Contents - Hackney Council

Contents - Hackney Council

Housing and homelessness|1 Contents 6. Housing and homelessness ................................................................................ 3 6...

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Housing and homelessness|1

Contents 6.

Housing and homelessness ................................................................................ 3 6.1

Introduction and definitions ........................................................................... 3

6.2

Key facts about housing in Hackney and the City ......................................... 5 Housing conditions ................................................................................. 5 Affordability and availability .................................................................... 5 Housing tenure ....................................................................................... 6 Homelessness ........................................................................................ 6

6.3

Health and wellbeing impacts........................................................................ 7 Housing conditions ................................................................................. 8 Affordability and availability .................................................................. 10 Housing tenure ..................................................................................... 11 Homelessness ...................................................................................... 11

6.4

Number of people affected .......................................................................... 12 Housing conditions ............................................................................... 12 Affordability and availability .................................................................. 14 Tenure share ........................................................................................ 16 Homelessness ...................................................................................... 18

6.5

Inequalities .................................................................................................. 19 Age and family composition .................................................................. 19 Gender and sexuality ............................................................................ 22 Ethnicity ................................................................................................ 22 Socio-economic differences.................................................................. 24 Other vulnerable groups ....................................................................... 25 Location within Hackney and the City ................................................... 25

6.6

Comparison with other areas and over time ................................................ 27 Housing conditions ............................................................................... 27 Affordability and availability .................................................................. 29 Housing tenure ..................................................................................... 32 Homelessness ...................................................................................... 33

6.7

Evidence and best practice ......................................................................... 35 Improving housing conditions for better health ..................................... 35 Improving access to affordable housing ............................................... 38 Support for vulnerable tenants.............................................................. 39 Published December 2016; January 2017

Housing and homelessness|2 Reducing homelessness and associated health harms ........................ 40 6.8

Services and support available locally ........................................................ 41 Improving housing conditions ............................................................... 41 Support for vulnerable residents ........................................................... 42 Reducing homelessness and associated health harms ........................ 43

6.9 6.10

Challenges and opportunities ...................................................................... 46 References .............................................................................................. 47

Published December 2016; January 2017

Housing and homelessness|3

6. Housing and homelessness 6.1 Introduction and definitions Ensuring an adequate supply of appropriate, affordable housing for the growing and changing populations of Hackney and the City is a key priority in both local authority areas. In the recent Hackney: a place for everyone (HAPFE) consultation, housing was the top concern of Hackney residents when asked what has got worse in the local area over the last five years. [1] Affordable housing also remains a very significant priority for the City of London. Housing affects health in a number of important ways and, to illustrate this, this section is broadly themed around four overarching housing-related ‘drivers’ of health and wellbeing as described below. •

Housing conditions: risk factors that affect the health and wellbeing of people living in particular housing stock, which may be ‘physical’ (such as damp and mould, disrepair, cold or overcrowded homes) or ‘social’ (such as isolation and sense of place).



Affordability and availability: issues relating to residents’ ability to access adequate housing at a cost that reflects their circumstances. Housing costs (e.g. rent or mortgage payments) are strongly linked to housing availability and the extent to which supply is sufficient to meet demand.



Housing tenure: the differences in housing circumstances, housing-related support and health-related outcomes experienced by residents of social housing, private rented accommodation and owner-occupied homes.



Homelessness: homelessness is essentially the effect of a lack of affordable accommodation, but is a significant cause of health harms and inequity in its own right (see Box 1 for definition of homelessness, as well as other definitions used in this section).

Published December 2016; January 2017

Housing and homelessness|4 Box 1: Definitions of key terms used in this section Affordable rent - rent levels set by housing associations that can be up to 80% of the local market rate. Most council providers of social housing still charge ‘social rents’, set with reference to a national ‘target rents’ formula, and typically around 40% of the local market rate in the area. Decent Homes Standard - a national measure of housing conditions, which requires homes to meet four criteria: 1. free of serious ‘category 1’ HHSRS hazards (see below) 2. in a reasonable state of repair 3. has reasonably modern facilities and services 4. provides a reasonable degree of thermal comfort. Excess winter deaths - the seasonal increase in average mortality rates during the winter months. Fuel poverty - households living on a lower income in a home that cannot be kept warm at reasonable cost. Homelessness - lack of a place to live that is supportive, affordable, decent and secure. Rough sleepers are the most visible homeless population, but the vast majority of homeless people live in hostels, squats, bed and breakfasts or in temporary and insecure conditions with friends and family. [2] In England, Scotland and Wales, only 'statutory homeless' people are a mandatory priority for social housing – i.e. those who are eligible for public funds, have a connection to the local area and can prove they are 'unintentionally homeless'. Houses in multiple occupation (HMO) - typically, properties rented by at least three people who are not from the same family or household, but who share facilities such as a bathroom or kitchen. Another type of HMO is a house or block converted into smaller self-contained units for rent.1 Housing Health and Safety Rating System (HHSRS) - a method of risk assessing the health and safety hazards in a home. [3] Local Housing Allowance - a calculation used to work out Housing Benefit for tenants who rent privately. How much tenants receive is usually based on where they live, their household size, and their income. Overcrowding - the situation in which more people are living within a single dwelling than there is space for, so that movement is restricted, privacy curbed, hygiene limited, rest and sleep difficult. This is commonly measured by the ‘bedroom standard’, where the number of bedrooms is allocated to each household in accordance with its age/sex/marital status composition and the relationship of the members to one another (definition of statutory overcrowding uses the ‘room standard’, which is deemed to be too strict and rarely used). Private Rented Sector (PRS) - housing that is owned by a private individual, company or organisation, and rented to tenants. Other housing arrangements include social renting (from a council or housing association) and owner-occupying Temporary accommodation - interim housing used to support residents while their homelessness application is being investigated or where they are awaiting suitable permanent housing. Tenure - the legal status under which people have the right to occupy their accommodation. The most common forms of tenure are home ownership (including homes owned outright and with a mortgage) and renting (including social rented housing and private rented accommodation). Published December 2016; January 2017

Housing and homelessness|5

6.2 Key facts about housing in Hackney and the City Housing conditions •





Well over 90% of council properties in Hackney now meet the Decent Homes Standard and most housing associations are above 99%, but many properties in the private rented sector are in poor condition. Reported problems with the home cited in Hackney are mainly associated with cold, mould and damp. More issues are reported for social rented homes than privately rented accommodation (though this may not reflect the true picture), with owner-occupied homes having the least problems. Overcrowding is a major concern in both Hackney and the City. Affordability and availability









Despite Hackney Council building the second highest number of homes in London between 2011 and 2015 (the third highest number of affordable homes), the borough faces significant future housing challenges. The City has projected a shortfall of affordable housing supply to meet its needs. Increases in housing costs, the selling off of many council homes under Right to Buy and further government housing and welfare reforms (see Box 2) have all created a situation where housing supply is struggling to meet the needs of many vulnerable residents (including older people and low income families). According to the latest Hackney housing needs survey, over 30% of households report housing costs are either difficult/a strain or just about manageable. [4] Inadequate supply of affordable housing is expected to impact on levels of homelessness and tenure insecurity in the private rented sector, with many living in inappropriate accommodation without any real prospect of moving to more suitable housing. As of January 2016, there were 11,189 households on Hackney Council’s social housing waiting list, a slight increase on the previous year.2 In the City, a total of 781 households were registered on the City of London Corporation’s general needs Housing Register in January 2016 Private rents in Hackney increased by an average of 27% between April 2013 and September 2015 (for bedsits the increase was 62%). Median private rented sector (PRS) rents in the City have risen by 23% since 2012.

1

A full HMO definition, including how they are licensed, is available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/15652/HMO_Lic_landl ords_guide.pdf 2 This figure can be quoted with confidence, following a recent review of the housing register http://mginternet.hackney.gov.uk/documents/s48009/CDM-16832187-v1Housing_Register_Review_Update_Report.pdf Published December 2016; January 2017

Housing and homelessness|6

Housing tenure •



Hackney has one of the largest social housing stocks in the country, a growing private rented sector and a comparatively small owner-occupied sector. The City, like much of central London, has a housing stock polarised between very high-cost owner-occupied or private rented housing on the one hand and social rented housing on the other. Homelessness



Statutory and street homelessness is a growing problem, especially in London.



Hackney has a significantly higher rate than average of both homeless acceptances and households in temporary accommodation, and these numbers are growing. In 2015/16, 1,017 households in Hackney were accepted as homeless (an increase of nearly 50% since 2010/11). In the same year, 148 people were seen rough sleeping in Hackney.



Despite its small resident population, the City faces major challenges in terms of homelessness, especially rough sleeping. In 2015/16, a total of 440 people were seen rough sleeping on the City’s streets - a significant increase on the previous year.

