Housing benefits have been frozen since the 2000s. So, affordability of housing is a problem and the housing cost is driving child poverty.
And we’ve got far less social housing. The natural consequence of that is over 50,000- 60,000 people who are in a homeless household and residing in temporary accommodation arranged by London boroughs.
When you stack all of that together, you can see why people’s mental and physical health would be affected in all sorts of ways.
VV: So, how do you, as an ICB, begin to make an impact on this?
AB: We’ve got shared leadership in each of our boroughs or places. That means for each borough – Lambeth or Southwark, for example – the place lead will report to me as chief executive of the ICB, but also to the chief executive of the local authority. So, we are geared up to have shared decision-making about a whole number of areas.
As the ICB, we spend about £3bn-£4bn a year. We have a siloed public sector budget framework. If we can get to a position where we consider the public sector spending in the round, not only looking at the money spent in the health service in isolation, then, in the end, it’s going to provide us with a return on investment. The neighbourhood bit is a meaningful thing if they spend money in a coordinated way.
We have a health and housing coalition and have had big meetings with citizens across South London. It’s a listening exercise where 12 local authorities and NHS bodies, such as providers and commissioners, are meeting citizens to talk about the things that we might have an impact on.
The reason for the listening exercise, which finishes in October, is that we weren’t sure that we knew what the most impactful things to do were and we haven’t got an awful lot of spare cash to try stuff out without some sense of return investment.
At our first meeting, a respiratory physician from Guys and Thomas’s said that if he could change one thing in his outpatient clinic, it would be doing something about people’s condensation. They can’t afford to leave the windows open in their flats and they’re drying the clothes on the radiator because they don’t have another way of doing it. Mould ensues and then he gets the results of that.
Then, out in the community, social prescribers are saying that 90% of the things they ended up discussing were housing issues.
And I want to talk about GP letters. At the moment, people who are new to the capital – maybe new to the country – want to get housing, and they’ll be spending between £20 and £180 to get a letter from a GP. Some local authorities will need it and some won’t. So, unfortunately, it may be money down the drain – and many of these people don’t have a spare £20, let alone £180.
VV: What sort of solutions are you looking at?
AB: We want to agree a standard and common understanding, not just for ourselves, but also for residents, as to what is required by housing departments across South East and South West London. We need to determine whether it’s actually the case that one needs a clinical view – perhaps you did in the past, but not now. And if it is needed, find out what needs to be contained within that and be very clear on what is a reasonable charge for that to be undertaken.
If we looked at the NHS estate that’s available, and at its utilisation, we could take action to free up land, so that partners and those in local government can build affordable housing. We think a conservative estimate in South London would be between 1,000 and 2,000 houses if we were to look at our current estates and really push the boundaries of what’s available.
We also have the opportunity to invite housing colleagues or advocates into multidisciplinary clinical teams for asthma, let’s say.
For example, we agreed in our April board that we would have 25 ‘natural communities’ across southeast London. So it’s a population of just under 2.1million across six boroughs and we think between 50 and 100,000 per natural community.
We agree with the local authority – and all of its parts and the rest of the health service – to work on focusing on that size of community and put housing advocacy into those discussions.
VV : How will the 25 natural communities work and fit into the London-wide neighbourhood plan?
AB: We’ve decided what the 25 natural communities are and are now trying to organise teams around each of those – multidisciplinary and multiagency teams that meet two to three times a week, looking at the population by virtue of where you live.
For some London boroughs, this is quite new, and for others it’s not. By Christmas, we want a team organised in each of those places. Importantly, each of those communities has been agreed and signed off with the local authority. They are geographically coherent and organised in that way.
VV: How’s the funding going to work, given the required cuts for ICBs?
AB: The Health and Housing Coalition is a lot of bodies all contributing a very small amount of money so we can get together and have a community listening exercise and a grassroots approach. We are talking teas, coffees and community village halls.
