## Healthy Homes, Healthy Lives

Public health │ Case studies

## Foreword

Councils all over the country understand how the quality of housing affects the health and wellbeing of their residents. Poor housing costs the NHS at least £2.5 billion a year in treating people with illnesses directly linked to living in cold, damp and dangerous homes. Treating children and young people injured by accidents in the home costs A&E departments across the United Kingdom around 
£146 million a year. Among the over 65s, falls and fractures account for 4 million hospital bed days each year in England, costing £2billion. Over 25,000 people die each year in the UK as a result of living in cold temperatures much of this is due to living in poorly heated homes. Public health made the formal transfer to local government in April 2013, and in the subsequent months great strides have been made to tackle the wider social and economic determinants of poor health. This resource commissioned by the LGA describes how public health in a number of councils has started to use the opportunities of a local government setting to improve health and wellbeing. The case studies were chosen because they show a range of ways in which public health in councils is approaching health and housing. They include councils spread across England, covering both rural and urban environments and with varying levels of deprivation and affluence. The case studies in this document demonstrate that local government is enthusiastically embracing the new opportunities of the public health reforms, and imaginatively responding to local issues. For example, there are the district councils in Suffolk which have come together to carry out a joint housing survey that looks at not only housing and finance, but health and care too. There are programmes that have been set up to improve the condition of housing whether that be cold-related, safety or to do with the fabric of the property itself. These are saving money as well as lives. One council, Birmingham, has made homelessness a priority and begun to see impressive results. It is striking how many local authorities are taking a whole-council approach to public health, based on an understanding of the interconnectedness of the social determinants of health. Working across organisations is important, but so too have the new relationships that have developed within councils following the transfer of public health responsibilities. 

We look forward to seeing many more such examples of local energy and innovation in the months and years to come, and seeing the measurable impact it will have. The challenge for us all is not just to identify good practice, but to champion and share it. We look forward to seeing many more such examples of local energy and innovation in the months and years to come, and seeing the measurable impact it will have. The challenge for us all is not just to identify good practice, but to champion and share it. 

	

Chair Chair 	 	
                	
                                                 Chair

Community Wellbeing Board 	
	

Community Wellbeing Board 	
	
Environment, Economy, Housing 


	
                                                                      and Transport Board

## Case Studies Suffolk'S Districts And County Council

younger adult groups. Between 2008 and 2031 those aged 65 years and over in Suffolk are projected to increase from just under a fifth of the population to over 25 per cent - a rise of 85,000 people.

The seven district and borough councils and county council in Suffolk have come together to carry out the first-ever joint housing needs survey. But rather than focus solely on traditional housing issues, they expanded the survey to take into account of other essential areas of daily life.

These changes are putting a strain on the housing stock. There are currently just over 329,000 properties - a figure which has grown by about 30,000 in the past decade. New homes are currently being built at a rate of 1,900 a year.

## Key Messages - Think About The Wider Determinants When

it comes to housing surveys - health, care and finances.
- Look at innovative ways to promote the 
With people living alone in big houses for longer, more innovative accommodation solutions are required. It's clear more needs to be done to support younger adults move out of the family home to live independently. 

questionnaire.
- Consider carrying out surveys in-house 
and in partnership - it drives collaborative working and can be more cost effective than using consultants.
The old age support ratio (the number of people of working age to over state pension age) is 3:4 and due to drop to 2:4 by 2033, which is likely to make recruitment of care workers more difficult and put pressure on working adults to provide unpaid care for relatives.

The context About 740,000 people live in Suffolk. Approximately one third live in the three main towns of Ipswich, Bury St Edmunds and Lowestoft, a third in the market towns and a third within the rural areas. While deprivation rates are low, just over seven per cent of the population live in the fifth most deprived areas. All of these are found in Ipswich and Lowestoft.

In terms of health-related outcomes, the picture is mixed. Life expectancy outstrips the national average by at least 12 months for both sexes. But that masks the variation between different areas. Life expectancy is 5.7 years lower for men and 4.4 years lower for women in the most deprived areas of Suffolk compared with the least deprived.

The story so far It is a legal requirement for every district or unitary council to carry out a periodical assessment of overall housing need for their area, but this time Suffolk's seven district and borough councils along with the county council wanted to do more. 

According to data from the 2011 Census, the population has risen by 8.9 per cent since 2001, which makes it the fifth fastest growing shire county in England. By comparison, the population of England has only grown by 7.9 per cent. Like many areas, some of the biggest rises have been seen in the older population groups. The number of over 75s has increased by 17 per cent - outstripping So this year the councils came together to carry out a county-wide housing survey with a difference. The five-section questionnaire covered not only housing issues, but also health, care, finance and employment. Suffolk County Council's planning strategy manager James Cutting explains: "The traditional way of doing these surveys is pretty comprehensive, but perhaps rather one-dimensional. They do not really cover the wider determinants - health, care and economic prospects. "You can get some of this via the census, but really there was still quite a lot we didn't know, particularly about what could happen in the future, so we wanted something that would dig down a bit further. "By gathering together information on all these different issues we felt we could put together a good evidence base for developing policy in the years to come. The fact that the whole county is involved will ensure we get a clear picture about what matters, what could be improved and how needs change as people grow older." The survey was led by the Suffolk Strategic Housing Partnership, but involved a range of partners, including voluntary sector groups such as Age UK and Community Action Suffolk. Public health, adult social care and the University Campus Suffolk (UCS) were also widely consulted on the format of the survey. It included a range of questions covering issues such as:

- current housing - future housing aspirations and expectations 
including self-build
- reasons for moving house and barriers 
preventing people moving
- proximity to schools, work, leisure and 
recreation services
- long-term illnesses and disability, such as 
dementia and chronic conditions
- how care needs are met - NHS, social 
care, family / friends or privately
- whether any caring responsibilities prevent 
someone working
- what home adaptations have been made or 
needed
- whether elderly relatives will be moving to 
the area and details on their care needs
- financial problems, including whether 
paying household bills is an issue
- willingness to pay for an accessible home.
But it was not just the breadth of topics that marked out the questionnaire, it was the different way the questions were asked. For example, in regards to the future, the survey asked what households wanted and also what they expected. Mr Cutting says: "You get different answers depending on how you ask the question. Both are important and that is why we asked them. But we were also mindful that the questions needed to be kept to a minimum so each one was carefully chosen." Postal questionnaires were sent to a random sample of nearly 83,000 households - representing 25 per cent of the population, while an online version was also made available. The project was promoted via radio and posters as well as through the rural coffee caravan service, a mobile cake and coffee stall which tours towns and villages across the length and breadth of Suffolk. The promotional literature sought to present the survey in a different light to normal housingrelated questionnaires. For example, one of the posters featured a nest with eggs in it alongside the caption 'young ones struggling to fly the nest, tell us more…', while another had a tin of sardines with the words 'need more space, tell us more…'. It certainly seems to have had an effect. The poll was run for a month from the end of March to the end of April. In total, nearly 15,000 postal questionnaires were returned and 300 online forms filled in.

Simon Aalders, from Suffolk's public health team, believes when the results are available in the summer they will prove invaluable.

particular groups and obtain more qualitative information to enrich and build on the data collected by the survey. This will include a young people's survey to ask those between 16 and 25 about their situations. The housing survey was sent to householders and while it asked them about young members of the household it did not get their views directly. 

"Information comes into public health from a variety of sources. But on the whole the data we have been getting tends to be very strategic. We don't really get that level of detail below and that is what this survey will give us. 

There is definitely a gap here in our local evidence that we want to fill. It won't be done by a postal survey. We want to find a method that is more likely to engage young people."
"Having local level information about needs and trends should really help us tailor our approach. But it goes further than that. As a few different partners are involved I can also see it galvanising future partnership work."
Contact: 

gillian.cook@midsuffolk.gov.uk 

(on behalf of the Suffolk Housing Survey Partnership)
Collating the data is the next step on the journey and is currently being undertaken by the Suffolk Housing Survey Partnership. Gill Cook, who is the housing strategy officer for Babergh and Mid Suffolk district councils, says: "We wanted to start a wide ranging housing conversation and I think that is what we have done. The response rate was pleasing and while there is a lot of work to be done going through the results at the end we should have a really good shared evidence base to move forward with. "By doing it this way, we have avoided some duplication by not asking the public the same question again and again via different services. We now have to make sure the data is robust and test it for statistical confidence. 

We should be in a position to publish something in the autumn - We know it was an ambitious, fast paced piece of collaborative work and we are really pleased by what we have achieved together over the last 4 months. "Traditionally local authorities would get a consultancy doing this type of exercise. By doing it in-house, we have speeded up the process, all partners have direct access and ownership of the data and we feel better value for money has been delivered thus far. But the compiling of the results does not mark the end of the work. Later this year the partnership is planning to carry out a number of further exercises to focus on 

## Amber Valley Borough Council

Amber Valley Borough Council's housing team has encouraged local health and care staff to see it as partners in trying to improve the wellbeing of vulnerable residents. Through the support it can offer with housing options advice, home improvements and fuel poverty, the team is playing a vital role in keeping people warm and well.