Published December 2016; January 2017

Housing and homelessness|7 Box 2: Government housing and welfare reforms The measures below are being brought forward as part of the Housing and Planning Act 2016. There are concerns that they will increase affordability pressures and further reduce the availability of social housing. • Extending the Right to Buy to housing association tenants − A number of government pilots are currently underway, and a further pilot was announced in the Autumn Statement in 2016. The government’s intention is that the scheme will be funded from the sale of higher value council homes and other assets (see below). • Forced sale of council housing (higher value local authority assets) − Powers granted to the Secretary of State to collect a levy from councils who own housing and other stock. It is understood that the levy will be comprised of receipts from the sale of higher value council homes (as they become vacant), as well as receipts from other disposals. • Tenancy reform − The government has changed the succession entitlement for household members and removed the right to a lifetime tenancy for council tenants (except where a household has to move as a direct result of a housing regeneration scheme). Welfare reform In addition to these reforms, changes to the welfare system are ongoing that place further pressure on household incomes. These include: • the lowering of the benefit cap to £23,000 for families and £15,410 for single people, implemented in November 2016 • the removal of Housing Benefit for under 21 year olds, from April 2017. For more detail on welfare reform and associated health and wellbeing impacts see the ‘Living standards’ section of this JSNA chapter. Social care and supported housing The Care Act (which received Royal Assent on 14 May 2014) consolidates the framework of social care law and creates new responsibilities for councils. The Act creates a new focus on preventing and delaying the need for care and support, rather than only intervening at crisis point. It also provides a framework to support integration and cooperation with the aim of joining up services. Key aspects of the Act related to housing include the provision of suitable accommodation as an integral component of care and support. Housing is also fundamental to the general duty to promote wellbeing and a focus on prevention that promotes independence. Housing is defined clearly within the Care Act as a health related service.

6.3 Health and wellbeing impacts There is strong evidence on the relationship between housing and health, although the causal effects can be difficult to unpick. In general, the evidence on the relationship between housing and physical aspects of health (such as the link between damp homes and respiratory conditions) is more well-established than the evidence on mental wellbeing impacts. [5] However, there Published December 2016; January 2017

Housing and homelessness|8 is growing evidence of the effects of poor housing conditions on increasing stress and feelings of disempowerment and loss of control, all of which have clear links with mental health outcomes. Figure 1 provides a simplified overview of the various links between housing and health, highlighting the four main housing-related ‘drivers’ of health covered here as described in the introduction. Figure 1: The links between housing and health

Housing conditions The Housing Health and Safety Rating System (HHSRS) provides an assessment of the level of health-related hazards within a property. The key (‘category 1’) hazards used to assess properties under HHSRS are listed in Table 1, grouped into four categories - physiological requirements, psychological requirements, protection against infection and protection against accidents. These hazards give an idea of the range of health risks associated with the housing conditions in which people live.

Published December 2016; January 2017

Housing and homelessness|9 Table 1: Housing Health and Safety Rating System (HHSRS) category 1 hazards Physiological requirements

Protection against infection

Damp and mould growth etc

Domestic hygiene, pests and refuse

Excessive cold

Food safety

Excessive heat

Personal hygiene, sanitation and drainage

Asbestos etc

Water supply

Biocides

Protection against accidents

Carbon monoxide and fuel combustion productions

Falls associated with baths etc

Lead

Falling on level surfaces

Radiation

Falling on stairs etc

Un-combusted fuel gas

Falling between levels

Volatile organic compounds

Electrical hazards Fire

Psychological requirements

Flames, hot surfaces etc

Crowding and space

Collision and entrapment

Entry by intruders

Explosions

Lighting

Position and operability of amenities etc

Noise

Structural collapse and falling elements

Source: Housing Health and Safety Rating System enforcement guidance - housing inspections and assessment of hazards

Poor housing conditions can affect health in a variety of ways. Outcomes of poor housing conditions – such as overcrowding, damp, indoor air pollutants and cold have been shown to be associated with illnesses such as eczema, hypothermia and heart disease. [6] They are also linked to increased incidence of infections, respiratory disease and asthma. However, it can be difficult to separate out the impact of specific housing-related hazards from other confounding factors (such as socioeconomic status or age), which in themselves may give rise to poor health outcomes and are also linked to housing circumstances. A study carried out by Shelter in 2006 outlined the significant health consequences associated with poor housing conditions specifically for children, including: [7] • mental health problems (such as anxiety and depression) • risk of contracting meningitis • respiratory problems Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 10 • •

long-term ill health and disability slow physical growth and delayed cognitive development.

The physical health impacts most commonly experienced by those living in cold homes are circulatory diseases and respiratory illnesses, and these are also the main causes of excess winter deaths (although it is important to remember that the health problems associated with cold homes are experienced during ‘normal’ winter temperatures, not just during extremely cold weather). [8] [9] One of the causes of excess winter deaths is fuel poverty (see Box 1), which has been shown to be as important a driver of health for young people as it is for frail elderly people (see Box 3). Box 3: Health harms of fuel poverty for children The Chief Medical Officer’s 2013 report highlighted the health harms of fuel poverty for families, noting the following issues: [10] • more than one in four adolescents living in cold homes are at risk of mental health problems, and are less likely to have a good diet • infants living in fuel poverty show poorer weight gain • affected children and young people are at greater risk of hospital admission and accidents in the home • impacts on the ‘wider determinants’ of health include poorer educational attainment, emotional wellbeing and resilience. Poor housing conditions can increase the risk of depression, stress and anxiety. For example, there is strong and growing evidence on the mental health and wellbeing impacts of fuel poverty and cold homes, and the significant benefits to mental wellbeing from tackling fuel poverty across the entire age range. [11] Overcrowding also has significant health implications for residents. Living in an overcrowded home disrupts sleep patterns and affects family relationships, child development and mental wellbeing, as well as creating noise nuisance and (perceptions of) anti-social behavior, especially where people live in close proximity to their neighbours. [12] [13] Affordability and availability The current housing crisis is having a major impact in Hackney and the City, as a result of increases in all costs associated with housing combined with reductions in welfare payments (see the ‘Living standards’ section of this JSNA chapter), and fuelled by population growth that is putting pressure on existing housing stock. Younger single people, larger families and low-income households are most sensitive to these pressures, which may lead to a widening of health inequalities as the effects of the crisis are played out (for further discussion of housing-related inequalities see Section 6.5). Problems with housing availability and affordability are linked to mental health problems as well as fuel and food security. [14] The stress and anxiety associated with struggles to meet high housing costs tend to accumulate over time, typically affecting men more than women. [15] Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 11 Housing tenure Health outcomes are typically worse among residents of social housing compared with other tenures, while owner-occupiers tend to report better health and wellbeing (and live longer) in general. [16] Some of these patterns may be attributed to the fact that housing tenure is strongly related to socio-demographic factors (such as age or income levels) and psychological factors (such as self-efficacy), which in themselves have a strong influence on health and wellbeing. [16] [17] However, some of the observed variation in health outcomes across housing tenures holds true even when these factors are taken into account. This may be because tenure is strongly linked to housing conditions and the type of neighbourhoods in which people reside, both of which have important, independent health and wellbeing impacts for residents. The maintenance and upkeep of a person’s immediate surroundings, and the extent to which someone feels connected to their neighbours and the local area, can make a real difference to a person’s sense of place and wellbeing (see the ‘Community cohesion and social networks’ and ‘Places and spaces’ sections of this JSNA chapter. [18] [19] These physical and social features of the neighbourhoods in which people live can vary significantly across tenures. In general, owner occupiers have greater control over the immediate environment in which they live and social landlords provide a range of services for their tenants (such as repairs and maintenance, employment support, health and wellbeing services, as well as opportunities to meet other residents through social events). By contrast, isolated tenants of sub-standard private rented accommodation are often at greatest risk of housing-related harms. [20] Houses in multiple occupation (HMOs) often have poorer physical and management standards than other privately rented properties, sometimes involving poorly converted self-contained units without the requisite building regulations, and/or colocated with commercial premises. Added to their high occupancy, this means that HMOs are subject to greater risks of certain hazards, such as fire. Occupiers of HMOs tend to have the least control and choice over their housing circumstances, and ensuring that standards in this sector meet the legal minimum is important to protect these tenants. Homelessness While many groups suffer poorer health outcomes as a result of their housing situation, it is undeniable that those worst affected are those without a permanent home. A recent study reviewing health across the social gradient concluded that: ‘In comparison with the slope in health inequalities, the health experience of the homeless is more akin to a cliff, with homeless people experiencing a significantly disproportionate burden of morbidity.’ [21] Homelessness is strongly associated with poor physical and mental health and short life expectancy. For example, according to a 2011 report by the homeless charity Crisis, the average age of death of a street homeless person was just 47 years, 30 years younger than average in the general population. [22]

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 12 A common cause of death among homeless people is drug and alcohol abuse; while suicides, fatal traffic accidents, infections and falls are also much more common causes of death in this population. As well as homelessness causing or exacerbating health problems, health needs are often the reason that people become homeless in the first place (along with relationship breakdown and other factors). [23] [24] The longer people remain without a stable and safe place to live, the more these problems multiply and the harder they are to overcome. Physical, mental and substance misuse issues remain prevalent among the homeless population and at levels that are much higher than those experienced by the general population. Analysis conducted by Homeless Link found almost all longterm physical health problems are more prevalent in the homeless population than in the general public (except heart and circulation issues, possibly because of the shorter life expectancy of homeless people). [25] The proportion of homeless people with diagnosed mental health problems (45%) is nearly double that of the general population, with depression especially prevalent. The analysis also found that 77% of homeless people smoke, 35% eat fewer than two meals a day and two thirds consume more than the recommended amount of alcohol each time they drink. Displacement, temporary accommodation and frequent moves are also linked to a wide range of negative childhood outcomes, including behavioural problems and poor mental development, as well as increased risk of poor health in adulthood.3 [26]

6.4 Number of people affected This section primarily describes the number of local people affected by housingrelated issues that impact on health. See the ‘Mental health and substance misuse’ and ‘Children and young people’s chapters of the JSNA which describe a range of specific physical and mental health outcomes for adults and children, including those linked to housing as described in Section 6.3. Housing conditions The 2014 Hackney housing needs survey highlighted that problems with the home across all tenures are mainly associated with cold, mould and damp (Figure 2) – all major causes of housing-associated ill-health (see Section 6.3.1). [4] Housingrelated problems were found to be much less common in the owner-occupied sector than in other tenures.

