Housing pathways to better health

A member of the whg repairs team greets a resident at their door. The team member is wearing a whg uniform and head covering and carries a bag of tools
Walsall Housing’s repairs team responds quickly through the integration of clinical and housing teams. Image credit: Walsall Housing Group.

Curiosity, collaboration, clarity and keeping going are personal characteristics needed to integrate health and housing initiatives through clinical pathways. CATHERINE MAX finds out how it’s done outside London.

The panel highlighted success factors for embedding services in health and care pathway planning and delivery at the final event in the first year of the Heath and Housing Impact Network. They demonstrated how individuals, housing providers and clinicians can use different levers and experiences to improve housing conditions and health outcomes.

You can watch a video of the event here and download the speaker slides here.

Why Health and Care Pathways?

Diagram of a healthcare pathway showing the five stages - Patient presents, test, referral, treatment, review
Key stages of a clinical pathway

A pathway is a structured and comprehensive plan for patient care from diagnosis, through treatment and follow-up. In the NHS, there may be a standard, evidence-based clinical pathway for treatment of a specific disease. An integrated care plan will extend to wider multidisciplinary services, such as social care or occupational therapy as well as GPs, and the role of the patient’s support network such as family and friends.

Increasingly, planning and delivery of pathways for groups or individuals take into account people’s circumstances such as the nature and condition of their home and the accessibility of community support. However, as we heard from our speakers, official policy and guidance lags behind this good practice which is not yet universal.

Key takeaways on housing in health pathways

  • The inverse care law still applies: those most needing services often have least access. These under-served people aren’t hard to reach, they are “failed to reach”. Housing providers can act as a “human bridge” between people and services.
  • Long-term or mainstream health service funding continues to be a challenge, even with evidence of impact. Some initiatives rely on charitable funding or smart use of other channels such as social value money.
  • Evidence and confidence is growing that technological solutions, such as damp and mould sensors, can help detect problems early and empower residents.
  • Organisational values and a relentless focus on wellbeing and tenancy sustainment help ensure change is culturally as well as operationally embedded.
  • Partnership with housing providers enables the health sector to understand the needs and also the strengths of communities and individuals.

What works to achieve change

  • Draw on community assets to respond most effectively, by employing residents and local people who know their estates and neighbourhoods.
  • System-wide health and housing integration means working on a place basis, providing services to residents regardless of tenure (i.e. not just a housing association’s own tenants).

Social Housing (Regulation) Act 2023

From April 2024, Social Housing providers will be regulated and assessed against the Tenants Satisfaction Measures and new Tenancy Consumer Standards, both of which require housing providers to listen and react to tenants.

  • Use collective resources and collaborate at all levels in order to
    • build “health and housing” capacity throughout the system 
    • provide holistic support which can also be preventative, helping people to stay well
    • identify NHS priorities and challenges, such as hospital discharge or specific illnesses (like asthma), and actively demonstrate how housing can provide solutions.
  • Combine quantitative and qualitative evidence to make an economic or strategic case which also captures hearts and minds
    • Overlay health statistics with postcode data to pinpoint areas of need, such as poor housing, so that action can be targeted
    • Gather personal stories direct from individuals to bring the problems to life
    • Utilise new ICB population health management tools and datasets to build further understanding e.g. the relationship between housing locations and use of A&E.
  • Test, evaluate and improve – Models and approaches to tackling specific issues are often replicable for others.
  • Foster personal qualities of curiosity and persistence, hope and optimism.

Highlights from the presentations

Breaking down the barriers between housing and health

Sarah Roxby, Executive Director of Housing
David Thorpe, Senior Director, Technical Services, Wakefield and District Housing (WDH)

“We aim to use our collective resources wisely”

Sarah and David both combine their substantive positions with the largest local housing provider with roles within the West Yorkshire Partnership’s Integrated Care Board (ICB), regional housing networks and local Health and Wellbeing Board.

Formal structures plus ways of working ensure that housing is considered as a determinant of health strategically and operationally. A devolved model of regional system leadership builds on a history of collaboration and local evidence-building which pre-dates the establishment of the ICB itself.

One important consequence is an emphasis on building senior and frontline workforce capacity to understand, value and act on housing issues with implications for health and wellbeing. WDH itself has a clear focus on tenancy sustainment, wellbeing and reducing health inequalities.

They ensure that independent evaluation of trial initiatives informs service improvements as well as helping make the case for health partner funding and replication in other locations. 