## Key Messages - Keep It Simple, If You Overcomplicate Things

you are less likely to engage.
- Even if financial assistance or practical 
help cannot be offered, simple advice can still help.
- Think about all ages - young families as 
well as older residents are affected by homes that are cold and are in a poor condition.
Context Amber Valley is a district in south Derbyshire. It has a population of 123,000 people and covers a semi-rural area with a number of small towns formerly based around coal mining and engineering. The health of the population is varied compared with the England average. Life expectancy at birth stands at 78.6 for men and 82.7 for women - both of which are broadly in line with the England averages. Although the gap between the most deprived areas and the least deprived is 6.4 for men and 6.2 for women. Levels of deprivation, violent crime, drug misuse, incapacity benefits for mental illness and statutory homelessness all appear better than the England average although 3,800 children still live in poverty. However, rates of over 65s 'not in good health' and people diagnosed with diabetes appear worse than the average for England. The proportion of adults that smoke is just below 20 per cent (below the national average), while adult obesity is just above 25 per cent (above the national average).

Over the last 10 years rates of deaths from all causes, early deaths from cancer and early deaths from heart disease and stroke have improved, but remain close to the England average. Children's health in Amber Valley is generally better than the England average. 

Levels of breast feeding initiation, obese children, children's tooth decay and teenage pregnancy are all better than the England average. However, rates of physically active children are lower.

The story so far What has made Amber Valley Borough Council's approach to housing and health so effective is its simplicity.

The housing team has long-recognised the risk that cold homes in a poor condition present. So to reach out to those who are most in need the team, working with the Home Improvement Agency, has sought to work hand-in-hand with the local health and care services. Housing manager David Arkle says: "They are the ones who have face-to-face contact with the most vulnerable people, but we realised that they did not always consider the condition of the property people were living in. "Take someone with a cancer diagnosis. They could see their income drop, they are likely to feel the cold and they will be at home more, which will mean expensive heating bills. If we can do something to help with that whether it is maximising benefits or improving the energy efficiency of their home that it is worth it. We feel that we can help support the NHS's investment in the patient to help them recover. "But our problem is identifying those people and getting in touch. You will get the worried well coming forward, people who are savvy enough to know where to go. You have to work harder often to reach out to those who really need the help." To reinforce the point, the team has spent time developing a relationship with local partners, spelling out the dangers cold homes present. It has done this by detailing the risks at key life stages:

- Starting well –Likely to cause life-long 
it is also important to see if anything can be done to make their home warmer. 

respiratory problems as babies have immature immune systems.
- Developing well - Harms a child's ability 
"If they are sitting there at home cold, their living conditions could make their condition worse. When we explained what we could offer and built up mutual confidence and understanding I think it opened their eyes a little and they were happy to work with us."

to concentrate and do their homework, existing medical conditions, such as 
asthma, are made worse, while comfort eating is more likely increasing the risk of obesity.
- Living and working well - Rising prices lead 
Over the winter at least 55 referrals came from GPs over from December to February, which represented a real change. 

to anxiety about paying the bills, greater consumption of comfort food and smoking, increase sickness rates and anxiety about paying bills.
- Ageing well - Greater risk of strokes, heart 
Help given to patients included everything from basic advice about how to use their central heating system more efficiently, help accessing funding to complete boiler replacements and in one case an individual had to be moved as the house was in a very poor state.

disease and respiratory problems. Mental anxiety about paying bills can also develop, while hazards can increase the risk of trips and falls.
Mr Arkle says "The house was totally unmodernised. It only had cold running water. There was no toilet and bathing facilities. For others, they did not qualify for any benefits or financial assistance but we could give them a bit of advice. If you have an A rated boiler and have the thermostat on 28 all the time you are not going to see the benefit. "Of course, we can't help everyone. Even if you help just one in 10 or even one in 100 it is still worth it."
In recent years this has helped the team develop a good working relationship with adult social care and it now receives regular referrals, especially those enquiring about adaptations. During their assessments, care staff are encouraged to note the state of the housing condition and then support clients to contact the housing team or pass on the individual's details. Citizen's Advice has also been another source of referrals. Until the last year the team did not enjoy such a close working relationship with their NHS 
counterparts. Following the reforms to the health service and the creation of clinical commissioning groups - that changed. 

His work has been appreciated by local GPs. CCG chair Dr Sheila Newport says: "We need to be doing more work like this which gets us out of our silos. The collaborative work is raising the profile of the non-medical determinants of health in a really practical way that has made a difference to patients."
Mr Arkle was invited onto one of the locality boards of the Southern Derbyshire CCG. It enabled him to build a relationship with the GPs in his area. He says: "We did not want to make it complicated. Like anything, if you do that you are less likely to form positive working relationships. So we tried to get the message across that if a cold home is a risk for a patient get in touch with us and we will do the rest.

And GP Dr Andrew Mott, whose practice has got directly involved in referring patients to the council, says: "Our jointly developed scheme has been seen as valuable by the GPs and practices. I am convinced that clinicians are thinking differently as a result and that much more can be achieved via community support teams or with our recent discussions about sharing information to better target our interventions." But Mr Arkle does not want to stop there. He wants to see a closer working relationship develop with children's services to ensure 
"We said that we can have a positive role in helping patients with non-clinical side of things. If someone is suffering from coldrelated illness GPs are there to treat them, but families with young children get the help they need. He is also involved with a pan- Derbyshire affordable warmth project involving the county council and local CCGs, which is looking to create a more formal approach to partnership working between housing and health. The aim of the scheme is to identify those with low incomes and in poor health so they can get help accessing fuel poverty help. Mr Arkle says: "In local government, we know who would qualify for help from the Energy Company Obligation and the NHS knows those who have long term conditions that cause ill-health. We could match them up and really target our support, but we have to overcome the information governance issues first." Derbyshire's public health team have now committed £180,000 to the project over the next two years to systematically identify and target those people most in need.

Contact: david.arkle@ambervalley.gov.uk

## Calderdale Council

There are thousands of old stone terraces in Calderdale and unsurprisingly these homes are plagued with problems regarding energy efficiency. Many are in the private rented sector with low-income tenants in the unhealthy position of being unable to heat their home. But the council has often struggled to identify the worst properties. Until now.

Key messages Local authorities have a wealth of data. Cross-referencing information can identify areas that need attention.

Work across departments sharing powers, duties and expertise to make sure that enforcement is an option where persuasion does not work. Help tenants look for funding by advising about national and local grants, loans and tax incentives .

Context The borough of Calderdale consists of the towns of Halifax, Elland, Brighouse, Sowerby Bridge, Hebden Bridge and Todmorden as well as a number of villages. It is one of the smallest metropolitan districts in terms of population, but at 140sq miles one of the largest in terms of area. 

Despite being a metropolitan district, Calderdale has very distinct rural elements. Most of the area is classified as rural and, while definitions vary, up to a quarter of its population lives in rural areas. It faces many issues related to rurality and dispersed populations and the mix of service needs and access issues are distinctly different from a more urban area. The population of just over 200,000 accounts for almost 4 per cent of the Yorkshire and Humber total. After a long period of reasonable stability - with declines in the early 1990s - the population has been growing since the turn of the century, up by over 10,000. The increase, to a substantial degree, has been the result of migration into Calderdale from other parts of the UK. 

According to the 2010 Index of Deprivation, Calderdale ranks as the 105th most deprived out of the 354 districts in England. This is fairly similar to 2007 when Calderdale was the 107th most deprived. 

"The rented sector provides housing for some of the poorest residents in the borough. But while social rented housing has been vastly improved over the last decade with large scale investment to bring properties up to the decent homes standard, the private rented property sector has fallen behind and is now considered to have some of the worst living conditions."
The health profile is varied compared to national averages. In terms of life expectancy, Calderdale fares worse. For men the average is 77 compared to 78.9 nationally and for women it is 81.9 compared to 82.9 nationally.

The programme is based around energy performance certificates, which have been compulsory for anyone letting or selling a property since 2008. The expectation is that by 2018 it will also be a requirement for those that are to be let to achieve an E rating.

Rates of smoking and higher-risk drinking are also worse. But in areas such as child obesity - one in five children in the final year of primary school are obese - and breastfeeding, the situation in Calderdale is better.

Ms Rhodes, who is the lead officer for the project, says: "The sector has really been hidden for some time, but through crossreferencing council-held data with EPCs we have been able to get a really good picture of the situation. In some wards there are up to 80 per cent of rented properties with no EPC.

The story so far The private rented market has grown quickly in Calderdale. Over the last 10 years it has increased by nearly a third to 18,000 properties. But the quality of the accommodation is not always high, particularly in terms of energy efficiency.

"It is also clear that even when there are EPCs there are a number falling below the E category. It is not surprising. The private rented sector does tend to be focused around this older stock, which is characterised by small, stone terraces which have attic rooms. They are difficult to insulate, although there is still a lot that can be done and that is what we hope to support landlords to do.

About half the housing stock in the borough was built before 1919 and as long ago as 2000 a study found that one in 10 homes fell below the industry-standard SAP rating of 30, which signifies serious deficiencies in terms of insulation and heating. The private sector rental market is predominantly based in these older properties.

Amid concern about rising energy prices and the impact of the cold on health, Calderdale Council's public health and housing teams in collaboration with West Yorkshire trading standards have launched a jointly-funded project to tackle the problem.