3

Displacement in this example is defined as the forced disenfranchisement of poorer residents from the spaces and places in which they have legitimate social and historical claims Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 13 Figure 2: Housing problems in Hackney (all tenures) You are under notice of eviction/repossession, real threat of notice Someone in your household is suffering harassment or threat of…

98%

0% 1%

98%

1% 1% 5%

You feel isolated in your home

94%

Your home is too hot (in summer) You have difficulty paying your fuel bills

2%

85%

11%

77%

13%10%

Your home has mould

59%

22%

20%

Your home is too cold (in winter)

57%

21%

22%

Your home has damp

56%

23%

21%

Not a problem

A problem

5%

A serious problem

Source: Hackney housing needs survey 2014

The condition of social housing in Hackney has significantly improved since the Decent Homes Standard was first introduced in 2003, with well over 90% of council and housing association homes now meeting the criteria. [27] The position regarding private rented housing is less clear, since no study of conditions has been carried out since 2009 - this estimated that only 69% of private sector homes in Hackney met the Decent Homes Standard. [28] A separate estimate suggests that around 10,000 privately rented properties in Hackney have at least one HHSRS category 1 hazard (based on data from the 2010 English Housing Survey applied to the estimated total number of privately rented properties in Hackney). In a recent survey of private tenants in Hackney, most respondents (76%) considered that the properties they lived in were in a ‘fair’ condition or better. [29] However, nearly a quarter of respondents (24%) rated the condition of their properties as ‘poor’ or ‘very poor’. Private renters were also asked if they experienced any issues with their current accommodation. A large majority (72%) indicated that they experienced some issues, with repairs being a significant problem - almost half of respondents (47%) agreed that their accommodation was in a poor state of repair and two thirds (66%) were of the view that repairs were not undertaken when needed. Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 14 The City of London Corporation met its Decent Homes target by 2010, with the exception of one tower block. The Standard will be achieved across all council stock by the end of 2016. Table 2 shows levels of overcrowding in Hackney and the City based on the bedroom standard (see Box 1) using data from the 2011 Census. An occupancy rating of -1 or less indicates that a household has at least one bedroom too few for the number and composition of people living in the household – this is defined as overcrowding using the bedroom standard. On this measure, Hackney has the fifth highest rate of overcrowding in England and the City is ranked 43 (out of 437 areas). Table 2: Overcrowding levels in Hackney, City of London, London and England (2011) – totals and percentages of total Hackney

City of London

London

England

Households

101,690

4,385

3,266,173

22,063,368

Occupancy rating of - 1

12,882 (12.7%)

221 (5.0%)

301,325 (9.2%)

870,540 (3.9%)

Occupancy rating of – 2 or less

2,625 (2.6%)

37 (0.8%)

69,206 (2.1%)

153,933 (0.7%)

Source: ONS, Census Note: an occupancy rating of -1 indicates that a household has one bedroom too few for the number and composition of people living in the household. An occupancy rating of -2 indicates that a household has at least two bedrooms too few.

Affordability and availability High housing costs are a significant issue affecting affordability, both in Hackney and the City of London. Over 30% of respondents (all tenures) to the 2014 Hackney housing needs survey said that housing costs are either ‘difficult’, ‘a strain’ or ‘just manageable’ (see Figure 3). The greatest levels of reported difficulty are found in the private rented sector, followed by social housing.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 15 Figure 3: Manageability of rent or mortgage charges in Hackney (2014)4

North East

55%

30%

16%

Stoke Newington

61%

28%

10%

Shoreditch

63%

24%

13%

Homerton

OVERALL

16%

76%

64%

24%

8%

12%

Well within budget / about right Just manageable A strain on budget / extremely difficult Source: Hackney housing needs survey, 2014 Note: Overall 9% of respondents report that they do not make rent or mortgage payments in Hackney. By area this varies, the percentage by area are as follows; Homerton = 8%, Shoreditch = 3%, Stoke Newington = 12%, north-east = 15%

National government reforms of social housing and the welfare system have exacerbated problems of affordability in Hackney in particular (see Box 2 of this section). For many households who are renting locally, a significant proportion supplement their employment income with state benefits and tax credits - for example, 80% of households in the social rented sector and 20% in the private rented sector are supported by Housing Benefit. As described in Section 6.2.3, the social rented sector houses a large number of local people. In Hackney and the City of London, the council allocates social housing to applicants on a housing register, both for homes becoming available in its own stock and for homes managed by housing associations within the borough. The latest data available are for 2014/15 when, through its Choice Based Lettings System (see Box 4), Hackney Council provided permanent accommodation for: • 377 ‘urgent’ households (including those with serious medical conditions, overcrowding, and under-occupiers who can free up larger properties) • 687 ‘priority’ households (including homeless families) 4

For housing management purposes the borough is separated into 4 neighbourhood areas. These are listed here http://www.hackney.gov.uk/housing-offices Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 16 •

147 ‘general’ applicants (affected by minor overcrowding, ‘non-priority homeless’, and ‘general needs’).

As of January 2016, there were 11,189 households on Hackney Council’s social housing waiting list, a slight increase on the year before. The projections for applicants likely to be eligible for urgent and priority need categories decreased for 2016/17, and rose for the general needs category. [30] Box 4: Allocating social housing in Hackney and the City of London Allocation of social housing in Hackney is managed through a Choice Based Lettings System, with individuals using an online system to apply for available properties that suit their household size, budget, and personal preferences.5 Applicants are prioritised into categories according to their assessed need, and homes are allocated to households in the highest priority band and to those who have waited longest for a property. A similar scheme is used in the City of London, also based on the Choice Based Lettings model.6 As with the Hackney scheme, once registered on the Housing Register, applicants are assessed, put into a housing need band and awarded reasonable ‘preference points’. Residents can then apply online for available properties. In the City, a total of 781 households were registered on the Corporation’s general needs Housing Register as of October 2016. Of these, 166 are current tenants seeking a transfer and 615 are on the waiting list. The majority of applicants require studio (327 applications) or one bedroom (163 applications) accommodation. Almost 300 applicants require family-sized homes, but these are in much shorter supply. The City commissioned a Strategic Housing Market Assessment in 2016, which predicted a net deficit of 69 affordable homes per annum in the period from 2014 to 2036. [31] Tenure share A description of the household tenure shares for Hackney and the City of London is provided in Table 3.7 The social housing sector in Hackney is the one of the largest in London and houses more residents locally than any other tenure. The recent growth in the private rented sector (see Section 6.6) has mainly been at the expense of home ownership which, at 26%, is one of the lowest levels in the country.

5

‘Bid for Properties’ http://www.hackney.gov.uk/hackneychoice ‘How the City of London prioritises applications’ https://www.cityoflondon.gov.uk/services/housing/looking-for-a-home/Pages/housing-register.aspx 7 2011 Census data has been used for comparison purposes throughout this document- more recent data are available through the Annual Population Survey, but the sample for the City of London is too low to provide any meaningful data. The Annual Population Survey is available at https://data.london.gov.uk/dataset/housing-tenure-households-borough/resource/785f6f0e-cc4b42fd-8093-597b009555f2 6

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 17 In the City, the private rented sector is the largest tenure, followed by accommodation that is owned outright and then buying with a mortgage and the social rented sector. These patterns at least in part reflect the age profile of the City’s resident population. A relatively high proportion of City residents (5%) live ‘rent free’, which could be explained by residents living in company-owned flats. [32] Table 3: Household tenure share, Hackney, the City of London, London and England Hackney

City of London

London

England

Owned (all)

26%

43%

50%

64%

Owned: Owned outright

9%

25%

21%

31%

Owned: Owned with a mortgage or loan

15%

17%

27%

33%

Shared ownership (part owned and part rented)

2%

0%

1%

1%

Social rented (all)

44%

17%

24%

18%

Social rented: Rented from council (local authority)

24%

10%

14%

9%

Social rented: Other Private rented (all)