In terms of our funding across South London, we’ve set plans that will all have to be on maturing investment. We think it’s likely that investment here will have a payback, but we have confidence in the short term too. For example, I think delayed discharge in London costs about £56 million. We’re not going to eradicate that, but we can make inroads in delayed discharge where the cause is attributed to the housing available.
If we get to a position in autumn, where we are signing off pledges and timescales, there’s no reason why in the year that follows that you’re only paying for a GP letter if you need one, NHS land is being offered for housing and housing advocacy should be part of the neighbourhood teams across our patch by then.
So those three things we think are achievable without changing the budgetary position.
VV: What’s the land that you’re going to free up and to make these houses? Are they trust sites?
AB: Essentially, it is the footprint of the NHS in southeast London – that’s nine hospital trusts, but it’s also running into several hundreds, maybe thousands, of community sites as well. All of them obviously have land associated. So it’s then whether we are able to reorganise that land. It’s the availability of land and access to land that often stymies the ability to build those homes.
There’s a historical example I can give – Dulwich community hospital sites near East Dulwich station. We worked with the local authority and changed the use of the site from one Victorian community hospital to now having a health centre, a school, and supported housing on the land.
So, it’s that type of project that we’re trying to systematise across the NHS footprint. It’s particularly important because that’s our land and it’s at our discretion,
VV: What’s the hold-up when it comes to discharging from hospital? What’s the connection with housing?
AB: The neatest discharge example I can give is people in a mental health bed who do not need to be, but the type of supported housing needed is unavailable. So, if we’re able to get the right housing for those people, they can be discharged.
Of course, there are other examples where we will have people in the health service, for want of straightforward availability of housing. In the past, it proved to be more financially beneficial for trusts to pay for bed-and-breakfast accommodation to free up hospital beds to allow flow through the system. We can no longer afford to do it.
The stock needs to be right, the planning needs to be there from the health service through to local government housing, and that’s what we’re trying to address.
VV: You mentioned 90% of the contacts with social prescribing were about housing. How does that change the dialogue with your community?
AB: Social prescribers end up doing housing advice, and they’re not housing advisors. In Peckham, they’re delighted to have a social prescriber who has a background in the law and in housing. So, in Southwark, I think we will certainly be looking at how you pivot the training for social prescribing towards housing when that’s what the need is.
VV: Coming back to the cuts that have been mandated from the centre, how do you maintain your priorities in the face of them?
AB: This latest mandate says to reduce the size of your ICB. I’m supportive of it, and we’ve been on that journey anyway, but the pace and the assumption around the end point and the skillsets worry me.
It’s far quicker than any structural change we’ve made previously and with that comes risk. It relies on other things being in place that are not yet in place. For us to transfer some of our functions at a lower cost relies on providers being in a position to collaborate to that standard. We’re trying, but it’s not yet there.
And then the skill set. People may do a sterling job day in, day out, but they don’t necessarily have the particular skill set of a health economist, for example. So, we need to train those people and it doesn’t happen quickly.
By 1 April 2026, we should cost, in our case, 35% less than we previously did. To do that, you have to have done quite a lot of planning and consultation and human resource change.
For us to reduce by 35% in southeast London, that means we will remove £21million in cost. Between £1.5m and £2.5m will be from non-pay things – perhaps renegotiating our rents and our buildings and that type of thing – but the vast majority, about £19m, will be coming from pay. It will have a real-world consequence for jobs and the people that we employ. It’s important to be clear on what we are asking of ourselves when we talk about this stuff.
VV: Where do you hope to be with housing in five years? What do you hope has happened and what difference do you hope it will have made?
AB: I think we would be presiding over a system that can demonstrably show it’s improved health inequalities, that is amenable to change through housing. We would have done that in a targeted way around our Core20PLUS populations in each of our boroughs, so that we’ve had a disproportionate impact on those most vulnerable communities.
And structurally, I’m hoping that we can describe a neighbourhood health service to people that essentially says we are interested in you when you’re living, not just when you fall ill. And this is connected to your neighbourhood service.