"It is probably the case that landlords don't realise all this. I suspect a number may be accidental landlords - those that have just fallen into renting out properties because they were not able to sell them - and tenants don't feel in a position to question this. So we feel we can help here and get improvements made."
The scheme, tackling excess cold in private rented properties, will cost £50,000 over the next two years with the aim of making the private rented sector properties healthier and more affordable to live in.

Over the next few months the council will launch a marketing campaign aimed at encouraging landlords to make the most of the energy industry grants to help with heating repairs, boiler replacements and subsidised insulation. There is also the tax reduction entitlement of £1,500 a year that landlords are entitled to for making properties more efficient, which will be highlighted.

Helen Rhodes, the council private sector housing manager, says: "Cold, damp housing has been proved to have very detrimental effect on the health and wellbeing of the occupants. 

Letters will be sent to those they have records for, while information will be published in the local press and the council will work with local landlord groups to encourage action. The project will initially focus on two wards, which have yet to be identified, although the hope is that it can be rolled out wider. "We will have to wait and see how it goes,"says Ms Rhodes. "I am sure we will have to iron out a few things as we go, but I am hopeful it will be extended." The scheme may also have the knock-on effect of helping identify the rental properties that they do not know about.

"Our work with the landlord groups and letting agents will probably identify some and we hope the publicity around this will get others thinking," adds Ms Rhodes. The £50,000 funding - split evenly between public health and housing - is helping pay for the hiring of two part-time posts, a coordinator and enforcement officer, along with the cost of the promotional material. But the plan is that the mainstream teams from housing, public health and environmental health will contribute their expertise, advice and time where appropriate. The power to fine those who breach the EPC regulations has also been shared by trading standards with housing. 

Ms Rhodes says: "Trading standards have other priorities, housing staff have the expertise and the powers to enforce sit alongside the environmental health current duties. We think that this scheme will be more about persuasion, but obviously we can use enforcement if landlords are refusing to provide an EPC. But we hope it won't come to that." If it is successful, it has the potential to have a significant impact on public health. One of the consequences of fuel poverty is the detrimental effect that cold conditions have on individuals, particularly the old and the young.

At room temperatures below 16oC, there is a marked decrease in the body's ability to stave off respiratory illness. At temperatures below 12oC there may be a rise in blood pressure, which in turn increases the risk of heart attacks and strokes. Other effects of the cold include worsening arthritis and increased risk of falls and other accidents through stiffening and tightening of the joints. Meanwhile, dampness and mould increases the risk of asthma. Paul Butcher, Calderdale's Director of Public Health, says: "Poor and cold housing is extremely important to health so we hope this project can make a big difference. It is about tackling the social determinants of health and that is one of the values of being in local government that these things can be addressed. But tackling housing is just one aspect of this. You also have to look at the surrounding environment." Calderdale has been doing this through several different projects. Plans have been put forward to extend the number of 20mph zones. Currently 30 per cent of residential streets are covered by the zones, but there are proposals under consideration to extend this to all areas. This forms part of a wider push to help residents make the most of their streets. Through the Living Streets project - the national initiative to get people walking and cycling more - residents will be consulted on what would make them be more active around their neighbourhoods to inform the council's planning processes. There has also been investment in local green spaces, including the introduction of outdoor gyms. "Through both improving housing and making the local environment more conducive to living healthy lives we can have a real impact in some of our most disadvantaged areas," Mr Butcher adds.

Contact: helen.rhodes@calderdale.gov.uk

## Wakefield Council

Wakefield has a relatively small ethnic minority population. The most recent census showed the proportion of the population that were not white British was just 7 per cent - although that did represent a doubling from the decade before.

Wakefield has sought to tackle health inequalities by targeting its interventions at the most in need. Examples include joint work with the major local housing provider to put residents in touch with a range of services from healthy lifestyle advice to financial support and, more recently, a project with GPs working in the most deprived neighbourhoods.

## Key Messages - Think About Who Has Most Contact With The

According to the 2010 Index of Deprivation, Wakefield is ranked the 67th most deprived area in England. Over 40,000 people in the district are estimated as living in neighbourhoods among the top 10 per cent most deprived in England. This is 12.5 per cent of the district's population, although the figure has fallen slightly since 2007 when 14.6 
per cent lived in such areas.

people who you are trying to reach out to. 

Housing services offer great opportunities.

- Consider how you can maximise the 
contacts that are already taking place, such as GP consultations. 
- Micro-commission by encouraging projects 
to be tailored to the needs of individual neighbourhoods.
Context Wakefield is a city in West Yorkshire, It has a population of over 325,000, making it the 18th largest local authority in England and Wales.

Overall, life expectancy in Wakefield lags behind the national average and while it has improved at a steady rate in recent years the gap has not been narrowed. From 2008 to 2010 life expectancy at birth was 77 for men, compared to 78.2 across the UK, and 81.1 for women, compared to 82.3 across the UK. Within the district, the figures vary greatly, again illustrating the scale of the health inequalities challenge. Life expectancy is 9.9 years lower for men and 7.2 years lower for women in the most deprived areas compared with the least deprived.

When compared with many other metropolitan districts, Wakefield's age profile is older. In particular, it has much smaller than average proportions of people in the late-teen and early 20's age bands. This reflects the absence of any sizeable university presence within the Wakefield district. 

In terms of disease, Wakefield also fares poorly with higher than average mortality rates for cardiovascular disease and cancer. 

The district also has one of the highest rates of COPD in the country. Meanwhile, adult obesity rates are higher than average - 28.5 per cent as opposed to 24.2 per cent nationally - and levels of harmful drinking are above the norm.

In large university cities such as Leeds, by contrast, increasing levels of participation in higher education in recent decades have created a population where 17.3 per cent of people are aged 16 to 24, compared to 11.3 per cent in Wakefield district.

The story so far The challenge for any public health intervention is reaching out to the most vulnerable and in need. But research shows that those who are most likely to engage with interventions tend to be the people who are most healthy. Wakefield has sought to address this and in turn tackle health inequalities head-on by targeting its work through innovative joint working.

It means nearly 20 per cent of the population is over the age of 65, higher than the national average. In the coming years, that figure is expected to increase. According to projections, the numbers of elderly is likely to grow by over a fifth by 2021 and by 50 per cent by 2051 to top 100,000. While this is happening, the working age population is not predicted to grow at anywhere near the same level, approximately 1.6 per cent by 2031 
In 2009, a partnership between public health and Wakefield and District Housing (WDH), the main social housing provider, was launched. WDH manages 31,000 properties, which are home to over 60,000 people. Nearly two thirds have a long-term illness or disability.

Dr Furber says: "Many of these are low level mental health problems - tier zero - such as anxiety and depression that were not being picked up by the formal NHS services. But what we realised was that we did not have the services in place to support these people so that is something we are now trying to rectify."
To achieve this, WDH is looking at funding the case workers, freeing up £120,000 of public health money to invest in services such as befriending schemes.

So public health funds were used to employ five health inequality case workers. Their job has been to carry out health assessments and signpost people to the relevant services and support they need. This can include help for:

- Lifestyle issues - smoking, drinking, weight, 
physical activity and substance abuse.
But Wakefield's public health team has also used the move into local government as an opportunity to assess how else it can reach out to the most in need. One of the areas it has looked at is GPs. 

- Emotional wellbeing - anxiety, depression, 
stress and loneliness.
- Life skills - employment, education, literacy 
and confidence building.
- Financial issues - debt, rent arrears, benefit 
maximisation and money management.
Dr Furber says: "If you want to address health inequalities and premature mortality we realised one of the best ways is optimising the GP offer. Many of the people who you want to contact are using that service so we set about designing something that would maximise that contact."
The reasoning behind the scheme was that WDH - through its network of estate officers, debt teams and technical staff - would have much more contact with these residents than many other services.

In the end, a joint NHS and council scheme was launched in April 2014 which will see over £1m being invested over the next two years. The money is being targeted at 22 of Wakefield's 40 practices. The practices were chosen because they have the highest concentrations of patients from deprived neighbourhoods. In total, nearly 55,000 people will be targeted.

That has been proved right. Thousands of assessments have taken place and the case workers have worked with more than 1,500 
people, making over 3,000 referrals to other services. Evaluations show that 94 per cent of people have reported improvements to their health and wellbeing.

The practices have been split into seven networks to allow resources to be pooled, while at the same time developing bespoke solutions to local problems by allowing each group to come up with their own plans. The measures being taken include:

- Network one - Extra smoking cessation 
Wakefield's Director of Public Health Dr Andrew Furber says: "It has proved very effective at engaging people. These groups were not being reached by traditional services, but by using the reach of the housing provider it has made a big difference. Addressing health inequalities requires interventions to be targeted in this way."

support, a men's health project for the 30 to 50 age group and a cancer prevention campaign to increase awareness of symptoms and low uptake of screening.
- Network two - Extra weight management 
But the work has also resulted in gaps in services being identified. About 40 per cent of people the case workers have supported have mental health problems.

support, a new public health nurse and counsellor to work with troubled families and a new respiratory nurse.
Network three - A programme to invite all five to 15-year-olds for a health check with direct referrals to weight management support if needed, extra care home visits and the appointment a nurse or GP with a specialist interest in female health.

supermarkets, bus garages and even the at the local rugby stadium. Local business encouraged their staff to take part and the campaign was heavily publicised in local press and on radio in a bid to encourage the estimated 30,000 people with undiagnosed high blood pressure to get tested.

