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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 My dining room has become an office; trips to the gym have been replaced by PE with Joe in the living room; and having people round to visit in those few brief weeks in the summer typically involved perching on wobbly chairs either end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 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/945013/2019-20_EHS_Headline_Report.pdf[2] BRE. The Cost of Poor Housing to the NHS. https://www.bre.co.uk/filelibrary/pdf/87741-Cost-of-Poor-Housing-Briefing-Paper-v3.pdf[3] Healthy Urban Development Unit, Rapid Health Impact Assessment Tool, 4th Edition https://www.healthyurbandevelopment.nhs.uk/wp-content/uploads/2017/05/HUDU-Rapid-HIA-Tool-3rd-edition-April-2017.pdf[4] NPPF, 2019. Paragraph 117[5] Public Health England, Preventing Homelessness to Improve Health and Wellbeing https://www.homeless.org.uk/sites/default/files/site-attachments/Final%20Rapid%20Review%20summary.pdf[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. https://www.housinglin.org.uk/_assets/Resources/Housing/OtherOrganisation/good-housing-better-health-2016.pdf[8] NICE, 2015. Excess Winter Deaths and Illness and the Health Risks Associated with Cold Homes. https://www.nice.org.uk/guidance/ng6/chapter/3-Context[9]  The Academic Practioner Partnership, 2016. Good Housing, Better Health. https://www.housinglin.org.uk/_assets/Resources/Housing/OtherOrganisation/good-housing-better-health-2016.pdf[10] English Housing Survey https://www.london.gov.uk/sites/default/files/gla_migrate_files_destination/Final%20overcrowding%20report%20-%20print%20version.pdf[11] Scottish Housing Condition Survey: 2019 Key Findings[12] Judge, L. and Pacitti, C. 2020. The Resolution Foundation Housing Outlook. https://www.resolutionfoundation.org/app/uploads/2020/04/Housing-Outlook-April-2020.pdf[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 https://www.homeless.org.uk/sites/default/files/site-attachments/The%20unhealthy%20state%20of%20homelessness%20FINAL.pdf  

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The Liverpool City Region’s Spatial Development Strategy:  Show me the numbers!
Following approval by the Liverpool City Region Combined Authority [LCRCA], a public consultation on the Liverpool City Region [LCR] Spatial Development Strategy [SDS] commenced on 10th November and will run up to the 1st February 2021. This consultation represents the second public engagement on the SDS, following an initial consultation exercise in 2019. This blog assesses the key content of the consultation, and explores whether the objectives of the LCRCA can realistically be achieved through its proposed strategy for housing and economic growth. What is the LCR SDS? The SDS will set out a spatial planning framework for the LCR for the next 15 years, covering the City of Liverpool and the Metropolitan Boroughs of Knowsley, St Helens, Sefton, Wirral and Halton. The SDS will be different to the Greater Manchester Spatial Framework [GMSF] in that it will not allocate housing and employment sites throughout the region and will not make changes to Green Belt boundaries. In the LCR, these policies will be contained within the development plans for the constituent local authorities. Based on the recent struggles experienced by the Greater Manchester Combined Authority in adopting the GMSF (see my colleague Brian O’Connor’s blogs on this topic[1]), this key difference may lead to a quicker adoption of the SDS – but does it really harness the huge potential of the City Region? Purpose of the Current Consultation It is encouraging to see the SDS progressing and taking shape despite complications presented by the pandemic. In terms of its content, the consultation is focused on the overall vision for the SDS, and is based around 5 key strategic objectives and policy areas (see Figure 1): Figure 1: 5 Strategic Objectives of the SDS Source: Liverpool City Region Combined Authority These objectives are well-intentioned starting points from which to develop detailed policies.  The LCRCA is obligated to address key themes such as climate change and health and well-being, and has also sought to pursue an inclusive growth strategy alongside this with a clear focus on promoting social value and creating high-skilled, quality employment across the City Region.  There is significant merit in this approach, which if addressed effectively alongside an ambitious plan for housing and economic growth, will benefit both current and future generations living and working within the LCR.    However, my concern with the LCR is not necessarily what it is saying at this stage - which are generally high level aspirations that in many cases are difficult to disagree with - but what it remains silent on.  There is next to no detail on what will ultimately be the most crucial (and most controversial) aspects of the SDS, namely the scale of housing and employment need and its spatial distribution across the LCR.  Although this is expected to be published in the next round of consultation in Summer 2021, it is difficult to be too enthusiastic about the latest draft without understanding the direction of travel that its growth agenda will ultimately take. It is acknowledged that the LCR had sought to wait for the outcome of the Standard Method review, though question marks remain over the general approach being pursued by the Combined Authority. Scaled Down Ambitions? In the context of the Government’s aim to try and ‘level up’ the north, there is a considerable opportunity for the LCR to take a leading role for growth and set ambitious housing and employment targets which go above and beyond. However, the LCR will not be reviewing or releasing Green Belt through the SDS, and will instead pursue a ‘brownfield first’ approach to development.  