Putting public health, planning and housing on national and local agendas

Written by Professor John R Ashton, President of the Faculty of Public Health of the UK Medical Royal Colleges

Last month, the King's Fund hosted a major housing and public health conference, 'Bringing together health and housing - enabling better health and wellbeing'. It featured a selection of examples of joint working between housing and health and care services that are showing real successes in improving health and wellbeing outcomes for their populations.

Housing has always been a central public health issue. Shelter from the elements is essential to human survival. However, the nature of the public health issues in the past has changed over time and, in particular, with respect to the phenomenon of rapid urbanisation and slum dwelling. This was what confronted the Victorian public health movement and the town hall and led to the intimate connection between public health and town planning, a partnership that was very effective in heading off the epidemics of cholera and other diseases in Europe, North America and some of the far flung parts of Empire. These classical environmental challenges are just as relevant today in the emergent mega cities around the world where peasants flock in seeking a better life.

For those of us in the post-industrial world, the demographics have moved on. Large families are a distant memory. Mobility, the changed position of women in society, the contraceptive pill and the remarkable phenomenon of mass survival to a great age have all contributed to a transformation which would have amazed my grandparents. Yet, we are stuck with paradigms of housing which are rooted in earlier times; one of suburbs, nuclear family housing and sprawl. Paradigms in which you can have any kind of shelter you wish as long as it a free standing or semi-detached box for a man, a woman and 2.14 children.

Today as many as a quarter of women elect to have no children at all and on average between them they manage less than two children each (below the population replacement rate in the medium term). Beginning in the 1970's a large proportion of people began to live past their 70's into their 80's, 90's and more. The proportion of a lifetime involved in child care has shrunk from more than half to more like a quarter for those involved in it at all. And segregation, isolation and protracted loneliness is increasingly the fate of those of us who are benefiting from this 'bonus' of longevity. In the meantime, the vital connection between town planning and public health has been fractured.

In my view, planning has long been a dirty word and housing has been left to a largely private market lacking in imagination, vision, government support and direction and a commitment to the disadvantaged. The menu of housing types on offer is restricted and largely inappropriate .Family houses, flats, care homes and institutions. So what do we need?

• First, we need to reconnect town and country planning into the debate about what the good life in our towns, cities and villages could and should look like.
• Second, we need to commit ourselves to redesigning and regenerating our Victorian residential infrastructure to be supportive and user-friendly for populations in which more than half are over 50 years old. Places where the elderly are not segregated from the young and where people can continue to play an active part in their communities until biology finally intervenes.
• And thirdly, we need environments and housing forms that facilitate mutual care and support and take the pressure off our overloaded health and social services and help to keep people 'young as old as possible', 'fit til they fall off the perch'. What might this look like?

In Boston they have buried the main roads in 'the big dig' which has created new parkland linking the residential districts of the city. In Scandinavia and the Netherlands, cycle path provision is such that most people are both cyclists and motorists, the car no longer dominates residential areas and it is commonplace for 80 year olds to cycle to the shops. Also, in the Netherlands, students can have free accommodation in care homes by providing a certain number of voluntary hours support to the residents.

In the private sector, communal housing forms in which older people can maintain equity in a property whilst being able to titrate their social engagement and their privacy behind their own front door or in the communal areas are increasingly to be found. Not so much in the world of social housing. And, despite the impressive work on HAPPI, there remains a dearth of imagination and of innovative housing options by dwelling type and tenure mix.

While the media coverage is dominated by the dysfunctional private sector market of London and the south east and the impossibility of young adults finding anywhere to live, we have watched for decades as the lack of regional policy has led to perfectly good infrastructure in the north and elsewhere going unused, good housing being demolished dreams vanishing. Initiatives such as the health and housing Memorandum of Understanding, the Northern Powerhouse and the emerging Healthy New Towns programmes provide an opportunity to redress the balance.

And finally, above all, we need to reframe the housing issue as one which defines what it is to have good government at a national and local level. We need politicians, policy makers and planners that care enough to make sure that everybody has housing options and choices and not just those with secure financial resources.

Furthermore, we need an 'a la carte' menu that extends to social as well as private housing and we need to remove the perverse incentives to maintain a housing shortage to inflate the asset value of those fortunate enough to be on the housing ladder. In short, we need to plan and we need to plan together, community by community. While the recent Housing and Planning Bill makes some positive noises on neighbourhood planning, the primary focus continues to perpetuate home ownership for first time buyers or those in social rented housing through the proposed new right to buy measures.

As a baby boomer born in 1947, God willing I will be 80 in 2028 along with almost one million others. It's the demography stupid. It's time to shout louder and help us to move!

Published on Tuesday, 3 November 2015 by the Housing LIN