Network four - A new nurse-led clinic to identity patients at risk of stroke, extra support for COPD and asthma patients to reduce emergency hospital admissions and a new nurse-led healthy lifestyle service.

"Again it is about thinking of different ways to reach out to people," says Dr Furber. "If you can increase awareness and get people to come forward for testing you can save lives."
Contact: afurber@wakefield.gov.uk Network five - Scheme to target teenagers and young adults on sexual health and teenage pregnancies, prevention and screening service for alcohol accompanied by the appointment of community development worker to encourage sensible drinking and to work with families, and cancer screening promotion work. Network six - Additional support for patients with asthma and COPD, dedicated smoking cessation support for pregnant women, project to target people with alcohol problems and home visits to support the development of dementia care plans. Network seven - Project to reduce dependency on benzodiazepines (sedatives used to treat anxiety) and campaign to increase attendance at bowel and breast cancer screening services.

Dr Furber says: "The schemes have all been developed by the networks to address particular problems unique to those neighbourhoods. It is micro-commissioning really, accepting that one-size does not fit all. "In doing that we are making the interventions more effective because they reach directly into the communities they need to. By comparison, a mass public health campaign would be much less effective." Another proactive project that has also been run was a four-week campaign to identify people with high blood pressure. The scheme, which took place in March, was part of a Public Health England pilot aimed at the over 40s. It saw 50 drop-in clinics run across Wakefield in settings as diverse as 

## Birmingham City Council

Birmingham's public health team has made tackling the city's high rates of homelessness a key priority following the move into local government. This is being done through a combination of building on existing schemes and developing new ones to support one of the most vulnerable groups in society.

## Key Messages - Consider Whether You Are Working As

one council. For example, when finding accommodation for homeless people are you taking into account where children go 
to school?
- Spend time gathering evidence. It is easy 
to assume you know what is happening.
- Look at A&E readmissions. Research 
suggests homeless people use hospitals for safety and shelter.

Context Birmingham is England's second biggest city with a population of just over 1m people. The population is relatively young with 66 per cent of people being under the age of 44. The 20 to 29-year-old age group represent around 19 per cent of the total population - higher than the national average. Meanwhile, the over 65s represent about 13 per cent of the population - lower than the national average.

Birmingham is the most ethnically diverse cities in the country. People of white, Asian and black ethnicity account for 68 per cent, 20 per cent and 7 per cent of the population respectively. Pakistani is the most represented Asian ethnicity. Most of the area is urban and the city centre accommodates some of the most high profile financial, legal, and retail centres outside of London. Over the last 15 years, Birmingham has reinvented itself to become a vibrant city with many leisure attractions and quality urban spaces. More than one fifth of the city consists of open space and 16 per cent of Birmingham's land area is designated as Green Belt. Despite the success of the regeneration of the city as a whole there are still inequalities within it. Birmingham is ranked the 9th most deprived local authority in England out of 354, according to the Index of Multiple Deprivation. Looking at the local neighbourhoods, over half are in the most deprived 20 per cent in the country. And while life expectancy has been increasing, Birmingham still lags behind the national averages for both men and women. For males it is 76.8 years, compared to 
78.6 across England. For females it stands at 81.6 years, compared to 82.6 nationally. In fact, in recent years the gap in life expectancy between the national average and Birmingham has actually widened for men.

The story so far When Birmingham's Director of Public Health Dr Adrian Phillips made the move from the NHS to local government he was quick to identify homelessness as one of his two key priorities. It may seem quite a niche population group, but for Dr Phillips it is part of a long history of public health focussing on housing issues. "The link has actually been known for many millennia," he says. "It was recognised by ancient civilisations including the Greeks and Romans and in England the first Public Health Act in 1848 was a tool whereby local towns could improve aspects of their infrastructure to improve the health of the local population, including housing. "So I think it has always been there, although recently it has become more of a priority. Housing costs are rising and energy costs are rising. It is a real struggle for many people. "But in terms of housing and its effect on health, the biggest issue remains homelessness. We have a situation today where many people, especially families, find themselves homeless and require urgent state support."
with both social housing providers and private landlords to increase the stock of accommodation available to house homeless people. Dr Phillips says: "We know bed and breakfast is not good for families. Often they are moved several times disrupting the children's education. Our long-term aim is to actually stop this altogether, but to start with we will priorities families."
Birmingham has a particular problem with this. It receives nearly 7,000 applications for homelessness a year and accepts 4,000 - four times that national average per head. The most common reasons for someone becoming homeless are a breakdown of relationships with friends and/or family, ending of assured short-hold tenancies and domestic violence. These account for three quarters of applications. But what makes homelessness a "major society issue", according to Dr Phillips, is the subsequent effects on the individuals.

Meanwhile, a homelessness needs analysis is being planned, with a focus on exploring new ways of working particularly in regards to preventative approaches. This will be a six-month project with the express aim of getting really in-depth evidence of what is happening.

Research shows that 70 per cent report mental health problems, while 80 per cent have a substance misuse problem. There are also high rates of dietary deficiency, low levels of physical access and poor access to primary care services. Dr Phillips says: "We have real problems with homelessness in Birmingham. Over the last 10 years the population has increased by 10 per cent. That is an extra 100,000 people.

Work is also under way to run some targeted TB screening at migrants at places such as colleges providing English-as-a-secondlanguage courses. In the future this may be extended to include screening for Hepatitis C and HIV. This is likely to include working with SIFA Fireside, a local charity which runs dropin clinics offering everything from dentistry to optician services for homeless people.

"Like London we attract people fleeing from difficult situations, like domestic violence, and that puts a lot of pressure on services and the impact on health is immense. That is why we have made it a priority."
Another scheme Birmingham wants to build on is the Think Family - the city's version of the national Troubled Families programme. Multi-professional teams are working with more than 1,000 families at the moment.

A number of strands of work have got under way in the first year. Some of these are new projects, while others build on existing programmes.

Dr Phillips says: "This sort of work is key to preventing homelessness in the first placed. Domestic violence is one of the single biggest factors in homelessness and nearly 40 per cent of troubled families are troubled because of domestic violence so it is clear there is a lot more we can do," says Dr Phillips. 

A pilot Department of Health-funded hospital discharge project across seven hospitals in the Birmingham and surrounding Solihull and Sandwell areas is focussing on stopping readmissions among rough sleepers. Research shows homeless people are six times more likely to attend A&E and once there 70 per cent do not have their needs assessed properly before discharge.

"Homeless people are some of the most vulnerable in our society. It leads to poor outcomes for individuals and is really expensive for society. So getting this right and helping people is essential.

A local charity, Trident Reach, has been commissioned to work specifically with these patients. A bed-and-breakfast reduction project has also just been launched, which aims to ensure no families are placed in this type of accommodation. It involves working 
"Much of what we are doing is through existing budgets, but what we are using the public health grant is for a bit of pump priming to get pilots and schemes going like the TB screening and needs assessment." But Dr Phillips says which budget the money comes from takes secondary importance to the involvement of different services. "Now we are in local government the key thing is to work closely with other departments and that is what we are trying to do. "The whole cabinet has been really supportive on this, particularly the member for health Councillor Steve Bedser. They have given it a lot of air time and now we have got it on the agenda we can start pushing forward."
But, of course, homelessness was just one of two key priorities Dr Phillips identified after the transfer. The other was tackling child obesity. Just over 23 per cent of children in year six - the final year of primary school - are obese, which is higher than the national average. "I suppose there are three key tactics we are focussing on," he says. "Firstly, we want to set the right environment so that means working with planners to restrict the supply of fast food takeaways and ensure the built environment is right." He says the next one is related to behavioural change, which involves things such as organising motivational therapy with dinner ladies so they become more effective at encouraging good behaviours in children as well as making use of Food Dudes, a social marketing initiative that links healthy eating with rewards based around cartoon characters. And the final strand of this work involves a greater targeting of the city's Be Active free leisure scheme at children. The programme has undoubtedly captured the imagination of adults since it was launched in 2008. More than 350,000 people have signed up to it - a third of the population. Participants register and are given a card which allows them to use a range of facilities from swimming pools and gyms to exercise classes and badminton courts for free during certain times. But use by under 18s has been somewhat limited. 

"We think with the right programmes in place and the right targeting of children we can make a positive difference on obesity," Dr Phillips adds.

Contact: adrian.x.phillips@birmingham.gov.uk

## Liverpool City Council

Poor housing is one of the key factors for Liverpool's high levels of deprivation. But the council and its partners have been working together in recent years to drive up standards in the private rental sector while at the same time addressing other wider determinants of health through its Healthy Homes Programme.

## Key Messages - Make The Most Of Every Contract By

In terms of life expectancy, Liverpool has lower rates than the national and regional averages. Life expectancy for men at birth stands at 80.2 years compared to 83 for England. For women it is 76.1 compared to 79.2 nationally. In fact, that means Liverpool has the second lowest life expectancy of the eight core cities in England - only Manchester fares worst. However, this does represent a steady increase over time. Males are now expected to live 4.9 years longer than they were in 1995-97 and females 3.3 years longer. 

addressing both housing issues and other factors from access to services to lifestyles.
- Good preparation is essential. You get 
better engagement if you inform people 
what you are trying to do and when you are doing it.
- Learn the lessons as you go along - 
Encouragingly this has resulted in the gap in life expectancy between Liverpool and England narrowing by nearly 9 per cent for men since 1995-97, while remaining stable for women. It also means the difference between males and females within the city has reduced too from 5.7 years in 1995-97 to 4.1 years in 2010-12 - a reduction of 28 per cent.

schemes should evolve as you work out what works.

