As part of our work on understanding and supporting a move to place-based population health systems, we held a dinner at the Fund recently to discuss the role of housing in sustainability and transformation plans (STPs).
Much was said and insights were shared; my reflections are as follows.
First, although there are exceptions – particularly in Nottingham and Nottinghamshire – most STPs do not include housing as a core theme. On the upside, housing is ‘in the narrative’ of three out of every four STPs. That’s a start, but they need to go further.
Second, there is much evidence of lots of innovative practice; we heard a wide range of examples where housing organisations provide care and support in partnership with the NHS and social care. Housing is much more than a roof and a bed. Support for people with mental health needs, substance misuse, older people’s independence and with health behaviour change are all good examples of the benefits housing services can offer. We heard of the great work done by housing organisations to help with lesser known but highly complex mental and physical health issues such as hoarding, and of mental skills training for young people at risk of homelessness.
Third, sharing good examples is not enough on its own. This needs to be supported by better financial incentives, including capitation-based payments for health care providers, and financial models that reward the NHS for improving health and wellbeing when patients are not in need of care, as much as treating them when they are. The small scale of many housing providers, including housing associations, and the variation in their offers, is a big barrier to NHS engagement. The offer from housing needs to be clearer and, where appropriate, more standardised.
Fourth, let’s make sure we take the opportunities offered by a difficult situation. Increasing concerns over delayed discharge, for example, creates the burning platform for a serious and coherent look at how housing organisations with high-quality spare capacity and support can help. Being part of the response to delayed discharges could be a segue into a stronger strategic relationship between health and housing that is currently missing, despite examples of good practice (especially around new care models). We should have a head-start in this over many other countries given our national health system, but perhaps the United States also can offer some lessons. There they are trialling ‘social ACOs’ (accountable care organisations), where medical and social support, including for housing needs, are funded through full capitated payments.
Fifth, things won’t move fast enough without the right policies and signals from policy-makers and system leaders. While housing and the home are recognised as important by the Department of Health, NHS England and Public Health England, there is not a clear, overarching strategy that brings together a cohesive approach by all these bodies, and which the housing sector can engage with.
The recent housing White Paper had very little to say on health explicitly (with the exception of an honourable mention for Healthy New Towns) although there are likely to be complex and uncertain consequences as planning laws and policy change are reinterpreted (as the Town and Country Planning Association have pointed out). Health system leaders clearly need to do much more to understand, influence, and plan for wider housing policies that impact on health, as well as those that directly affect the NHS and social care.
This was reinforced for me in the week following the dinner, when I attended the Resolution Foundation’s launch of its report As time goes by: shifting incomes and inequality between and within generations. Despite the title, much of the debate at the launch event was about housing and health, the role of housing as a windfall asset for the wealthy, and how this locks in inequality in wealth, opportunity and health between classes and between generations over time. Housing policy is health policy.
So, this is complex and there are no easy solutions. But it does demonstrate the importance of addressing long-term policy questions and the delivery of health and housing services together, not in separate silos. This obviously includes housing’s place in the development of future STPs but, dare I say it, we need to look beyond that.