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The importance of good quality housing in addressing health inequalities
Perhaps unsurprisingly, I have never spent as much time in my own house as I have in the last year. My dining room has become an office; trips to the gym have been replaced by PE with Joe in the living room; and having people round to visit in those few brief weeks in the summer typically involved perching on wobbly chairs either end of the garden. Unlike many, I’ve not had the additional challenge of trying to create a classroom environment!
The Covid-19 crisis has highlighted a number of inequalities in our society but the impact of housing inequality is one of the most apparent. Indeed, last year, Housing Secretary, Robert Jenrick acknowledged that the pandemic has highlighted “the importance of having somewhere secure and comfortable to live”. Some households have been locked down in homes with room for separate workspace, reliable Wi-Fi, affordable heating and insulation, and gardens. Their experience of lockdown is clearly very different to that of families living in overcrowded, cold or damp homes, with limited or no outdoor space, and no room or capacity for working from home, meaning no choice but to travel to work and risk exposure to the virus.
However, housing inequality is nothing new. It is estimated that in 2019, over 4 million homes in England failed to meet the Decent Homes Standard[1] and, whilst this figure has fallen over the last decade, it still amounts to 17% of homes. The situation is particularly acute in the private rented sector, where 23% of homes do not meet the Standard. As such, poor quality housing is a challenge faced by a huge number of families in England. It also has significant economic impacts; research by the Building Research Establishment estimates that treating patients with illnesses or injuries caused by poor housing costs the NHS £1.4 billion a year[2]. Yet, despite its far-reaching impacts, the issue of poor-quality housing and housing inequality seldom receives the attention it deserves.

The link between housing and health

It has long between accepted that there is a direct link between housing and health. The Healthy Urban Development Unit[3] identify decent and adequate housing as being critically important to health and wellbeing and the NPPF highlights the importance of ensuring safe and healthy living conditions[4].
Having access to good quality, suitable and secure housing has a profound impact on our health and wellbeing and, therefore, our quality of life. As summarised by Public Health England, “the right home environment is critical to our health and wellbeing; good housing helps people stay healthy, and provides a base from which to sustain a job, contribute to the community, and achieve a decent quality of life”[5].
There are myriad direct and indirect impacts that housing quality can have on health. These include, but are not limited to:
  • Affordable housing – a lack of affordable housing may negatively impact lower income families by reducing the amount they can spend addressing other health and wellbeing needs. Conversely, provision of affordable housing as part of a mix of tenures helps to create mixed and balanced communities.

  • Accessible and adaptable homes – most literature shows a preference of older people to remain in their own homes as they age[6]. Provision of accessible and adaptable homes makes this possible for older people and those with disabilities. It also enables them to receive care in the community. As the country’s population ages, provision of this type of housing is likely to become increasingly important.

  • Thermally and energy efficient homes – cold, damp homes can cause and exacerbate many health conditions but particularly respiratory illnesses. It is estimated that excess winter deaths are almost three times higher in the coldest 25% of houses compared to the warmest 25%[7], and with older people being particularly vulnerable. Homes with poor insulation or inefficient heating can also result in fuel poverty[8], causing stress for lower income families who may be unable to afford both fuel and food.

  • Housing design – internal layout and windows can provide good access to daylight which improves quality of life and reduces energy needed for lighting, and ventilation[9]. Sound insulation reduces disturbances from traffic or neighbours which can disrupt sleep and lead to psycho-physiological effects. Good design can mitigate against potentially dangerous design features, such as stairs, uneven levels, or trip hazards.

  • Provision of outdoor space can create room to exercise, play or grow healthy food and provides private amenity.

  • Overcrowding – The extent of overcrowding is often hidden but severe. In 2019/20, there were 829,000 (4%) households in England living in overcrowded conditions[10]. In Scotland, an average of 51,000 (2%) of households were overcrowded[11] and in Wales, it is thought that 6% of working age family units live in overcrowded housing[12]. Overcrowding has particularly negative impacts on children and is associated with increased risks of meningitis, tuberculosis, anxiety and depression, and delayed cognitive development. Overcrowded housing also impacts children’s ability to learn at school and study at home, with research from the US showing that children living in crowded homes, particularly during high school, have lower educational attainment, contributing to inequality later in life[13].

  • Homelessness – Housing insecurity can lead to homelessness which is closely related to ill health. 73% of people experiencing homelessness report a physical health problem and 80% report mental health issues[14]. In what can be a vicious cycle, ill health is often a trigger for becoming homeless.