Context Liverpool is one of England's major cities and has a population of nearly 470,000, according to latest figures. While this is substantially down from the 517,000 living in the city in 1981, it represents a marked increase from the low point seen in 2001. Since then the number of people in the city has increased by 6.3 per cent.

Nonetheless, Liverpool still remains the most deprived local authority areas in England, according to the 2010 Index of Deprivation. A position it held in both the 2004 and 2007 indices. An illustration of the impact this has can be seen with healthy life expectancy - that is the years of disability free life. For both men and women it is around the 58 years mark, compared to 63.2 for men and 64.2 for women nationally. This has a significant burden on the city's health and social care services, according to Liverpool's most recent joint strategic needs assessment.

The large student population means Liverpool has a younger than average population. Some 11 per cent of people are aged between 20 and 24 years old and, as a result, the average age of residents is 35 years, compared to 39 years for England. 

The story so far Poor housing takes its toll on the residents of Liverpool with research suggesting it contributes to about 500 deaths a year and 5,000 illnesses. Over the past decade there have been big improvements in social housing thanks to the Decent Homes programme. But until the launch of the Healthy Homes Programme in 2009, the same could not have been said for the private sector market.

While the city has a relatively young population, the Office for National Statistics predicts there will be a substantial increase in the number of older people over the coming decade. By 2021, it is estimated that the number of people aged over 65 in Liverpool will increase by just over 9 per cent. But this is likely to be accompanied by a large increase in the number of children with the number of under 15s increasing by 6.8 per cent. This will mean Liverpool's population will retain its relatively young age profile.

At the start of the programme, there were nearly 150,000 properties in this sector with data showing 7.5 per cent lacked central heating and over a quarter classed as being in fuel poverty. Hazards such as falls risks and electrical safety were also all too common. Most of these problems were in the rental market. But that is now changing. Healthy Homes provides support - and at times applies pressure on landlords - to improve the condition of properties. To ensure outcomes are maximised the programme also uses the contact it has with these residents to address a range of other factors that affect health. Initial contact is made via the team of advocates that target neighbourhoods with high levels of deprivation. They knock on doors offering to carry out assessments, which are then used to help refer people on to a host of services. These include everything from smoking cessation and lifestyle support to help maximising benefits. The service can also put people in touch with local NHS services, such as dentists, and the support provided by other partners such as Age UK and the fire service. Liverpool's Director of Public Health Dr Paula Grey says: "It is about making the most of every contact. These are some of the most vulnerable households in the city and so reaching out in this way is proving extremely effective. "You can deal with the fabric of the building, but also address these wider determinants and wellbeing issues." Since the programme was launched, more than 33,000 assessments have taken place, which have resulted in nearly 25,000 referrals to services. Housing surveys have been carried out over 17,700 times, identifying 3,750 serious hazards. The most common have been excess cold-related issues, fire risks, damp and mould problems and fall risks. Where hazards have been identified, officers have placed an improvement notice on the property under the Housing Health and Safety Rating System, which was introduced as part of the 2004 Housing Act. This has led to improvements worth nearly £5 million being made. Although the programme has also provided advice to landlords about how they can access grants and there has been a hardship fund available for extreme cases for owner occupiers. This has involved the programme itself paying for the repairs and then a charge being put on the property allowing Liverpool to recoup its money if the property is sold. The impact of all this is likely to be significant. An evaluation of the scheme by the Building Research Establishment has estimated that over a 10-year period the savings to the NHS and wider society could amount to £55 
million and save 100 lives and 1,000 hospital admissions a year. Dr Grey says it was this potential that convinced the council to continue funding the programme once public health moved to local government. When it was launched in 2009, it was a four-year programme and received £6m of funding from the old primary care trust. The programme is now getting slightly less - just under £1.5million in 2013-14 and 2014- 15 - but Dr Grey says the good work should continue. "Money is tight so we have to make it stretch a bit further," she says. "But the programme has been really successful and had a big impact.

 "What we have been able to do is learn as we go along and that is holding us in good stead now." One of the key lessons has been the need to prepare the ground for the advocates' door knocks. The programme, which employs 33 staff including eight advocates, has found that letting residents know in advance that people are coming and explaining what they can offer improves levels of engagement. So letters are sent out in a few weeks before their visits telling households about the service and allowing them to make appointments at set times if that suits them better. The advocates have also been given training in interview techniques and customer services to help them engage with people. 

Local radio stations also promote the work and the advocates wear uniforms with the Healthy Homes branding and council and NHS logos.

"What we are seeing is many more connections being made within the council. You can see that at the meetings of the Health and Wellbeing Board. It is bringing people together and getting them thinking about what can be achieved."
Programme manager Phil Hatcher says: "You can't just go cold-calling as it puts people on the back foot. We have found that by promoting the work we are much likely to get a positive reaction. "There is real recognition of the service now and that certainly helps, but you still need to keep doing the groundwork."
But she also says that has come at a price as well. "It has not been without problems. The NHS has become so fragmented that we have lost some of the closeness that we had. Cracks are appearing in the system that we are still trying to mend. There are bits of public health in NHS England, Public Health England and clinical commission groups. We are still trying to get clarity and build those relationships too."
Contact: phil.hatcher@liverpool.gov.uk The programme has also expanded the ways it reaches out to local communities. An alert system has been set up to flag up to GPs which of their patients could benefit from the Healthy Homes Programme and recently some have started proactively trying to identify patients on their register who could be helped. "Hazards in the Home" workshops have also been run in schools to get children to recognise the dangers and risk signs. The focus on the private rented sector has also encouraged the council to launch a 10 Point Pledge to help continue driving up standards. It includes promises to rebrand and promote a landlord accreditation scheme, set upa phone line to whistle-blow on poor landlords and advisory group to improvement engagement with landlords. But Dr Grey, who is now retiring, says there is much more that can be done now public health is in local government. "There are lots of opportunities," she says. "We are beginning to think about the smoke free homes agenda and how you designate certain properties smoke free. You have to be careful, but I think some people will welcome this and it will get others thinking about their smoking habits.

## St Helens

St Helens public health team has sought to harness the power and reach of the council's own services, including its home improvement team, to boost the health of the local population. Priority areas have included reducing excess winter deaths and reaching out to inactive and isolated older male residents.

## Key Messages - Use The Joint Strategic Needs Assessment

(JSNA) to prioritise areas where support can make the most difference.
- Make the most of the council's own teams. 
In St Helens there has been an enthusiasm across different departments to help the public health drive.
- But remember a small investment in these 
services is important to generate the goodwill and capacity to get involved. 
Context St Helens is in Merseyside, a few miles north of the River Mersey. Latest population estimated suggested there are about 176,000 in the area, a figure which has remained largely static over the past decade. However, this is expected to change in the coming decades because of the rising birth rate and the fact people are living longer. Despite there being little population growth in recent years, the age structure of the population has changed significantly. Since 2002, the number of people aged 65 and over has increased by almost a fifth, and now people in this age group make up nearly a fifth of the population. The number of very elderly people aged 85 and over has increased by 900, a rise of 36 per cent and this group now makes up 2 per cent of the population. Population projections indicate that the ageing population is set to continue with the proportion of older people in St Helens likely to increase at a faster rate than the national average. In common with most areas across England, the population of St Helens is becoming increasingly diverse. Since the 2001 census, there has been a small increase in the number of people from black and ethnic minority groups in the borough. Non-white ethnic groups currently make up about two per cent of the total resident population, up from 1.2 per cent. But this remains significantly lower than the north west and England averages which are 10 per cent and 
15 per cent respectively. The 2010 Index of Multiple Deprivation ranked St Helens as the 51st most deprived local authority in England out of 326. However, this was an improvement on the 2007 ranking of 47th.

The Story So Far The cold winters of recent years have taken their toll on St Helens. Figures show excess deaths are up to 27 per cent higher during the winter months. That is well above the north west average of 18.4 per cent and puts the area in the worst quintile nationally. This winter it was decided something had to be done about it - and with public health newly installed in the council there was the perfect platform. "The problem was one of the key issues flagged up by the JSNA that was completed last year", says Director of Public Health Liz Gaulton. "So we decided it needed to be one of the priority areas for the money we had free once the mandated services and programmes we were already committed to were funded". "We got nearly £13m through the public health grant, but once the budget allocations were completed we were able to identify £300,000 a year for discretionary spend". About £110,000 has been allocated this year and the same again next year to tackle winter death, that is over 50 per cent more that had been spent on winter-related programmes in the past. This has enabled the council to put an additional post into the Home Improvement Agency, the not-for-profit arm of the council that carries out home repairs and improvements. The extra post has been used to identify the most vulnerable residents who are most at risk from the cold.

including activities such as archery, curling and darts as well as organised heritage walks and talks, are then organised with the idea of engaging the men in activities they will get involved with in the long-term.