20% 30%

6% 41%

11% 26%

8% 18%

Private rented: Private landlord or letting agency

28%

33%

24%

15%

Private rented: Other Living rent free

1% 1%

3% 5%

1% 1%

1% 1%

Source: Census 2011

The proportion of HMOs as a share of Hackney’s total housing stock is estimated to be one of the highest of all London local authorities. As of September 2016, Hackney had 191 licensed HMOs. The City currently has five licensed HMOs. Tenure and health Figure 4 shows that people living in social housing are the least likely to report their general health as ‘good’ or ‘very good’, followed by those residents who own their own home outright. These patterns are likely to be linked to the socio-demographic profile of these tenures – those who own outright tend to be older in general and people living in social housing are more deprived. Figure 4 also shows that tenants in the private rented sector have the highest levels of self-reported general health overall, which reflects a mixed profile of private tenants locally - some vulnerable families living in poor housing conditions alongside younger, more affluent single people (see Section 6.5). See Section 6.4.1 for a

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 18 description of housing conditions and section 6.4.2 for information on levels of welfare dependency in the private rented sector. Figure 4: Self-reported health, by housing tenure in Hackney and the City of London (2011)

Source: ‘Hackney Public Health Intelligence Bulletin’, 8 April 2016 Note: this graphic combines Census responses for residents in Hackney and the City of London

Homelessness It is very difficult to accurately gauge the level of homelessness across the country, as it affects people in very different ways. There are two main sources of data councils accepting households as homeless (and assuming responsibility to help house them) and rough sleeper counts. In 2015/16 1,017 households were accepted as homeless in Hackney, with 355 unsuccessful applications. The number of households accepted as homeless has risen by nearly 50% from 2011/12, when 686 households were accepted as homeless. In 2015/16, the City took 48 applications from households who were homeless or at risk of homelessness, which represents a marked increase on recent years. The City accepted a duty to secure settled accommodation for 27 of these applicants (i.e. they were deemed eligible for assistance, in priority need and not intentionally homeless). The City also provided temporary accommodation to: • 31 households who were either homeless applicants awaiting a decision on their case, or people whom the City had a duty to house who were awaiting an offer of settled accommodation • 13 households on a discretionary basis, without a homeless application being accepted. Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 19

Data on rough sleeping reported in this section are taken from the CHAIN (combined homelessness and information network) database - a GLA commissioned system managed by St Mungos (a third sector organisation that works with single homeless people). The database monitors rough sleeping across London. All verified rough sleepers - i.e. people who have been seen sleeping rough by local authority outreach teams - are placed on the CHAIN database. [33] Across London in 2015/16, over 8,000 people were seen rough sleeping by outreach workers in 2014/15 (an increase of 7% compared to 2014/15). Of these, two thirds (65%) were seen sleeping rough for the first time in London, but just 3% of the total were seen in all four quarters of the year. In Hackney over this same period, 148 people were identified as sleeping rough across the borough (virtually the same as the previous year) and 87 had been seen for the first time in Hackney. In 2015/16 440 people were seen rough sleeping on the City’s streets, an increase of 18% from the previous year. Of these, 225 people were recorded as rough sleeping for the first time in London, 158 people were longer-term rough sleepers and 57 people had returned to the streets after a period away.

6.5 Inequalities Housing is an important cause and consequence of health inequalities. This section describes inequalities relevant to housing and health, including differences by age, gender, ethnicity and socio-economic status and also describes within-area inequalities and housing-related outcomes of other vulnerable groups. Age and family composition Many housing-related health harms are particularly damaging for the youngest and oldest age groups. For example: [34] [35] • vulnerable older people and young children are at particular risk of harm from cold homes • children are more likely to live in overcrowded housing compared with working age adults and pensioners – with lasting impacts on their social, mental and physical development • older people are at increased risk of falls, including those caused by housingrelated hazards. Section 6.3.2 described how the impact of rising housing costs is being felt disproportionately by young single people (among others). While social housing is the largest single tenure in Hackney (Section 6.4.3), Figure 5 shows that couples with no children are much more likely to be owner-occupiers, while private renting is the most common tenure among ‘other’ households with no dependent children (which includes groups of younger adults living together, e.g. in HMOs). However, nearly one fifth (19%) of private renters in Hackney are households with dependent children. [32]

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 20 According to the 2014 Hackney housing needs survey, among low income households (for this purpose, annual household income of less than £20,000), it is couples with children who are most likely to be living in the private rented sector, which may be exposing them to poor housing conditions and therefore exacerbating health inequalities.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 21 Figure 5: Household composition in Hackney, by tenure (2014)

Source: Hackney housing needs survey 2014 Note: ‘Owned’ in this context includes properties owned with a mortgage and those owned outright.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 22 In 2015/16, the CHAIN data suggests that most rough sleepers in Hackney and the City of London were aged between 26 and 55, though it does appear that the local rough sleeping population is getting younger. This age profile was similar to that of London as whole, with most rough sleepers being aged 26 - 45 years, around one in ten under 26 years old and one in ten over 55. Gender and sexuality As mentioned previously, the stress and anxiety associated with struggles to meet high housing costs tend to accumulate over time, typically affecting men more than women. In 2015/16, four in five rough sleepers (84%) identified by CHAIN data in Hackney were male and 16% were female. In the City in 2014/15, again most rough sleepers were male (89%) and 11% were female. Across London, the average proportion was 15% female. The sexual orientation of rough sleepers is not recorded on the CHAIN database, but research by the Albert Kennedy Trust has shown that many young people in particular will have become homeless as a consequence of their sexuality. [36] Ethnicity The 2011 Census found that owner occupation is most common among White British and White Other households in Hackney, while Black ethnic groups are the least likely to be owner occupiers and most likely to be living in social housing (Figure 6). In the City, White Other and Asian residents are the most likely to be owner occupiers (Figure 7). Private renting is most common amongst White British residents in both local authority areas.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 23 Figure 6: Housing tenure by ethnicity in Hackney residents (2011)

Source: Census

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 24 Figure 7: Housing tenure by ethnicity in City residents (2011)

Source: Census

A report from Shelter in 2005 highlighted the fact that overcrowding disproportionately affects Black, Asian and Minority Ethnic (BAME) communities. [12] The study found that BAME families were twice as likely as White British families to be severely overcrowded and more likely to perceive overcrowding to have had a negative effect on them. For example, more than three-quarters (78%) of Asian/Asian British families strongly agreed that “overcrowding harms the education of our children” compared with half (53%) of White British families. CHAIN data from 2015/16 shows that half of the rough sleepers identified in Hackney were of UK nationality, with a significant number (20%) from Central and Eastern European countries (much lower than the London average of 37%). Over the same period in the City, while half (48%) of rough sleepers again were UK nationals, a higher proportion than Hackney (37%) were from Central and Eastern Europe. Socio-economic differences The national Memorandum of Understanding on health, social care and housing notes that: [37]

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 25 “The home is a driver of health inequalities, and those living in poverty are more likely to live in poorer housing, precarious housing circumstances or lack accommodation altogether.” Hackney is the sixth most ‘housing deprived’ local authority in England, based on the ‘barriers to housing and services’ domain of the 2015 Index of Multiple Deprivation (see the ‘Living standards’ section of this JSNA chapter). [38] This domain includes issues relating to access to housing (such as affordability), as well as ‘geographical barriers’ relating to proximity to local services. Other vulnerable groups Among rough sleepers, it is worth noting that 10 of those identified in Hackney in 2015/16 had been in the armed forces, six had been in care and 46 had been in prison (although this may not have been immediately prior to rough sleeping). For the City over the same period, 23 rough sleepers had been in the armed forces, 44 had been in care and 141 had been in prison. CHAIN data also records support needs for substance misuse and mental health among rough sleepers. In 2015/16, 54 Hackney rough sleepers had alcohol support needs, 49 had substance misuse needs, 47 had mental health needs (some of whom presented with more than one need) and just 10 had none of these. For the City over the same period, 82 had alcohol support needs, 54 had substance misuse needs, 90 had mental health needs, and 94 had none of these. Location within Hackney and the City Figure 8 shows that, on the whole, housing deprivation is relatively evenly spread throughout Hackney, but with relatively lower levels in some parts of the north and west of the borough (around De Beauvoir and Stoke Newington), demonstrating localised inequalities relating to housing. In the 2014 Hackney housing needs survey, however, residents in north east and Stoke Newington areas were the most likely to say that housing costs were either “difficult”, “a strain” or “just manageable”.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 26 Figure 8: Housing deprivation in Hackney (2015)

Stoke Newington

De Beauvoir

Source: Indices of Multiple Deprivation 2015 Briefing

Figure 9 presents data on a different measure of overcrowding to that reported earlier, namely household density (as measured by the percentage of households with more than 1.5 people per bedroom). Levels of household density are shown to be slightly higher in the City of London than the London or national average, and significantly higher in Hackney.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 27 Figure 9: 1.5 or more people per bedroom, Hackney and the City of London

Source: ONS Census 2011 Note: Range in overcrowding levels between Hackney wards, with 18% in De Beauvoir and 28% in Springfield wards.