Cause for optimism

The link between housing and health is clear and the importance of considering how development can affect health is becoming more widely acknowledged, with steps being taken to try and improve the quality of housing.
For example, last year, MHCLG announced that new homes delivered through Permitted Development Rights will now have to meet space standards, in order to prevent the delivery of small homes without justification and ensure proper living space. Likewise, homes delivered through Permitted Development Rights are now also required to provide adequate natural light. As we await publication of the forthcoming Planning White Paper and planning reforms, it will be interesting to see how much explicit emphasis is placed on what housing quality can do for health in the context of the Government’s increased focus on design and quality.
At a local level, there is also reason to be optimistic and the North East has numerous examples of inspiring developments that have set out to address housing quality and creating healthier neighbourhoods.
The Green in Hartlepool is an example of the power of regeneration. Awarded the RICS best residential property 2019, the Placefirst scheme involved the transformation of 175 semi-derelict terraced houses into 86 modern, high-quality, 1, 2 and 3 bedroom homes for long term rent. The properties have been made bigger and lighter, larger homes have been created where two houses have been knocked into one and extensions have been added to enable more open-plan, spacious living. Insulation, double glazing, and efficient boilers ensure the homes are warm and dry, crucial to promoting the good health of residents. Placefirst state that the homes cost around 50% less to run than typical terraced properties in the local area, helping to reduce the stress on lower income families. Courtyard gardens provide private outdoor space and selective demolition has cleared space for a communal green, promoting community engagement and creating new spaces for children to play.
Similarly, as an area of housing market renewal, The Rise in Scotswood in the West End of Newcastle is unrecognisable from the older terraced houses that dominated the area previously. The £265 million Joint Venture between Barratt, Keepmoat, and Newcastle City Council, who together have formed the New Tyne West Development Company, will eventually comprise 1,800 new energy efficient homes on a site that two decades ago comprised dense terraces of partly derelict, dated, and poorly ventilated houses. A mix of housing types and tenures are provided, including private sale, shared ownership, and affordable rent. The homes make use of green technologies to provide heating and hot water from a district heating system and are designed to the latest space and security standards. In addition to providing quality homes and community infrastructure, the development has created opportunities for employment and training aimed specifically at local people.
However, it is not just regeneration schemes that need to consider health. A holistic strategy is needed across the housing sector, ensuring that all housing developments, be that new build homes, conversions, regeneration schemes or empty properties being brought back into use, are of a high quality to mitigate against negative health impacts and maximise positive health outcomes. In doing so, housing can make a hugely significant contribution to reducing health inequalities within our communities. Whilst Covid-19 has highlighted the importance of high-quality housing, including well-designed and useable space within and around new homes, the impact our homes have on our health and wellbeing will remain relevant long after the current pandemic ends.

[1] English Housing Survey[2] BRE. The Cost of Poor Housing to the NHS.[3] Healthy Urban Development Unit, Rapid Health Impact Assessment Tool, 4th Edition[4] NPPF, 2019. Paragraph 117[5] Public Health England, Preventing Homelessness to Improve Health and Wellbeing[6] Mulliner, E., Riley, M. and Maliene, V., 2020. Older People’s Preference for Housing and Environment Characteristics. Sustainability, 12, 5723. doi:10.3390/su12145723[7] The Academic Practioner Partnership, 2016. Good Housing, Better Health.[8] NICE, 2015. Excess Winter Deaths and Illness and the Health Risks Associated with Cold Homes.[9]  The Academic Practioner Partnership, 2016. Good Housing, Better Health.[10] English Housing Survey[11] Scottish Housing Condition Survey: 2019 Key Findings[12] Judge, L. and Pacitti, C. 2020. The Resolution Foundation Housing Outlook.[13] Lopoo, L.M. and London, A.S., 2016. Household Crowding During Childhood and Long-Term Education Outcomes. doi: 10.1007/s13524-016-0467-9.[14] Homeless Link, 2014. The unhealthy state of homelessness