These residents are then offered anything from help and advice on switching energy suppliers and reducing energy usage to simple draught-proofing and boiler repairs. Fuel-poor households will also receive support to access energy company funding to upgrade their old and inefficient boilers so they can more easily afford to keep their homes warm.

"It is about mental health as well as physical activity. If we can get these isolated groups involved it will have a really good impact on their overall health and wellbeing", says Ms Gaulton. "Bowls is something that is culturally acceptable and recognised in the local community so we felt it was a good way of reaching out to these men.

The aim is that about 300 households will be visited and assessed each year. More than 5,000 winter warm packs have also been handed out. These contain supplies such as an emergency blanket, thermal mug and LED 
torch. Whilst a call centre run through Age UK Mid-Mersey has offered people help and advice.

"Again we have funded two extra posts in the sports development team to get this going." This project also overlaps with a scheme targeted at mental health, which uses the power of the arts and theatre. The 2013 North West Mental Wellbeing Survey showed the wellbeing score of residents in St Helens was going down. In fact, the area has the third worst rate in the north west with men again among the highest risk groups.

The council has also worked in partnership with the local CCG and GPs to identify those most at risk during the winter to check they have had the flu vaccination. Uptake has generally hovered around the 70 per cent mark, but this year it has topped 78 per cent. A winter volunteers' register has also been established. This lists people often from local guide and scout groups and colleges who are on hand to clear snow and support people who are vulnerable during periods of snowfall. Ms Gaulton says: "This winter has not been as cold as the previous ones. We have not had the snow we have had in recent years, but hopefully with these measures in place it will mean we have lower rates of excess deaths". But dealing with winter deaths is not the only area the council has prioritised this year. The JSNA also flagged up a rising trend in deaths from circulatory disease among older men.

St Helens had already done some work with a theatre outreach group as part of an Arts Council-funded scheme two years ago. So, with the help of the council's arts service, the group, Collective Encounters, has been invited back to run regular workshops in settings such as libraries and put on performances. This engages both men and women with previous work seeing an equal number of male and female participants. Future outreach work will focus on specifically engaging male participants who can get involved in productions by also getting involved back-stage with the technical element of performance. Ms Gaulton says these projects and the work on winter deaths illustrate the advantages of being in local government.

To combat this, a project has been established to get the over 60s active and socialising using the medium of bowls. The public health team has worked in partnership with the council's sports development officers and Helena Partnerships, a local social housing provider. The scheme has just started, but the idea has been to identify men who are inactive and isolated and get them involved with local bowls clubs. Taster days, 
"What we have done is make use of the existing services within the council. Being in local government has enabled us to get to know these services and develop these partnerships. "It is the sort of thing that probably would not have happened before or at the very least not as regularly". "What I have found is that there has been a great deal of enthusiasm among officers and members. We have funded extra posts, but really the entire teams have got involved. They see it as really adding value to the work they do. It has been really positive". The public health grant has also stretched to fund two other projects. One is aimed at tackling harmful drinking, particularly among women. Like many areas, St Helens has a separate community alcohol service, provided by Addaction, and a seven-day, hospitalbased alcohol liaison nursing service, staffed by four specialist nurses. The two work closely together, but despite the alcohol nurses identifying people who are much in need of community-based support, less than half of the people assessed consent to a referral. Of those who do consent, only 30 per cent go on to access treatment in the community. The data suggests that women, in particular, are the least likely to want help. Ms Gaulton says: "We are not sure exactly why this is. 

We think it could be something to do with the stigma of alcohol misuse especially amongst women who are often the main carer within the family even concerns over safeguarding, they may think their children will be taken into care." The public health team has responded by funding an alcohol link worker post, who will focus on improving the transfer between the two services. Some of this will involve outreach work, perhaps accompanying women on their first few visits to the community team. They will also be responsible for liaising with GPs and other health and care professionals as well as coordinating a "recovery champions" 
network, which will involve individuals who have undergone treatment before offering support to people currently going through the process. In total, £50,000 is being put into this work. Investment has also been made in the drug service through the creation of a hepatitis C champion. The aim is to raise awareness about the infection among the drug service staff and users, to liaise with GPs to improve testing rates and work with clients to increase the take-up of treatment. Ms Gaulton adds: "There are not huge sums left from the grant once everything else is accounted for. I think other areas are finding this too, but you can make a difference." Looking further ahead, she says 2014-15 will see a focus on children and young people - one of the key priorities identified in the Health and Wellbeing Strategy for 2013-16. "I am thinking about what we can do through early preventative work on issues such as self-harm, mental wellbeing and making sure children have the language skills they need to start school". "We will need to work closely with the schools, but the opportunity is there to make a difference".

Contact : lizgaulton@sthelens.gov.uk

## Knowsley Council

For women, there was an increase of almost three years to 81.0 years. This has meant that Knowsley has managed to narrow the gap in life expectancy with the rest of the country. But this needs to be seen in context. Significant inequalities in life expectancy still remain between different parts of the borough and in comparison with other areas and the country as a whole. 

Knowsley Council is building on its warm homes campaign by introducing a "Healthy Homes" initiative. Led by the public health team, the new programme will draw on expertise from internal and external partners, to tackle everything from poor housing conditions and fuel poverty to lifestyle advice and access to NHS services. 

## Key Messages - Don'T Underestimate The Impact Of Housing

The story so far Knowsley has worked hard to make the most of the Department of Health's Warm Homes Healthy People Fund.

on an individual's health. Excess cold, damp and mould are risks, particularly to 
the most vulnerable.
- In tackling these problems consider the 
opportunity to identify and address other determinants of health inequalities.
- Strengthen community engagement and 
information gathering to effectively target residents' needs.
- Partnership working through programmes 
The area received £160,000 in 2011-12 and 
£138,000 the following year. The investment has funded a range of work to be carried out in local owner occupied properties from boiler replacements through to the installation of carbon monoxide testers. Awareness campaigns have been developed, led by district nurses and community matrons amongst others, promoting the advice and support available. This included direct mailouts to all residents over the age of 85.

will bring multiple benefits to a range of organisations including the council, NHS, fire service, and housing associations. 

Context Knowsley is one of five local authority districts in Merseyside, situated to the east of Liverpool.

Community and voluntary sector projects have also been supported, aimed at tackling fuel poverty and helping the vulnerable during the winter months. Knowsley demonstrated its commitment to the issue in 2013-14 by committing £150,000 from its public health grant to continue running this programme.

But it was identified that more was needed. In 2012 the public health team conducted an evidence review to identify the council activities most likely to be cost effective and have a significant impact on health outcomes. Housing was identified as a "priority area".

The latest population estimates show the resident population stands at 145,900 - a reduction of 3 per cent in the last 10 years. Almost a third of Knowsley's population are under the age of 25 with a further 16 per cent being aged 65 or over. On balance, Knowsley has traditionally had a relatively young population compared with the national average. However, latest figures show that this gap has largely closed. The average age in Knowsley is now 39.3 years, compared with 39.4 for the whole of England. 

In particular, the review recommended a coordinated programme to tackle a wide range of factors from affordable warmth to home safety, and to signpost residents into other services which may benefit their health and wellbeing, including employment and debt advice.

Knowsley is one of the most deprived local authority areas in the country. Nonetheless, life expectancy for both men and women has increased in the past 10 years. Male life expectancy measured at birth has increased by three years and 10 months to 76.5 years. 

Matthew Ashton, Director of Public Health in Knowsley, says: "Keeping warm was just one part of the problem. Quite often we found that when we went into these properties there were other issues". "The condition of the housing was often poor - some people just had no central heating at all or the electrics were old and dangerous. But it went further than that - there were a whole range of health and wellbeing factors too". "So we decided we needed to do something that could address the wider social determinants." The public health team began working in partnership with the council's strategic housing team and environmental health service, Knowsley Housing Trust and Merseyside Fire and Rescue to develop a more comprehensive approach. This led to the creation of Knowsley's Healthy Homes programme. The initiative - to be launched in the summer - will focus on eight key areas for improvement: Housing condition (excess cold, damp, mould and pests). Energy efficiency and fuel poverty. Income maximisation (benefits, pensions, debt and employment advice). Home safety (preventing trips, falls, fire hazards and carbon monoxide poisoning).

Access to healthcare (doctors, dentists and the management of long-term conditions). Access to lifestyle services (smoking cessation, drug and alcohol treatment, healthy eating advice, exercise, health checks and mental wellbeing). Early help (including children's centres and support for older people). Safeguarding. These themes were identified following a cost-benefit analysis by the public health team, using both local and national evidence, which shows the expected benefits within each theme. For example, research shows that for every £1 spent on removing hazards, 
£1.69 can be saved in NHS care, and the cost effectiveness of debt advice has been judged at a saving of £3.50 for every £1 spent. In terms of the lifestyle measures, research shows that one in eight receiving brief intervention to combat their drinking will reduce consumption, while over a third of those who take part in stop smoking services will quit. The council will be investing £1 million into the scheme over the next two years. The programme will support six advocates who will visit over 38,000 homes over the next two years, as well as funding repairs and improvement works in homes and the development of materials such as advice and support leaflets. The project has been developed based on the experience of Liverpool, which runs a similar scheme. However, it has been tailored specifically for the needs of Knowsley. The advocates will complete electronic surveys based on their discussions with residents. Where a risk or need is identified it will be followed up by the advocate in conjunction with the relevant service. Mr Ashton says: "We talk a lot about strategic partnership working, but this is partnership working on the front-line. "We see this as a way of reaching out to the community and dealing with the full spectrum of needs, including prevention and early intervention, so responding to issues before they escalate into big problems. "If we can address these issues at an early stage it will actually help us save money in the long-run." Modelling by the council's policy, impact, and intelligence team has provided a detailed estimation of the likely reach of the programme - and where this help may be required. Over the two years of the scheme, the expectation is that 8,640 people will complete the doorstep surveys and that will lead to over 11,500 referrals to services (some people will be referred to more than one service). The programme will visit all housing within the target area regardless of tenure and funding is being set aside to help fund any additional demand for services.