6.6 Comparison with other areas and over time This section describes trends over time in the four broad categories of housingrelated ‘drivers’ of health introduced earlier (where data are available) – housing conditions, affordability and availability, housing tenure, and homelessness. It also compares the local situation with other similar areas, London and England (where data are available). Housing conditions As mentioned previously, households in Hackney experience some of the highest levels of overcrowding in the country, and the City is also adversely affected (see Section 6.4.1). A good source of comparison data for other health risks associated with housing conditions is the Public Health Outcomes Framework. [39] This provides comparable data for other local authorities (and London and England as a whole) in relation to households in temporary accommodation, excess winter deaths, fuel poverty, and injuries due to falls at home in people aged 65 and over. This data source reveals that: • the rate of injuries due to falls in people age 65+ in Hackney and the City combined are higher (worse) than the England and London averages • fuel poverty is lower (better) than the regional or national averages in Hackney and especially the City

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 28 •

the rate of excess winter deaths is comparable in Hackney and the City (again, data is combined for the two areas).

Comparison data for injuries due to falls in the over 65s and fuel poverty are presented for illustrative purposes in Figure 10 and Figure 11. Figure 12 also reveals that the rate of injuries due to falls in Hackney and the City has increased in recent years, while trends across London and England have remained broadly stable. Figure 10: Injuries due to falls in people aged 65+ (rate per 100,000 population) comparison with statistical peers, London and England 2014/15

2,125

2,253

2,292

2,340

2,439

2,444

2,653

2,879

2,933

2,970

Source: Public Health Outcomes Framework

Figure 11: Percetnage of population in fuel poverty - comparison with statistical peers, London and England 2013

10.4% 9.8% 7.6%

8.0%

8.3%

8.6%

9.2%

9.4%

9.9% 10.3%

3.9%

Source: Public Health Outcomes Framework

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 29 Figure 12: Injuries due to falls (rate per 100,000 population) - changes over time England

London

Hackney and the City

3,000 2,500 2,000 1,500 1,000 500 0 2010/11

2011/12

2012/13

2013/14

2014/15

Source: Public Health Outcomes Framework

Affordability and availability Figure 13 shows how PRS rents in London vary and how this compares to earnings, providing an indication of rent affordability in Hackney compared with other local authorities (no data are available from this source for the City of London). The chart shows monthly rent levels for a two bedroom property as a percentage of full-time earnings in the borough, based on the lower quartile for both earnings and rents.8 Other studies, using a different data source, have found that Hackney has the fifth highest ratio of gross earnings to rent on this same measure (behind Kensington & Chelsea, Westminster, Camden and Islington). [40]

8

The term ‘quartile’ is used to refer to a range of a quarter of the values. The lower quartile for a dataset is the value where 25% of the data is lower and 75% of the data is higher. Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 30 Figure 13: Lower quartile two bedroom PRS monthly rents as a proportion of lower quartile monthly gross earnings (2014)

Source: ONS Annual Survey of Hours and Earnings Note: Confidence intervals not provided. Gross earnings data is not available from this source for City of London and Lambeth (one of the statistical peer boroughs)

Levels of rent in the private sector are becoming increasingly unaffordable for many local people (see Section 6.4.2). Private rents in Hackney increased by an average of 27% between April 2013 and September 2015, whereas the rise in the level of support available through the Local Housing Allowance has been fixed at 1% for the last two years. Rents for bedsits have increased even more significantly over this period, by 62%. Median PRS rents in the City have risen by 23% since 2012. Figure 14: Affordability of private rented accommodation in Hackney (2011-16)

30%

Percentage of private sector housing accessible to Housing Benefit recipients in 2011

3%

Percentage of private sector housing accessible to Housing Benefit recipients in 2016

Source: Valuation Office

Figure 15 shows the average house price to earnings ratio, which is an important indicator of housing affordability for those looking to buy a home. This ratio is calculated by dividing median house price by the median annual income of a borough. Hackney has seen an 80% increase in this ratio in just six years, between 2010 and 2016, which is higher than most of Hackney’s statistical peers (Figure 16).

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 31 Figure 15: Ratio of house prices to annual income, England, London and Hackney (2010-2016) England

London

Hackney

20

15

10

5

0 2010

2011

2012

2013

2014

2015

2016

Source: ONS Annual Survey of Hours and Earnings and ONS House Price Statistics for Small Areas Note: the City of London is not included because annual income data is drawn from a survey and response rates are too small to be accurately included

Figure 16: Ratio of house prices to annual income, comparison to statistical peers (2016)

14

14

16

16

16

18

19

21

23

9

Source: ONS Annual Survey of Hours and Earnings and ONS House Price Statistics for Small Areas

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 32 Note: Confidence intervals not provided. The City of London is not included because annual income data is drawn from a survey and response rates are too small to be accurately included

Housing tenure Figure 17, Figure 18 and Figure 19 highlight Hackney and the City’s distinctive tenure patterns alluded to in section 6.4.3. Hackney has a much smaller owner-occupied sector and the second largest social rented sectors in London. The private rented sector is one of the smallest among Hackney’s statistical ’peers’, but the size of this tenure more than doubled in the decade up to the 2011 Census, and is now higher than the London average. The City of London has a much larger owner-occupied sector, but this is still lower than the London average. The percentage share of the City’s private rented sector is one of the highest in London, while social renting is less common. Figure 17: Tenure composition - property owned outright or with mortgage (2011)

63% 48% 32% 33% 34% 24% 24% 28% 29%

42% 46%

Source: ONS, Census

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 33 Figure 18: Tenure composition - social rented (2011)

18%

24%

40% 42% 44% 44% 35% 33% 31% 17% 20%

Source: ONS, Census

Figure 19: Tenure composition - privately rented (2011)

25% 17%

36% 29% 29% 32% 32% 32% 33% 27% 24%

Source: ONS Census Note: Private renting excludes living rent free (which explains the difference in the figures in Table 3).

Homelessness Statutory homelessness is a growing problem across the country, but has been felt most severely in London. Figure 20 shows that Hackney has the highest rate of households in temporary accommodation of all its statistical peers and is significantly higher than the London average. This trend over time shows the rate has increased from 14 per 1,000 households in 2010/11 to 23 per 1,000 in 2015/16. Temporary accommodation is predominantly used where a local authority has accepted a household as homeless, and are awaiting an available property for them to move to. Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 34

Figure 20: Statutory homelessness – households in temporary accommodation comparison with statistical peers (rate per 1,000 households)

Source: Public Health Outcomes Framework

Figure 21 compares rates of homeless acceptances in Hackney and the City of London to Hackney’s statistical peers, London and England. This shows how significant an issue homelessness is in both local authorities. Over the last five years, the number of households Hackney Council has accepted as statutory homeless has grown year on year, rising considerably in 2013/14 and staying at around the same level in 2015/16 (around 1,000 households - 50% above 2011/12 levels). This coincides with the welfare reform timetable and, in particular, the restriction on rent support to tenants in the private sector. [41]

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 35 Figure 21: Rates of households accepted as homeless in Hackney, City of London, England and statistical peers (per 1,000 households), 2015/16

Source: Department for Communities and Local Government

6.7 Evidence and best practice This sub-section highlights evidence and best practice in addressing the health harms of housing as described earlier in Section 6.3. Improving housing conditions for better health Targeted investment to reduce and mitigate housing-related hazards plays a key role in addressing associated health harms. The largest recent example of a national scheme to improve conditions in the social rented sector is the Decent Homes programme, which has overseen improvements in over a million homes since 2001. The programme has thus improved the living standards of vulnerable people across the country and has been praised by the Public Accounts Committee. [42] A broad range of housing stock improvement programmes have also been led by local government, most of which have not been properly evaluated for their health impacts. A systematic review of studies of these programmes found that the data were not amenable to meta-analysis, for a number of reasons, but came to the following conclusions. ‘Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work.’ [43] The National Institute for Health and Care Excellence (NICE) has published specific guidance on reducing the health risks of cold homes, including a number of evidence-based ‘quality statements’ to improve the health and wellbeing of vulnerable affected groups, reduce the risk of fuel debt and improve the energy

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 36 efficiency of homes (see Table 4Table 4). [9] A case study from Leeds on the practical application of these NICE guidelines is summarised in Box 5. Table 4: Preventing excess winter deaths and illness associated with cold homes (NICE quality standard, 2016) Statement

Detail

Statement 1

Local populations who are vulnerable to the health problems associated with a cold home are identified through year‑round planning by local health and social care commissioners and providers.

Statement 2

Local health and social care commissioners and providers share data to identify people who are vulnerable to the health problems associated with a cold home.

Statement 3

People who are vulnerable to the health problems associated with a cold home receive tailored support with help from a local single point of contact health and housing referral service.

Statement 4

People who are vulnerable to the health problems associated with a cold home are asked at least once a year whether they have difficulty keeping warm at home by their primary or community healthcare or home care practitioners.

Statement 5

Hospitals, mental health services and social care services identify people who are vulnerable to health problems associated with a cold home as part of the admission process.

