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KEYWORDS
UK public health
policy;
Public health and
housing;
UK housing policy;
New public health
Summary Objectives. The aim of this paper is to review UK public health policy,
with a specific reference to housing as a key health determinant, since its inception
in the Victorian era to contemporary times.
Review. This paper reviews the role of social and private housing policy in the
development of the UK public health movement, tracing its initial medical routes
through to the current socio-economic model of public health. The paper establishes
five distinct ideologically and philosophically driven eras, placing public health and
housing within liberal (Victorian era), state interventionist (post World War 1; post
World War 2), neoliberal (post 1979) and Third Way (post 1997) models, showing the
political perspective of policy interventions and overviewing their impact on public
health. The paper particularly focuses on the contemporary model of public health
since the Acheson Report, and how its recommendations have found their way into
policy, also the impact on housing practice.
Conclusions. Public health is closely related to political ideology, whether driven
by the State, individual or partnership arrangements. The current political system,
the Third Way, seeks to promote a sustainable social contract between citizens and
the State, public, private and voluntary organizations in delivering community-based
change in areas where health inequalities can be most progressively and successfully
addressed.
Q 2004 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health.
0033-3506/$ - see front matter Q 2004 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health.
doi:10.1016/j.puhe.2004.07.006
526
Table 1
J. Stewart
Traditions in ideology.
Liberalism
Marxism
Social reformism
Conservatism
Freedom of individual,
not rights of groups
favour individual equality
not group equality
Possibility of progress
through government
intervention, e.g. equalopportunity policies as
policy is effective in itself
Date
Themes
527
Health/safety issue
Comments
Home accidents/fire
Noise pollution
Pest invasion
Anomie, alienation
Suitability of housing for actual/future needs, e.g. age, disability, ill
health
High numbers in bed and breakfasts; socio-economic impact, detrimental impact on childrens and adults physical and emotional health
Low income, poor housing, poor heating leading to respiratory disease,
accident, discomfort, hypothermia, etc.
Poor quality can cause ill health or death, e.g. carbon monoxide poisoning,
radon, etc.
Integration with local community; support networks; access to health and
welfare services; empowerment
Poor design and architecture; socio-economic exclusion; polarized
communities
Poor housing environments (e.g. some temporary accommodation) can
exacerbate poor emotional health
Mainly found in multiply occupied premises (bed and breakfasts);
increases risk of infectious diseases, e.g. tuberculosis. Opposite is
loneliness and isolation
Can cause tension, stress
May result from lack of refuse disposal provision/architecture, etc. rat and
cockroach infestations increasingly common
in conditions resulting from the industrial revolutionwere responsible for their own lot. Victorian
philanthropists and some politicians with counterideologies started to challenge the socio-economic
status quo and argue for a new role for government
in improving health.
Calls for public health reform stemmed from
differing philosophies based on capitalist, religious,
scientific or philanthropic beliefs. Pressure for
reforms continued to slowly improve poverty and
living conditions, but not in a systematic way.11
Edwin Chadwick followed Jeremy Benthams
utilitarian school of philosophy and became a
major influence in environmental health thinking,
although his theories on disease spread were based
on miasma rather than contagion, as later proposed
by John Snow.11 In 1842, Edwin Chadwicks Report
on the Sanitary Conditions of the Labouring Population of Great Britain (cited in Ref. 10) painted a
picture of poor living conditions and amenities that
aggravated disease. Although, he was strongly
criticized and opposed by many with vested or
528
Table 4
J. Stewart
Victorian era and interwar era until 1939: overview of housing and public health policy.