Mr Ashton says: "We do have that tradition so it has meant over the years there have been many examples of both sectors working well together. However, having public health as a core council service allows us to properly ensure the health and wellbeing of our residents is at the heart of everything we do.

The analysis suggests that the highest demand is likely to be for housing improvements with up to 1,000 referrals forecast each year - 10 times the number that are getting home improvement help through the warm homes campaign.  
"The relationship with different council departments is closer - as can be seen by the way we have worked on the Healthy Homes programme. "Looking ahead, there are other areas I want to see more work done on, such as green spaces and road safety. There is a lot public health can achieve going forward."
Contact: matthew.ashton@knowsley.gov.uk It is likely that housing improvements will be focussed on private sector housing as social housing has undergone significant improvement over the past decade as part of the wider Decent Homes initiative, leaving the private sector stock with some of the highest levels of energy efficiency in the borough. "We would imagine that housing condition is where the biggest cost-pressures will be," says Mr Ashton. "Where expensive improvements are identified, perhaps when a full electrical re-wiring or new roof is needed, we will be placing a repayment charge on the property. This cost will be reimbursed to the council if the property is sold within the next 20 years. "For landlords we will negotiate with them to make the required improvements to the property and where they are not compliant we will use the council's statutory powers to take enforcement action." In terms of the role of public health within local government, Mr Ashton says that the Healthy Homes programme is just the beginning of what can be achieved following the move in April 2013. Knowsley has a long history of joint working between the NHS and the local authority. It became one of the first areas to have a jointly appointed director of public health when the creation of primary care trusts in 2002 led to identical boundaries being formed between health and local government. 

## Sandwell Council

Improving the quality of housing has always been a key priority for Sandwell's public health team. But the move to local government has opened up greater opportunities for integration with other services as the plans the team has to work closely with children's services and adult social care show.

## Key Messages - Don'T Forget The Basics. Food, Water And

a home are the building blocks of good public health - and they cannot be taken 
for granted.
- Invest in training and raising awareness in 
staff from other departments so they truly understand the role and importance of public health.
- Look beyond how public health can be 
integrated with housing to other services, such as social care.
Context Sandwell lies to the west of Birmingham. The borough spans a densely populated part of both the Black Country and the West Midlands conurbation. It comprises the six towns of Oldbury, Rowley Regis, Smethwick, Tipton, Wednesbury, and West Bromwich. Sandwell has just over 308,000 residents, a rise of 8.9 per cent since 2001, compared to the 7.8 per cent increase seen across England and Wales. This increase reverses the decline seen in the population since 1971. Overall, Sandwell's age profile is younger in comparison with the Black Country and national 
averages - more than 20 per cent of Sandwell's population is aged 0 to 14 years old compared with 17.6 per cent in England and Wales. The largest percentage increases have been in the 20 to 24 age group (over 33 per cent) followed by the 45 to 49 age group (up 30 per cent) and then the 85 and overs (over 27 per cent).

Life expectancy has improved in Sandwell in recent years, but it still remains significantly lower than the national average for both men and women. For men it stands at 75.5 years compared to 78.6 nationally and for women it is 80.8 compared to 82.6.

Within Sandwell the gap in life expectancy between the areas with the lowest and highest has remained fairly stable for women, but for men it has widened between 2000 and 2010 to 9.6 years - one of the biggest differences in the country. According to the 2010 Index of Deprivation, Sandwell is the 12th most deprived area in England - a rise of two places from the 2007 index. Nearly a third of its local neighbourhoods fall into the 10 per cent of the most deprived in the country. In total, more than 20,000 children live in poverty. What is more, Sandwell has poorer outcomes for a host of indicators. Just over 25 per cent of children in the final year of primary school are classed as obese, higher than the national average. Levels of teenage pregnancy, GCSE attainment, alcohol-related hospital stays for under 18s, breastfeeding initiations rates and smoking in pregnancy are worse than average. Estimated levels of adult "healthy eating", physical activity and obesity are worse than the England average as are hip fractures, smoking-related deaths and hospital stays for alcohol-related harm.

The story so far Sandwell Director of Public Health Dr John Middleton has long championed the importance of housing during his 27 years in the job. Dr Middleton, who retires this year, has even taken a lead on housing at a national level through his work at the UK Faculty of Public Health where in recent years he has been serving as vice president.

cladding and installing new windows, changes to the lobby and communal areas, which includes landscaping and improved parking, and security and lighting upgrades.

"To me it has always seemed obvious," he says. "If you look back there were big life expectancy improvements long before the NHS through the push in Victorian times with the sanitary revolution and improved housing - all led by local councils.

"We have heard a lot about nutrition and exercise in recent years, but housing is just as important, especially now. I think there is a move back to the basics. That is to say, the need for food, water and a roof over our heads - we can't take those for granted anymore.

Liann Brookes-Smith, the council's acting public health consultant lead for housing, says: "The improved cladding and new windows will reduce noise, conserve energy and it will look better. In addition, improvements to the surrounding areas will improve how residents feel about their area and their overall wellbeing. The public health benefits are therefore great, but we were not measuring that. So we have started surveying residents before the cladding goes on and we will go back afterwards. 

"In Sandwell we have always tried to be active on housing and health. We had a housing and health strategy in 1997 and since then we have had all sorts of schemes from repairs on prescription for children with asthma to prioritised falls prevention work. It has been important part of what we do."
"If you gather this evidence it can have a real impact on getting backing for future schemes and helping you target your resources at what works best. The housing teams have really taken this on board." Another focus has been on Sandwell's affordable warmth and property repairs programme. The public health, housing and adult social care teams have worked together in the past year to see how services could be improved.

And so it continues. A key focus in the last year has been the development of a more integrated approach to health and housing. This is understandable. According to the latest information from the Housing Stock Condition Survey 40 per cent of households are classed as vulnerable elderly, children or long-term sick or disabled. Some 15 per cent are classed as living in fuel poverty.

Like many areas Sandwell has run an affordable warmth programme in recent years for deprived households. Those on incomes of less than £15,900 or over the age of 60 are eligible for the installation of efficient heating systems and insulation measures. In 2013- 14 the budget was just over £300,000 and funded nearly 80 pieces of work. 

The public health team has been organising a series of learning workshops for council officers. One, in the autumn, involved Dr Hilary Thomson, a leading expert in this field from Glasgow University, who gave a presentation to housing staff about the health impacts of housing improvements. Dr Middleton says: "The response of those who took part was really good. To be honest, we were pushing at an open door. There is a real willingness among housing teams to take this on."
There has also been a handyperson service run alongside the affordable warmth programme, which has been made available to elderly and vulnerable homeowners on a means-tested benefit. It has focused on actions that support people to remain living independently in their home, reducing the risk of falls, fear of crime and improve their physical and mental health.

One of the consequences of this workshop was that the council has started gathering evidence about a programme of work to rejuvenate the high-rise housing in Sandwell. This includes external improvements to increase thermal efficiency by updating In 2013-14 there was an annual budget of £100,000 and work was carried out for over 400 households. This included essential minor repairs up to a value of £250, hard landscaping, crime prevention and home security, portable appliance testing and home improvements such as the introduction of handrails. Traditionally services have relied on selfreferrals or for health professionals to refer patients to the healthy homes advocate. But this year Sandwell is looking to change that to ensure the services are targeted at the people most in need. This will involve a much more integrated approach with other parts of the council. Under the Prevention Platform, a team of social care assessors will incorporate home improvement surveys as part of their work with their clients. People with dementia will be a particular target group. They will be eligible for security measures, such as checking locks, doors and window, assessments for trip hazards such as loose carpets, fire safety precautions and space utilisation, which involves steps such as moving bedrooms downstairs. Those discharged from hospitals or suffering from long-term conditions will also be given help. This could include advice on reducing the levels of dust mites in the air or improved ventilation for people with respiratory conditions. Meanwhile, families with young children will be targeted via referrals from safeguarding teams and health visitors. Again this could include anything from fire safety to affordable warmth. Ms Brookes-Smith says: "We are still working out what the capacity and resource implications will be. We don't want to have this service and then not be able to meet demand so it needs to be carefully worked out. "But what it will hopefully ensure is that we reach the people who really need the help and avoid any duplication. To date, we have really relied on people referring into us. This will be much more proactive.