Statement 6

People who are vulnerable to the health problems associated with a cold home who will be discharged to their own home from hospital, or a mental health or social care setting, have a discharge plan that includes ensuring that their home is warm enough.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 37 Box 5: Case study – ‘Warmth for Wellbeing Service’ (Leeds) The ‘Warmth for Wellbeing Service’ was established in Leeds in October 2015, informed by evaluations of previous similar interventions, to support households with all their affordable warmth needs. The service provides tailored solutions to needs identified by/for vulnerable people living in cold homes, incorporating: • face-to-face advice • low cost energy saving improvements • heating serving or repairs • referrals to relevant support, such as large-scale energy efficiency improvements to their property. The service is offered to residents living in private sector housing who are in receipt of any income-related benefit, on a low household income (under £21,000 per annum) and have little or no savings. The emphasis is on those who live in fuel poverty. Eligible residents must also fulfil one of the following criteria: • over 60 years of age • expecting, or have children under age 16 • have a disability or cold-related illness. Preliminary findings show that the service’s freephone telephone number has experienced a month-on-month increase in calls, there have been a higher than expected number of referrals from frontline council officers, and fruitful connections have been made with local social prescribing schemes. Benefits to householders include: • significant savings on utility bills, mainly as a result of successful Warm Homes Discount applications and switching suppliers • timely heating repairs and improvements, ensuring that they have not been left without heat or hot water for long periods of time • support to apply for free or subsidised replacements of obsolete heating systems and other large energy-efficiency measures. It is now possible to calculate the health benefits of interventions to improve housing stock conditions using the Housing Health Cost Calculator, which has been developed by the Building Research Establishment (BRE) in partnership with RH Environmental. This tool quantifies the health impact of works undertaken to reduce and mitigate hazards defined under the HHSRS, and monetises these impacts as savings to the NHS and to wider society. [44] See Box 6 for an example of how the cost calculator has been applied by a local authority.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 38 Box 6: Case study – Using the Housing Health Cost Calculator (Derby) [45] Derby City Council facilitated housing improvements in Brindley Court, one of the poorer private sector accommodations in Derby. The council completed a retrospective health impact assessment to calculate the savings to the NHS and wider society achieved by these works, with measurements made using the Housing Health Cost Calculator. The total cost of works carried out within the project was £65,709. This work is estimated to produce savings to the NHS of £23,191 and to wider society of up to £58,000 annually. The largest estimated health cost savings were identified to arise from mitigating hazards associated with excess cold. It is estimated that, in total, these works will save 36 incidents of harm over a 10year period, some of which would be expected to involve hospitalisation or death. Improving access to affordable housing A recent report by the McKinsey Global Institute identified four necessary actions to improve housing affordability: [46] • unlock land supply • reduce construction costs • proper maintenance of homes once they have been built • lower financing costs for buyers and developers. It is clearly not possible to achieve all of this through local action alone, nor will these interventions address the significant loss of social housing into private ownership that is occurring in the UK through recent housing legislation. A recent review of the social and economic impact of government capital investment in affordable housing found that it improved a wide range of outcomes for local residents in areas including health, crime, education, employment and community cohesion. [47] Successive national governments have offered shared ownership schemes and low cost home ownership support for first time buyers, through a number of different models. Around 95,000 people were assisted into home ownership under these schemes between 1997 and 2008. [48] Further efforts have been curtailed somewhat following the financial crisis in 2007. Current schemes include Help to Buy, an equity loan scheme. In the first 30 months of this scheme (to 30 September 2015), 62,569 properties were bought, 81% of which by first-time buyers. This scheme has been much more successful in other parts of the country, outside London, where house prices are lower. In over three years of the scheme, between April 2013 and June 2016, just 60 equity loans were taken up in Hackney. [49] A national evaluation of the Help to Buy scheme concluded that: ‘the empirical evidence would support the view that it has provided an important stimulus to generate a not insignificant increased output in the housebuilding sector, as well as a stronger recovery in the mortgage market along with higher confidence among all these players and consumers.’ [50] Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 39

This does not mean it has been universally popular however. Among others, Shelter has raised concerns about its impact on house prices. Their analysis of these mortgages suggests that Help to Buy has added around £8,250 to the average house price, and that in the places where Help to Buy loans and guarantees have been used most, house price inflation has run above regional trend rates. [51] Support for vulnerable tenants Social landlords do a great deal more than just providing and managing accommodation. A range of support is commonly offered to address the often significant health and wellbeing needs of their tenants - including jobs and training, learning and skills, as well as support to specifically address health needs and enable people to remain independent in their own home. A 2012 audit by The National Housing Federation identified more than 9,000 neighbourhood projects being delivered by housing associations across the country. [52] One example of such a project is described in Box 7. Box 7: Case study – ‘Health Begins at Home’ (Family Mosaic) [53] The ‘Health Begins at Home’ research project began in 2013, to test the effectiveness of the following two interventions in improving the health and wellbeing of tenants aged over 50: • signposting to health and wellbeing services by a neighbourhood manager • intensive personalised support from a dedicated health and wellbeing support worker (including being accompanied to relevant local services). The study also included a control group. Across London and the south east, 547 participants were recruited to the study. An evaluation of the service found that impacts were small for many indicators, but that both interventions resulted in lower use of NHS services by residents (especially among vulnerable and socially isolated individuals) and some improvements were made in mental wellbeing. Health behaviours such as smoking, drinking and completion of health tests, and self-reported activity and mobility levels did not change significantly however. As Family Mosaic recognises in its final evaluation report: “As a social housing provider, we’re in a unique position to provide this support, because of our proximity to our residents, and our existing local connections.”

The examples described above demonstrate that social landlords can (and do) play a pivotal role in improving the health outcomes and life experiences of their tenants; benefits that can now be measured in social value terms using a tool developed by the housing charity HACT. [54] Vulnerable residents in private rented accommodation do not benefit from the same support from their landlords, which acts to further entrench tenure-related inequalities. However, in a number of areas across the country, innovative projects Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 40 are underway to identify these tenants and provide appropriate support to meet their health and wellbeing needs. One example of such a project is described in Box 8. Box 8: Case study – Healthy Homes (Knowsley Council) [55] Healthy Homes is led by Knowsley Council's Public Health team in partnership with a number of local agencies. The service began in September 2014 and aims to take a proactive and preventative approach to tackling housing and health related issues within the borough. By facilitating access to existing support services for those currently not engaged, the initiative encourages residents to be healthier, more financially secure, able to work, and to look after themselves and their properties. In the long term, this is intended to lower demand for more reactive council and wider public services including environmental health, social care, health care, the police and fire service. Healthy Homes targets areas of poor-quality housing and health for intervention via a team of trained advocates, who will visit every home within the area. A structured conversation is held with residents in relation to the condition of their property and a range of other issues affecting their health and wellbeing. The advocate collects information during the interview via a secure tablet computer and, where appropriate and with resident consent, will generate an automated referral to one or more local services. By January 2015, over 3,200 homes had been visited as part of the initiative. This has resulted in over 1,100 referrals to other agencies that can provide solutions and support. Many residents have been referred for energy efficiency advice, smoke alarms and housing issues. Evaluation of the scheme is ongoing.

Reducing homelessness and associated health harms Housing options and advice are provided by local authorities to address homelessness, but often not until a family or individual has already become homeless. The charity Shelter advocates for much earlier intervention, identifying those who are vulnerable to the threat of homelessness and then providing a range of preventative measures - from targeted advice and advocacy through to tenancy sustainment schemes and interventions to ensure that homes are not lost through rent arrears. [56] To prevent future episodes of homelessness, there is a strong case for providing support to children and young people to remain at home with their families or in wider family networks, when it is safe to do so. [57] Early action by agencies to mediate between young people and their families is key to achieving this. There is also a major preventative role for education through schools and other youth provision (in particular peer education and mentoring schemes), in highlighting the reality of homelessness and leaving home at a young age. A recent review found there to be limited robust evidence on effective interventions specifically designed to meet the health and wellbeing needs of people at risk of homelessness. [58] Most of the interventions that were identified focused on holistic in-tenancy support, hospital-discharge services and community outreach to Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 41 vulnerable high-risk groups (such as former rough sleepers, young people and people with complex needs). Action on primary prevention (i.e. interventions that minimise the risk of becoming homeless in the first place) is either absent or poorly documented in the literature. In 2010, the Ministerial Working Group on Homelessness published plans to end rough sleeping. Supported by the £20m Homelessness Transition Fund, it drove forward the national roll-out of No Second Night Out, the approach initiated in London to ensure that anyone sleeping rough received help quickly. Administered by Homeless Link, the Homelessness Transition Fund has supported 175 projects across England and had supported 12,235 people by early 2015. [59] The working group has also focused on youth homelessness, assisted hospital discharge and improved partnership working through technology (such as the StreetLink service).9

6.8 Services and support available locally Improving housing conditions For those living in council-owned properties, Hackney Housing provides a range of services to maintain and improve the condition of homes in the borough. This includes a repairs service, which is responsible for the structure and outside of the property, systems in the property for supplying water, gas, electricity and sanitation, and heating. Similar services are provided by all housing associations operating locally. For properties in the private rented sector, Hackney Council recently launched its campaign, ‘10 steps to better private renting for tenants and landlords,’ which aims to improve standards in this sector (see Box 9). [60] Hackney Council’s Private Sector Housing team also provides a tenant complaints service, which delivers a range of interventions aimed at improving housing conditions and removing hazards to mitigate health impacts and prevent homelessness. The service receives around 500 to 600 complaints related to substandard conditions and over 130 pest control and nuisance type complaints each year. Support available from the service includes negotiation with private landlords and, where necessary, enforcement action. The service also administers the statutory Mandatory Licensing Scheme for larger HMOs, which ensures that fire safety, housing management and housing conditions in the private rented sector meet prescribed standards. The government is currently consulting on extending the mandatory HMO licensing scheme to increase the number of properties subject to the scheme. In the City of London, minimum standards have been set out for the first time that are applicable to all HMOs and refer to basic minimum standards for fire protection, room sizes, management and amenity provision. They are intended to assist landlords to comply with minimum standards and assist with regulation if landlords are non-compliant.