Date
Event
18481900
First Public Health Act, followed by various Public Health and Housing Acts until early
1900s, that empowered local authorities to deal with poor housing conditions with
increasingly formalized structures, e.g. Common Lodging Houses Act 1851, Labouring
Classes Lodging Houses Act 1851 (Lord Shaftesbury), Torrens Acts 1868 and 1879, Artisans
and Labourers Dwellings Act 1868, Artisans and Labourers Dwellings Improvement Act 1875
(Cross Acts), Town and Country Planning Act 1909; A Royal Commission on Housing of the
Working Classes led to the Housing of the Working Classes Act 1890; Growth of Garden
Cities movement developed by Ebenezer Howard
Tudor Walters Committee, Homes for Heroes
Growth of building societies, increasing owner occupation, declining conditions, especially
private rented sector, slum clearance, overcrowding legislation introduced, some council
house building but building houses for sale was more profitable than building for rent;
steady stream of new housing legislation, e.g. Rent and Mortgage Restriction Act 1915,
Housing (Additional Powers) Act 1919, The Housing and Town Planning Act 1919 (Addison
Act), Housing Act 1923 (Chamberlain Act), Housing (Financial Provisions) Act 1924
(Wheatley Act), Housing Act 1930 (Greenwood Act), Housing Act 1935
Bombing destroyed 200 000 houses and damaged more than 3 million; Dudley Committee
(1944) recommended standards for council housing
World War 1
Interwar era
World War 2
Adapted from Refs. 813.
Table 5
Post 1945
1952
1954
1956
1957
1960
1961
1964
1964
1965
1965
1966
1966
1967
1968
1968
1969
1970
1972
1974
1974
1974
1977
529
organizations. Estates were seen as self-contained,
supported by their own community venues.16
There remained cross-party consensus for council housing building and management, which ironically led to new forms of yet untested architecture
as house building shifted from quality to quantity.
Competition for house completions between successive governments led to the construction of
thousands of modernist-inspired tower blocks for
social housing through the 1960s, with little regard
to the psychosocial impact of architecture, relocation of residents (often some way from their
original communities, such as on a peripheral
estate) or wider issues of exclusion, or indeed
views and needs of communities.8,9 The Ronan
Point disaster in London, early problems with
condensation, communal facilities and pest invasion also contributed to the end of the utopic vision
of the tower block as the answer to the nations
housing problems.
Even by the 1970s, such housing needed major
regeneration investment, but local authorities did
not have the capital resource available for such
major works. In addition, compulsory purchase for
the purposes of area regeneration was increasingly
Post World War 2 (19451979): overview of housing and public health policy.
Labour election victory; introduction of Welfare State, new organizational structure,
responsibilities to housing and National Health Service; development of New Towns
Census shows 1 million more households than dwellings
Housing Repairs and Rents Actlocal authorities could take over slum areas for site value; new
private rents removed from rent control
Extra height subsidy introduced for high-rise blocks
Rent Act decontrols rents; legislation protects sitting tenants; Rachman era
Park Hill Estate (Sheffield) becomes UKs first deck access block
Parker Morris Report establishes minimum space standards for council housing
Labour election victory; Wilson adopts target of 400,000 new homes/year
Housing Act established Housing Corporation in England
Milner Holland Report on housing and race in Greater London
Rent controls and rent officers introduced
Labour re-elected, pledging 500,000 houses/year
Cathy Come Home film released, highlighting the plight of homeless families
Erno Goldfinger designs 32-storey tower block
Housing White Paper calls for renovation, not redevelopment
Gas explosion at Ronan Point, kills five
Housing Act introduces General Improvement Areas and Home Improvement Grants
Conservative victory; Department of the Environment created to oversee housing, planning,
local government and transport; councils set up social service departments, combining
childrens mental health and welfare services
Housing Finance Act encourages slum clearance; boost to Home Improvement Grants
Local authority/National Health Service split
Housing Action Areas introduced
More than 100,000 council house completions; Rent Act extends security of tenure to most
furnished lettings
Homeless Persons Act; new duty for councils to house certain homeless people
530
J. Stewart
seen to be unjust, and frequently failed to acknowledge the views of those affected,17 although some
attempts were made to assess the experiences and
attitudes of households displaced by redevelopment of slum areas, which began to recognize the
importance of combining physical with social
planning.18
By the end of the era, the UKs housing stock
tended to be owner occupied or council housing.
Dissatisfaction was growing with many of the new
tower block estates, which were beginning to
present a new range of housing and health issues,
particularly emotional and behavioural, and then
unnamed and largely unrecognized concepts: social
exclusion and a growing welfare-benefit-dependent
underclass,8,9 which are now key public health
issues.