A health navigator from the whd team is greeted by a resident on their doorstep
WHD’s wellbeing team supporting residents. Image credit: WHD

Mental health navigators and wellbeing caseworkers

Mental Health Navigators are mental health professionals (such as nurses), employed by the ICB and embedded in the WDH Wellbeing Team. They work closely with housing and other colleagues to provide direct help, guidance on self-care, or referral as appropriate.

Along with Wellbeing Caseworkers, the Navigators are part of a package of holistic support which helps residents stay well and sustain their tenancies.

Read and example Health Navigator job description here.

For further information, including work on embedding housing support in hospital discharge and using technology to detect damp and mould, watch the event video.

A GP leading work to collaborate with housing

Dr Laura Neilson, Hope Citadel, Shared Health and Focused Care (Oldham and Greater Manchester)

“Be curious”

Laura combines one day per week in children’s A&E with leadership roles in primary care and the third sector. Laura initially moved to Oldham when a medical student and, for the first time, was exposed directly to the lack of good quality health services where they are most needed.

From setting up a GP practice on her estate, aged just 25, to her work now as CEO of the Hope Citadel CIC of 10 practices, and leading Focused Care’s work to help GP practices provide support to patients in challenging circumstances, Laura is all about maximising the potential for the NHS to tackle the impacts of poverty on health and reduce inequalities. For instance, The Crib provides practical and therapeutic support and basic supplies, like nappies, to pregnant women and families in crisis.

Integrating health and housing data for health equity: APPG for Households in Temporary Accommodation and the Silent Nightmare Campaign.

A shocking number of children are living for extended periods in so-called temporary accommodation (TA), particularly in cities. This affects their physical and mental health and educational attainment. Laura and colleagues noticed that multiple children from the same address were presenting with health issues, suggesting these houses are being used for TA. Curious, Laura investigated whether there had been a review of child mortality in TA settings: there had not.

With Bristol University’s National Child Mortality Database team, she found that there had been 34 child deaths in TA in 18 months (higher than expected). Delving into the causes, it transpired that key safety requirements do not apply e.g. cots, stair gates, radiator covers. This led to the formation of the All Party Parliamentary Group and a campaign which is resulting in government guidance for safety measures to protect under 2s in TA.

For further information about all this work and its impact, watch the event video.

Social prescribing and a holistic approach to health and housing

Connie Jennings, Director, Stronger Communities, Walsall Housing Group (whg)

“People aren’t ill, they’re merely poor”

Connie’s expertise comes from growing up and living in social housing as well as her professional roles. Similarly, over 60% of her team are whg residents, drawing on lived experience while also providing employment which is itself a major determinant of health. As a large housing association, whg is able to act as an anchor institution, delivering at scale to achieve demonstrable impact.

Close and longstanding collaboration with clinical leaders enables a holistic approach centred on an individual’s needs. Crucially, the emphasis is on prevention by embedding social interventions for “hope, health and happiness” (aka “the h factor”) in service provision as part of an overall care pathway.

Whg’s social prescribing model is not an add-on or substitute for clinical care. Rather, it is fundamental to the way they support residents, and takes a strength-based community development approach. At the same time, clinicians routinely ask presenting patients if they are whg residents (for example, when treating children with asthma).

This triggers contact with social prescribing colleagues to follow up with appropriate support or home improvements and explore wider concerns such as fuel poverty. It’s a model which has been tested and evaluated and can be replicated for different health conditions.

Integrating community and NHS assets for impact

Turning the adverse childhood experiences rubric on its head, in 2022-23 the health and housing Assisting Children to Excel (ACE) working group trained community champions/social prescribers in asthma awareness, distributed 100 asthma self management support packs and completed 87 asthma assessments with those who scored low – signposting them to GP services as necessary.

Ninety-three children have been provided with warm winter coats, shoes and fuel vouchers (funded via “social value” monies). Priority repairs were undertaken in 23 homes found to have damp or mould, with two families moved to more suitable accommodation. Informed by learning from this “proof of concept”, the programme is continuing and has been shared via Inside Housing. 

For further information about all this work and its impact, watch the event video.

This event was chaired by network advisor Sripriya Sudhakar, Head of Regeneration, London Borough of Tower Hamlets.  Nicola Kay, Director of Partnerships, Population Health and Reducing Inequalities, North West London Integrated Care Board, offered reflections from a London perspective, including opportunities for further sharing of the learning.

Catherine Max is a Future of London associate who jointly leads our Health and Housing Impact Network, which is supported by Impact on Urban Health.

Logo for Impact on Urban Health. Plain black writing