9

http://www.streetlink.org.uk/ Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 42 Box 9: Hackney Council’s 10 steps to improve private renting Topic

Detail

Inflation-capped rents

To ensure greater security for tenants, as well as continuity of income for landlords

Longer tenancies

These should be offered for years, not months, giving more stability, particularly for families with children

Government should publish a list of convicted landlords and lettings agents

To enable renters to check those offering a property are fit to do so

Fast-track licensing schemes

Cut red tape for councils setting up licensing schemes to ensure high quality standards of accommodation and service

Create a national quality kitemark

So tenants can identify good quality accommodation

Pay Housing Benefit direct

Explore further incentives for responsible landlords, including the choice of direct Housing Benefit payments to accredited landlords offering longer tenancies and stable rents

Public register of landlords and properties

To enable tenants to find out directly who they pay rent to and enable the council to provide information and support to landlords who need it

Require letting agents to protect paid rent and fees

Mandatory protection to ensure recovery in case a lettings agent goes into administration or misappropriates funds

Costs transparency

Make it mandatory for landlords to publish related costs of a property, such as utility bills, and for lettings agents to explain all their fees

Improve safety

Mandatory installation of fire and carbon monoxide detectors and mandatory annual electrical tests

Support for vulnerable residents Many local social landlords, including Hackney Housing, provide a range of interventions that promote wellbeing, social participation and financial inclusion for their tenants. The Hackney Financial Inclusion Steering Group brings together the council, Citizens Advice East End and most of the large housing associations in the borough including Hackney Housing. The main collaborative financial inclusion project is Hackney Money Smart (see case study in the ‘Living standards’ section of this JSNA chapter).

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H o u s i n g a n d h o m e l e s s n e s s | 43 Hackney’s Private Sector Housing team provides adaptations to the homes of disabled residents through the Disabled Facilities Grant programme, supporting people to live independently in their own homes as long as possible. As in other parts of the country, a not-for-profit home improvement agency operates in Hackney to provide support to elderly home owners and private tenants to improve, repair, maintain and adapt their home. This service also provides advice and information on entitlement to benefits and grants, making home visits as needed.10 To help residents remain independent in their homes after a stay in hospital, a discharge planning team at Homerton Hospital works with multi-disciplinary teams (including the patient, doctors, nurses, therapists, specialist nurses and social workers) to carry out needs assessments and make the necessary arrangements for patients to be discharged safely and in a timely manner. The City of London’s Housing Strategy 2014-19 includes a priority to support vulnerable groups locally, with the aim of building more resilient communities. Prevention, promoting independence and earlier intervention are central to this approach, which focuses on the following: [61] • preventing homelessness • tackling rough sleeping • supporting people with disabilities • supporting older people • intervening early to reduce inequalities and tackle deprivation. Reducing homelessness and associated health harms Independent advice for tenants is available from a number of local charities, most notably Shelter, whose Hackney Family Service supports families who are at risk of homelessness and deal with other housing issues as well. The charity offers free, expert housing advice on a range of topics, and works with specialist services to tackle recurring causes of homelessness (such as mental health issues, substance abuse, domestic abuse, anti-social behaviour and family breakdown) – through interventions coordinated by dedicated family support workers. The City Housing Needs and Homelessness Team provides advice and assistance to prevent or end homelessness for local people. The City of London Corporation also commissions advice services for vulnerable people, including those in need of housing advice or at risk of homelessness. Housing support is provided to key vulnerable groups in Hackney, including single homeless people and homeless families, those with mental health problems, exoffenders and young people at risk. This provision was originally funded through the Supporting People grant programme for local authorities. This support plays an important role in homeless prevention by enabling people to establish and maintain independent living, while also meeting a range of complex social and health needs of service users through a recovery model. Homeless people and Hackney residents 10

Information on how to apply is available at https://www.hackney.gov.uk/renovation-grants Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 44 with long-term health problems may also benefit from generic or specialist floating support services. In addition, Hackney is currently piloting a ‘Multiple Needs Service’, which provides intensive support to 24 clients with multiple needs - including substance misuse, mental illness, a history of offending and homelessness or living in insecure housing (it is estimated that between 90 and 150 people in Hackney had needs in all four areas in 2015).11 The service coordinates services around the individual and makes the system work for them (rather than requiring them to arrange access to different services for different needs). The primary aim of this service is to improve the physical health and mental wellbeing of an extremely vulnerable group of people. Box 10 provides an individual case study of one of the clients to benefit from this service. Box 10: Case study – coordinating support around disadvantaged residents (Hackney Council’s Multiple Needs Service) K is a 31 year old male who has a long history of service involvement and is known as a perpetrator of domestic violence (DV). K describes himself as an alcoholic and has managed to reduce his drinking only when subject to probation. His parents' relationship ended as a result of his father's behaviour towards him. Although he has a good relationship with mother and siblings, K has three children from a previous relationship and says he misses being able to see his children regularly. When K first presented to the Multiple Needs Service, K was street homeless and was bedded down around the Hackney Central area. K has a record of involvement with criminal justice services, with offences between 2004 and January 2016. K is known to the South Hackney Community Mental Health Team where he attended the first few appointments with a keyworker, but eventually disengaged. K was referred to the Multiple Needs Service in April 2016 by the Pause service, which works with women who have had, or are at risk of having, one or more children removed. The Pause service have been working with K’s partner G, who is the mother of one of his children and is also the victim in the DV case against him. K is a vulnerable adult with varying complex needs. He has expressed a desire to change his lifestyle, and needs support to assist with this. Initial engagement proved to be very difficult, caused in part by a short period in prison and on an acute mental health ward. Despite these challenges in the period immediately following referral, progress has been made. By the end of May 2016 K managed to get temporary accommodation. There were some issues with this as K’s benefits had been stopped due to him missing a health assessment while he was staying in the mental health ward. The Multiple Needs Service case worker obtained an extension on K’s stay in temporary accommodation and resolved the benefits issue. 11

Estimates compared various national databases including Supporting People, National Drug Treatment Monitoring System and Oasys offender management. Methodology http://www.lankellychase.org.uk/assets/0000/2876/Hard_Edges_Appendices_FINAL.pdf Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 45 The number of times K has presented in crisis has drastically been reduced and he is now relatively stable. K does realise that this is just the beginning and he will need to stay focused and motivated. However, he remains on the right track and is now talking about doing a catering course and being relocated out of the area to get away from ‘bad influences’. Note: some details have been changed to protect the identity of the person involved

Hackney Council also supports the Hospital Discharge Service, an integrated service with St Mungo’s Broadway that offers hostel places and Homeless Healthcare, which together with local primary care services provides support to hostel residents. The City also funds St Mungo’s Broadway to deliver a range of preventative and support services, including outreach to rough sleepers and arranging accommodation. The service refers rough sleepers to No Second Night Out and Noone Living on the Streets rapid assessment and response services - for rough sleepers who are new to the streets and intermittent rough sleepers who wish to stop living on the streets. The City also supports the Middle Street Hostel financially, and funds a part-time support post there. Box 11 provides examples of some of the innovative service models being implemented in the City to address the needs of its street homeless population. Box 11: Case study – Accommodation and support for rough sleepers (City of London and St Mungo’s) The City has developed innovative accommodation and service models to help its most entrenched rough sleepers leave the streets. Working with St Mungo’s Broadway, it has developed a new model of hostel accommodation for long-term rough sleepers, whose needs are distinct from those of more transient or chaotic rough sleepers. The accommodation, known as The Lodge, breaks away from the traditional model and approach of a hostel to offer hotel-style accommodation. In doing so, The Lodge has succeeded in engaging, accommodating and supporting a client group that would not otherwise have been helped. Some long-term rough sleepers remain resistant to support from services. In 2010 the City of London’s Outreach Team piloted a new way of working with this group, focusing on personalisation. The project moved away from the standard model of outreach to provide longer-term, more intensive engagement, and the offer of a personal budget to enable flexible and creative approaches. The project was developed and is delivered by St Mungo’s Broadway. It was rolled out across London in 2011, and the City of London, in partnership with St Mungo’s Broadway, received the Andy Ludlow Award for this work. The City of London operates regular pop-up hubs in association with St Mungo’s Broadway, local churches and the City of London Police. Pop-up hubs currently operate every six weeks over a six day period. These hubs provide an opportunity for those sleeping rough to engage with a number of key services, all in the same venue, to help them find the support they need to leave the streets. Their intensive, 24-hour approach is considered as being especially effective for rough sleepers who are not eligible for support through the No Second Night Out initiative and/or who need reconnection.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 46

6.9 Challenges and opportunities Housing affordability and availability will continue to pose significant local challenges for the foreseeable future in Hackney and the City, driven largely by regional, national and international influences beyond local control. However, there are significant opportunities for health and housing professionals to work closer together to improve outcomes for local residents. Staff working across the housing sector are key players in the public health ‘wider workforce’, and there are significant opportunities for greater reach into communities to address their health and wellbeing needs through closer working with housing associations. [62] This links closely to the concept of ‘making every contact count’, which aims to ensure that all public sector partners are able to identify and support the health and wellbeing of their clients (through signposting and/or brief advice). Now that Public Health teams are positioned in local authorities, the scope to further embed public health thinking in the work of social housing staff and those teams supporting private sector housing residents is greatly enhanced. Hackney’s Public Health Team is already working closely with housing colleagues to identify opportunities to better support vulnerable tenants (in both the social and private rented sector) to improve their health and wellbeing. A promising approach to housing support, in the context of reducing budgets and welfare safety net, is the Housing First Model - developed in New York and being implemented by many service providers across the US and increasingly in Europe. [63] This is a model of permanent supported housing, based on the premise that a homeless individual or household’s first and primary need is to obtain stable housing, and that other issues affecting the household can and should be addressed once this housing need has been met. This contrasts with many other programmes which operate from a model of ‘housing readiness’- that is, that an individual or household must address other issues that may have led to an episode of homelessness first before being granted access to housing. Housing First is being considered in Hackney as part of a wider review of the single homeless supported living service.