"It just goes to show what we can do now we are in local government. It is really exciting to be part of and I think we can achieve a great deal for some of the most vulnerable people in Sandwell." Dr Middleton agrees. "There has been a lot of support from within the council and a real willingness from officers to get involved. There are some close working relationships that are developing. I think the potential is there to make a huge difference."
Contact: liann_brookessmith@sandwell.gov.uk

## The Districts Of Leicestershire

Housing officials in Leicestershire have been looking at how they can improve health and wellbeing. Working in county-wide partnership, an evidence base has been gathered and a host of new projects are in the pipeline, including more coordinated hospital discharge planning and an integrated property and housing support service for older people.

But the impact of the demographic change will be felt in terms of housing too. The housing market will see growing numbers of single pensioner households - many living in larger family homes. Households headed by someone aged 65 and over are set to increase by 51,000 by 2033. This will both increase demand for smaller single-person houses and reduce the supply of larger family homes. Keeping warm in large, hardto-heat homes will need coordinated action on fuel poverty, according to the county's joint strategic needs assessment. 

## Key Findings - Develop An Evidence Base - That Will

enable you to attract funding and achieve 
results.
- Identify gaps and then build on existing 
services.
- Look at ways you can integrate support 
with other key services, such as GPs and hospitals.
The health of people in Leicestershire is generally better than the England average. 

Life expectancy in Leicestershire is 79.7 years for males and 83.4 for females. Life expectancy of men and women in Leicestershire falls into the highest 20 per cent of upper tier local authorities in England. But that masks the differences within the county. There is a gap of 6.2 years for men and 5.7 years for women between the most deprived and least deprived. The pockets of deprivation are highest to the west of the county.

Context Leicestershire is a largely rural and affluent county in the East Midlands. Seven district councils - Charnwood, Melton, Harborough, Oadby and Wigston, Blaby, Hinckley and Bosworth and North West Leicestershire - cover the 800 sq miles. Its population stands at 655,000 (excluding the city of Leicester). It increased by 7.4 
per cent between 2001 and 2011 and is predicted to increase by over 11 per cent by 2026.

In the past 10 years there have been significant improvements in people's health with substantial reductions in premature mortality rates from major killers. However, cardiovascular disease, cancer and respiratory diseases remain the major cause of ill health and premature mortality, driven by the major risk factors of smoking, obesity and alcohol misuse.

The story so far For the district councils in Leicestershire, the transfer of public health into local government represented an opportunity they were determined to grasp.

The 0 to 15-year-old and 30 to 39-year-old age groups are both predicted to increase. But the largest rises will be seen in the older age groups with the over 65s expected to represent 22 per cent of the population by 2026 - compared to 16 per cent now. 

The chief housing officers for the seven districts have always recognised the effect housing had on health. But following the move the officers decided it was now time to do more. Through the multiagency Housing Services Partnership they bid for funding from Leicestershire Integrated Commissioning Group to carry out some Among the over 65s, it is the very old who will see the biggest jump in numbers. The number of over 90s - is predicted to increase by 125 per cent to 11,500, the number of 70 to 74-year-olds by a third to 36,500 and the number of 65 to 69-year-olds by almost a fifth to 42,300. This, of course, will have a huge impact on health and care services.

research with the Chartered Institute of Housing. The aim was to set out a blueprint for using housing to improve health. The document - the Housing Offer for Health and Wellbeing - was published towards the end of 2013.

Hinckley and Bosworth Borough Council's Sharon Stacey says: "We know access to a settled, secure home that is fit for living, combined with timely, appropriate housing support and interventions can help address a range of health and wellbeing issues. "So the changes prompted us to want to look into how we could do more. It gave us that added impetus. If you are going to be taken seriously and attract funding you need to develop an evidence base. That is what this work set out to do." The over-arching theme of the report is reducing inequalities, but it also spells out what can be done to achieve improvements under the four key outcomes in the local health and wellbeing strategy. They are:

- Getting it right from childhood - Managing the shift to early intervention and 
prevention
- Supporting the ageing population - Improving mental wellbeing
Obviously there is already a great amount of work under way. So what the report does is to set out what is being done and what gaps there are and how those gaps are impacting on health It covers everything from poverty and homelessness to the quality of housing and the way services interact with the NHS. For example, it notes while most social housing meets the government's decent homes standards, action to tackle the quality of properties in the private rented sector is more "limited". It says nearly 13,000 children under 16 - 10 per cent of the population - live in poverty. But the report also suggests this is having an impact on older people, noting there were 354 excess winter deaths in the previous winter.

In terms of aids and adaptation, it says future funding is likely to be "insufficient" to meet demand and that there are long and variable waiting times. Delayed discharge from hospital is also flagged up. It says one of the causes is the lack of any appropriate housing to return to. In 2012-13, 8,000 bed days were lost - each one costing £260 a day. The work was steered by the Health and Housing Project Board, which is made up of representatives from housing, health, public health and social care. That board is now overseeing the next steps, which includes developing five strands of work. They are:

- Establishing a handy-person support 
service to carry out minor repairs and remove hazards.
- Securing money to deliver a targeted 
affordable warmth programme.
- Developing a joined-up model of holistic 
services for older people's support and care.
- Involving housing in the hospital discharge 
pathway.
- Linking up the First Contact Scheme, a 
central information and advice service for vulnerable adults run in partnership with the police, fire service and voluntary sector, with GP surgeries.
Talks are already under way with local hospitals into how discharge planning can be integrated with housing and over the First Contact Scheme. But the most wide-ranging piece of work is the Light Bulb project, which incorporates the first three strands mentioned. The aim is to bring together existing and new services under one umbrella. It will include affordable warmth support, a handy-person service, occupational therapy, assistive technologies, aids and equipment and links to informal support. The idea is referrals will come from GPs and First Contact as well as from word of mouth, with the vision of having a single support service that is tenure neutral, income generating, stigma free and shaped around an individuals need. The aim is to have this and the other initial projects up-andrunning by 2015-16. But already it is clear the work is going to play a central part in the way services are organised in the future as the housing offer document has become a key component of Leicestershire Better Care Fund unified prevention offer. Ms Stacey says: "It is still early days, but we have a solid foundation on which to move forward. When you deliver front-line services you can see the impact housing has on people's lives - whether it is tackling damp and cold, hazards in the home or just making their daily lives easier through aids and adaptations providing a more integrated, seamless service can make a real difference." Leicestershire County Council public health consultant Rob Howard, who sits on the Housing and Health Project Board, agrees. "Housing has such a huge impact on health and health inequalities and if we can better coordinate services and support to ensure all our residents have access to a warm, affordable and well adapted home, we will make a significant difference to people's lives. The transfer of public health has given us the opportunity to work much more closely with local authority colleagues from all tiers to influence the wider determinants of health."
Contact: sharon.stacey@hinckley-bosworth.gov.uk

## Further Resources

The Chartered Institute of Environmental Health has produced a toolkit on how housing improvements can contribute to better health, with case studies (Building Research Establishment 2008). http://www.cieh.org/policy/good_housing_good_health.html The Local Government Association has produced Reducing harm from cold weather - local government's new public health role. This briefing for councillors and officers explains the challenges facing councils and the opportunities they have to help to reduce harm to health from cold weather through effective, year round cold weather planning http://www.local.gov
.uk/
publications/-/journal_content/56/10180/5707983/PUBLICATION The Housing Health Cost Calculator (HHCC) developed by BRE is a tool for calculating the health costs of hazards in homes, and the savings made where these have been mitigated or significantly reduced. https://www.bre.co.uk/page.jsp?id=3021 The evaluation report of the Warm Homes, Healthy People Fund 2011/12 includes case studies (Sreeharan et al 2012). Interventions ranged from home checks and emergency repairs, to practical aids such as thermometers, cold alarms and warm packs. http://www.hpa.org.uk/ webc/HPAwebFile/HPAweb_C/1317136356595 The Local Government Association has produced case studies showing how local authorities have helped people reduce their energy bills through collective switching schemes (Local Government Association 2013). http://www.local.gov
.uk/web/guest/sector-led-improvement/-/
journal_content/56/10180/3984217/NEWS The Local Government Association has produced a report that highlights the vital role that councils play in addressing the housing needs of our ageing society Good homes in which to grow old? The role of councils in meeting the housing challenge of an ageing population http://www.local.gov
.uk/web/guest/housing/-/journal_content/56/10180/3377209/PUBLICATION
The Energy Saving Trust has produced a guide to community-run heat- and power-saving schemes, with UK-wide case studies (Energy Saving Trust 2013). http://www.energysavingtrust. org.uk/Communities/Getting-started RoSPA and Public Health England's handbook, Delivering Accident Prevention at the Local Level in the New Public Health System (Royal Society for the Prevention of Accidents 2013), focuses on accident prevention in the home and includes case studies of interventions targeted at children and older people. http://www.rospa.com/about/currentcampaigns/ publichealth/delivering-accident-prevention.aspx The Department of Health has produced a best practice guide on reducing the numbers of excess winter deaths among older people, which includes housing and other interventions (Health and Inequalities National Support Team 2010). http://www.institute.nhs.uk/ commissioning/general/health_inequalities_national_support_team_resources.html Local Government Association Local Government House Smith Square London SW1P 3HZ Telephone 020 7664 3000 Fax 020 7664 3030 Email info@local.gov
.uk www.local.gov
.uk
© Local Government Association, May 2014
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