Targeting brownfield land first signifies a policy compliant approach which ties in with Government objectives – though it arguably does not represent an ambitious ‘pro-growth’ plan. It is widely acknowledged within the industry that there are significant viability issues associated with developing brownfield land within the City Region, and the LCRCA has itself acknowledged this by seeking significant levels of funding from Government to unlock these sites for development. However, there is currently no indication as to how much funding the LCR will be receiving, and there are obvious question marks as to whether the amount due to be handed down will enable the LCR to fully address the scale of the viability issue. Furthermore, the Standard Method 2.0 will lift the housing numbers for Liverpool City by over 35% (as explored below), and even more land in the urban area will therefore be required to accommodate this hugely increased need.   Impact of the Standard Method 2.0 The Government launched the new Standard Method for local housing need on 6th August 2020.  However, the Government revised its approach and issued further updates to the Standard Method on 16th December, simply reverting back to the method it introduced in 2018, but with a modification to top up numbers in the 20 largest cities and urban areas by 35%[2]. This 'cities and urban centre uplift' of 35% applies to the City of Liverpool, which results in an increased need of almost 545 dwellings per year from the previous Standard Method figure (see effect of the uplift in Table 1 below). Source: Planning matters: Mangling the mutant: change to the standard method for local housing need The uplift represents a reduction on recent delivery (2017-2020) of 397 dwellings per year, which on face value would suggest that accommodating this increased need may not be an issue, as they have recently been delivering far in excess.  However, the uplift is expected to be met by the cities and urban areas themselves rather than the surrounding areas, with brownfield and other under-utilised urban sites prioritised[3].  For the City of Liverpool this increase will predominantly need to be met on land within the urban area.  With brownfield land already in scarce supply, this could create problems further into the next plan period. It will be interesting to see whether this uplift influences the proposed approach being taken by the LCR, or if they continue along the same path regardless. Where will the houses go? The factors outlined above leads me to one main question:   How does the LCR seek to tackle deprivation across the region and pursue objectives outlined in the current consultation (such as inclusive growth and achieving social value) and yet rely solely on delivering brownfield sites, the majority of which will only be viable with significant funding from Government? It is unrealistic to consider that a ‘brownfield first’ approach will provide even the bare minimum of land required, particularly with the additional 35% uplift also applicable in Liverpool.  Furthermore, delivering housing solely on brownfield land in the urban area is likely to result in the delivery of predominantly higher density development (i.e. apartments).  Over the last twenty years, the majority of new housing delivery in Liverpool City (some 90%) has taken the form of flats. A continuation of this approach neglects a clear need for a wider mix of market and affordable housing in the LCR, particularly the delivery of homes with gardens or outdoor amenity space.  The demand for traditional family homes with gardens is also likely to have increased as a result of the pandemic as people reflect on their living environments.  It is likely that the LCRCA will need to do 2 things in order to address this and achieve its overall vision and objectives: Balance the ‘brownfield first’ objective by identifying additional sources of land, such as Green Belt. Pursue an arrangement to distribute any unmet need across the City Region through the Duty to Cooperate. Based on evidence from around the country (including Greater Manchester), distributing any unmet need across constituent authorities has proven to be a painstaking process, and is rarely completely successful when numerous local authorities are involved dealing with large housing numbers within complex urban areas. Green Belt release will obviously be met with widespread objection.   The LCRCA may therefore view these options as undesirable, but could be left with no viable alternative.  Clear answers on this issue will need to be provided by the Combined Authority through the next consultation.    Final thoughts Preparation of an ambitious, ‘pro-growth’ spatial plan presents a significant opportunity for the LCRCA to take a leading role for growth in the North West, helping to deliver the Government’s levelling up agenda and tackling the deprivation experienced across the City Region.  This consultation provides a (tentative) first step on this path providing very limited detail on key issues, but does identify a number of important high level objectives centred around achieving inclusive growth, promoting social value and responding positively to health and well-being in light of the COVID-19 pandemic.  However, looking ahead, the Combined Authority must seek to do more than just provide the bare minimum in terms of housing and economic growth in order to realise its objectives. One only has to look down the East Lancs Road to see an example of a cautionary tale in spatial plan preparation, with the GMSF failing in its ambitions for achieving aspirational growth for the Greater Manchester sub-region.  Preparation of the framework has been plagued by mixed messages from politicians, a suppression of growth needs despite all available evidence, and an overriding reluctance to release Green Belt land.  This has led to consistent infighting amongst constituent authorities, considerable delays and ultimately a failure of the plan making process. It is hoped that the LCR takes note of this and seeks to avoid the same pitfalls and failures moving forwards.  The next engagement is key to identifying ambitious housing and employment land targets – and perhaps an entirely different spatial approach – in order to shape the SDS into a positive and transformational spatial plan for the City Region.   [1] Planning matters: The three certainties in life: death, taxes and delays to the GMSF | Planning matter: GMSF 2020 in a nutshell[2] Planning matters: Mangling the mutant: change to the standard method for local housing need[3] PPG Paragraph: 035 Reference ID: 2a-035-20201216 Image credit: Neil Martin on Unsplash

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