Budget 2021: Rishi’s moment of challenge and change
There’s no doubt that Rishi Sunak’s relatively short tenure at No 11 Downing Street has been a challenge. At the time of Budget 2020 (remember that?) in March last year, Sunak had been in the job for just three weeks – and within three of weeks of delivering his statement, the full impact of COVID-19 started to unfold as the country entered lockdown.
The ensuing recession – the deepest in the UK for 300 years – means we’ve heard much more regularly from the Chancellor over the past 12 months than might typically be the case, as various phases of the government’s support package have been rolled out, and then rolled out again, under the promise of “whatever it takes”.
But the resulting paradigm shift in the fiscal landscape can perhaps most easily be summed up as follows: in March 2020, the Chancellor set aside £12bn to provide support for public services, individuals and businesses whose finances have been affected by COVID-19; the actual cost so far has been around £280bn. Beyond the numbers, the pandemic has, naturally, also stalled much of the government’s wider economic policy agenda, such as the manifesto commitment to “levelling up” areas across the country. Many earlier announcements, such as the planned Comprehensive Spending Review, have also been pared back.
So it was against this backdrop that the Chancellor delivered his second Budget this week, which he summed up as a “moment of challenge and of change”. It had been widely trailed that the government would pursue a ‘spend now…but pay later’ approach when faced with the highest level of public borrowing since the Second World War; the effect of the further COVID-19 support measures announced will take the total bill to £407bn.
The Chancellor is taking a calculated risk that the economy will be on the mend and growing again at the point that various new tax rise measures start to bite over the next few years. In this respect, the Office for Budgetary Responsibility (OBR) brought some good news in their latest outlook – GDP is now expected to grow by 4% in 2021 and to reach its pre-pandemic level by mid-2022, six months earlier than had previously been expected. The OBR warned, however, that they expect the economy to be 3% smaller in the medium term compared to its pre-COVID path – in part due to recent falls in net migration.
But the Chancellor wants more than an economic recovery that is set to autopilot, stating: “it’s not enough to have some general desire to grow the economy…we need a real commitment to create jobs where people are and change the economic geography of this country.” The tone was set for change, including addressing the challenges of long-term green growth and levelling-up. On the latter, Rishi Sunak is starting close to home – by confirming the move of 750 HM Treasury officials to Darlington as part of the “Treasury North” campus.
The Budget was accompanied by the publication of Build Back Better: our plan for growth, a policy paper which sets out the government’s plans to support economic growth through investment in infrastructure, skills and innovation – it effectively provides a new framework that supersedes the 2017 Industrial Strategy as the central policy reference point. This paper also details a series of new funding arrangements, and confirmed that the long-awaited UK Shared Prosperity Fund will arrive in 2022 to replace European Union structural funds as they expire after 2022-23.
More immediately, government launched a new Levelling Up Fund worth £4.8bn until 2024-25, with a first round focused on local transport projects, town centre regeneration, and culture and heritage – the deadline for competitive submissions by local authorities is 18 June 2021. For this purpose, every local authority in the country has been placed into one of three levels of priority group – as shown on the map below – with preference to be given to bids from higher priority areas based on their need for economic recovery and growth, need for improved transport connectivity and need for regeneration. The exact details of how government arrived at this prioritisation have not yet been released, and a number of criticisms have already been levelled at some of the categorisation reported in the media. Potential candidate projects for funding are expected to align with relevant Local Plans, Local Industrial Strategies or Local Transport Plans.
Other key announcements included:
  • the creation of the first ever UK Infrastructure Bank to be headquartered in Leeds that will focus (at least initially) on investments to tackle climate change and support regional economic growth, and that will have a degree of operational independence from government;

  • the latest round of confirmed Town Deal settlements for 45 towns nationally;

  • the designation of eight Freeport locations[1] across the country which will be eligible for tax incentives to attract investment, easier customs processes and simplified planning measures;

  • the terms of reference for a new study from the National Infrastructure Commission (NIC) on how to maximise the benefits of infrastructure policy and investment for towns – with an emphasis on transport and digital – to report by September 2021; and

  • a signal that there could be further change on the way for Local Enterprise Partnerships (LEPs), as government indicated it would be looking at the future role of LEPs, including their geographies, over the coming months and will announce more detailed plans ahead of the summer recess.
Ultimately, this was a Budget very much defined by the long shadow of the pandemic on the state of the public finances, even at this moment when there is more confidence about the way ahead and an economy that can start to grow again. But it was also about the Chancellor attempting to kick start the government’s longer-term economic policy programme and delivering against its political commitments.

[1] East Midlands Airport, Felixstowe and Harwich, Humber, Liverpool City Region, Plymouth, Solent, Thames, Teesside.

Image credit: @rishisunakmp via Instagram