Published December 2016; January 2017

H o u s i n g a n d h o m e l e s s n e s s | 47

6.10 References [1] Hackney Council, “Hackney: a place for everyone (HAPFE) report,” 2016 (forthcoming). [2] Crisis, “What is Homelessness,” 2005. [3] Department for Communities and Local Government, “‘Housing health and safety rating system (HHSRS): guidance for landlords and property-related professionals’,” 26 May 2006. [4] Opinion Research Services, “London Borough of Hackney: Strategic Housing Market Assessment 2014,” March 2015. [5] Chartered Institute of Environmental Health, “‘Mental health and wellbeing – key issues’,” [Online]. Available: http://www.cieh-housing-and-healthresource.co.uk/mental-health-and-housing/key-issues/ References available at http://www.cieh-housing-and-health-resource.co.uk/references/. [Accessed April 2016]. [6] Chartered Institute of Environmental Health, “‘References',” [Online]. Available: http://www.cieh-housing-and-health-resource.co.uk/references/. [Accessed October 2016]. [7] L. Harker, “Chance of a lifetime: The impact of housing on children’s lives,” Shelter, 2006. [8] UK Health Forum, “‘Fuel Poverty: how to improve health and wellbeing through action on affordable warmth’,” April 2014. [9] National Institute for Health and Care Excellence, “‘Excess winter deaths and morbidity and the health risks associated with cold homes: NICE guidelines’,” March 2015. [10] Department of Health, “‘Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better: Prevention Pays’,” October 2013. [11] The Marmot Review, “The Health Impacts of Cold Homes and Fuel Poverty,” 2011. [12] Shelter, “‘Full house? How overcrowded housing affects families’,” 2005. [13] W. Wilson and C. Fears, “Overcrowded housing (England),” House of Commons Library, 14 November 2016. [14] S. Burgards, K. Seefeldt and S. Zelner, “Housing instability and health: findings from the Michigan Recession and Recovery Study,” Soc Sci Med, vol. 75, no. 12, pp. 2215-24, 2012.

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H o u s i n g a n d h o m e l e s s n e s s | 48 [15] R. Bentley, E. Baker and K. Mason, “Cumulative exposure to poor housing affordability and its association with mental health in men and women,” Epidemiol Community Health, vol. 66, no. 9, pp. 761-6, 2012. [16] E. Baker, “Evidence on the relationship between unaffordable housing and poor health,” University of Adelaide, 2011. [17] K. E. Mason, E. Bentley and E. Baker, “Housing affordability and mental health: does the relationship differ for renters and home purchasers?,” Soc Sci Med, vol. 94, pp. 91-97, 2013. [18] Glasgow Centre for Population Health, “The built environment and health: an evidence review,” November 2013. [19] M. Rounds, G. Evans and M. Braubach, “The interactive effects of housing and neighbourhood quality on psychological well-being,” Epidemiol Community Health, vol. 68, no. 2, pp. 171-5, 2014. [20] T. Cruwys, G. Dingle and M. Hornsey, “Social Isolation Schema responds to positive social experiences: longitudinal evidence from vulnerable populations,” Clin Psychol, vol. 53, no. 3, 2014. [21] A. Story, “Slopes and cliffs in health inequalities: comparative morbidity of housed and homeless people,” The Lancet, vol. 382, no. 93, 2013. [22] Crisis, “Homelessness: A silent killer- a research briefing on mortality among homeless people,” 2011. [23] Homeless Link, “Causes of homelessness,” [Online]. Available: http://www.homeless.org.uk/facts/understanding-homelessness/causes-ofhomelessness. [Accessed April 2016]. [24] W. Wilson, “Rough Sleeping (England),” House of Commons Library, July 2016. [25] Homeless Link, “The unhealthy state of homelessness: health audit results,” 2014. [26] L. Rumbold, L. Giles and M. Whitrow, “The effects of house moves during early childhood on child mental health at age 9 years,” BMC Public Health, vol. I, no. 12, p. 583, 2012. [27] Department for Communities and Local Government, “A Decent Home: Definition and guidance for implementation,” June 2006. [28] Fordham research, “London Borough of Hackney Housing Needs Assessment,” 2009. [29] Housing Quality Network (HQN), “The private rented sector in Hackney: stakeholder engagement and listening exercise,” 2015.

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H o u s i n g a n d h o m e l e s s n e s s | 49 [30] Hackney Council, “Lettings Plan 2014/15,” 24 March 2015. [31] G. L. Hearn, “City of London Strategic Housing Market Assessment: City of London Corporation,” June 2016. [32] Office of National Statistics, “Tenure by household composition,” 2011. [Online]. Available: https://www.nomisweb.co.uk/census/2011/dc4101ew. [Accessed November 2016]. [33] Greater London Authority, “Rough sleeping in London (CHAIN reports),” 2015. [34] NatCen Social Research, “People living in bad housing– numbers and health impacts,” August 2013. [35] World Health Organization, “What are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls?,” March 2004. [36] The Albert Kennedy Trust, “LGBT youth homelessness: a UK national scoping of cause, prevalence, response, and outcome,” 2015. [37] National Housing Federation et al, “A Memorandum of Understanding to support joint action on improving health through the home,” 2014. [38] Hackney Council, “Indices of Multiple Deprivation 2015 briefing,” 2015. [39] Public Health England, “Public Health Outcomes Framework: Hackney”. [40] Trust for London, “London’s Poverty Profile: Rents and Affordability”. [41] Hackney Council, “Homelessness Strategy 2015-2018,” October 2015. [42] House of Commons Committee of Public Accounts, “The Decent Homes Programme,” March 2010. [43] H. Thomson, S. Thomas and E. Sellstrom, “Housing improvements for health and associated socio-economic outcomes,” Cochrane Database of Systematic Reviews, no. 2, October 2013. [44] M. Davidson, M. Roys and S. Nicol, The real cost of poor housing, 2010. [45] BRE, “A retrospective health impact assessment of housing standards interventions in Derby,” 2012. [46] McKinsey Global Institute, “A blueprint for addressing the global affordable housing challenge,” October 2014. [47] Frontier Economics, “Assessing the social and economic impact of affordable housing investment: a report prepared for g15 and the National Housing Federation,” September 2014.

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H o u s i n g a n d h o m e l e s s n e s s | 50 [48] House of Commons library, “Extending home ownership: Government initiatives,” March 2016. [49] Department for Communities and Local Government, “Help to Buy Equity Loan Scheme, by district (Total Equity Loans & Equity Loans First Time Buyers),” September 2016. [50] Department for Communities and Local Government, “Evaluation of the Help to Buy Equity Loan Scheme,” February 2016. [51] Shelter, “How much help is Help to Buy? Help to Buy and the impact,” September 2015. [52] University of Birmingham, “Neighbourhood Audit 2011,” July 2012. [53] Family Mosaic, “Health Begins at Home,” February 2016. [54] HACT, “Measuring the Social Impact of Community Investment: a guide to using the Wellbeing Valuation approach,” March 2014. [55] National Institute for Health and Care Excellence, “Knowsley Healthy Homes Initiative,” May 2015. [56] Shelter, “Homelessness: Early identification and prevention,” 2007. [57] Homeless Link, “No Excuses: Preventing Homelessness for the Next Generation,” 2013. [58] Homeless Link, “Preventing homelessness to improve health and wellbeing,” July 2015. [59] Department for Communities and Local Government, “Addressing complex needs: Improving services for vulnerable homeless people,” March 2015. [60] Hackney Council, “10 steps to better private renting for tenants and landlords,” [Online]. Available: http://www.hackney.gov.uk/10-steps. [Accessed June 2016]. [61] City of London, “City of London’s Housing Strategy 2014–19,” February 2014. [62] Royal Society of Public Health, “Rethinking the Public Health Workforce,” 2015. [63] Shelter, “Housing First - a Good Practice Briefing,” November 2008.

Published December 2016; January 2017