Post 1979: the New Right: overview of housing and public health policy.
1979
1980
1981
1985
1986
1988
1989 onward
1989
1991
1991
1992
1993
1996
Conservative election victory; 1979 Priority Estates Project (HIP funded) to rescue unpopular
estates; Urban Programme established
Right to Buy introduced, urban development corporations, competitive tendering
Development Corporations begin, EHCS survey shows 1.1 million unfit houses; post-rioting
enquiries identify socio-economic and policing problems in rundown estates
Estate Action targets capital at rundown estates where management is localized and tenants are
consulted. Voluntary transfer, estate management boards, etc.
Unemployment reaches 3.5 million
Housing Act introduces assured tenancies and promotes stock transfer; UK housing market
collapses; Housing Action Trusts and Tenants Choice further break up council housing
Housing Associations become the major developers of new social housing, using private finance
for the first time. Needs-based lettings led to polarization. Increased funding for tenant-led
initiatives
Local Government and Housing Act introduces mandatory Renovation Grants linked to statutory
fitness; Home Improvement Agencies encouraged
City Challengenew competitive, quasibusiness publicprivate partnerships for inner city areas in
decline
Health of the Nation launched (following the Black Report)
Compulsory competitive tenderinghousing management to improve performance; private
finance initiative increases private sector role
Single Regeneration Budget introduced, consolidating social, economic, training and housing
budgets
Housing Act creates registered social landlords and local housing companies; restriction on
homeless peoples rights; end of mandatory Renovation Grants
1997
1998
1999
1999
1999 and 2000
2000
2002
2002
2003
2003
2003
Post 1997: the New Left: overview of housing and public health policy.
1997
2000
531
Labour election victory; first Public Health Minister appointed; Social Exclusion Unit
established
One in five families headed by single parent; nearly one-third of children live in households
where no one is in full-time unemployment
New Deal for Communities introduced
Best value introduced, requiring continual improvement of council and RSL services
White Papers: A Better Quality of Life (150 sustainability indicators) and Saving Lives as
responses to criticisms that UK has some of unhealthiest children in the developed world
Local Government Acts promoted modernization and social justice agendas; required
preparation of community strategy to promote the economic, social and environmental
wellbeing; also to contribute to UK sustainable development; partnership approach required
Health Development Agency introduced to raise quality of public health in England; National
Health Service plan re-inforced the need for local authorities and health authorities to work in
partnership
The Joseph Rowntree Foundation published results of the first national study to attempt to
measure social exclusion, confirming rise in poverty rates
Homeless Act to encourage development of local strategies to help prevent homelessness and
deliver partnership working
Regulatory Reform Order subsumed all earlier grant legislation, replaced with power to
provide assistance
National Health Service Priorities and Planning Framework introduces local delivery planning
Community Plan to create sustainable communities in all regions
Housing Bill provisions seek to more closely re-integrate housing and health
532
Paper Saving LivesOur Healthier Nation26 argued
for a comprehensive programme of action to tackle
the complex causes of ill health (personal, social,
economic and environmental); partnerships
between individuals, communities and the government, and more activity on addressing the determinants of health in the most deprived
communities. The emphasis is concerned with
assessing evidence-based need (health needs
assessment) and developing strategic responses
that sustainably address this need with maximum
health-promoting
impact
(health
impact
assessment).27
What is the current public health workforce?
Where is housing placed in the public health
agenda?
Public health is about the organizations and policies
that seek to promote health, but who makes up this
workforce, and with what interventionist powers
and outcomes to sustainably address key health
determinants?
The majority of the public health agenda has
been concerned with organizational change to the
NHS to deliver public health through the new
primary care trusts (PCT) in partnership arrangements with other organizations, notably local
authorities. Some public health doctors see themselves as best placed to promote public health,28
but others refute this, arguing in favour of those
dealing more directly with health determinants,
such as housing officers, environmental health
officers, etc. to adopt a higher profile role in the
public health agenda to sustainably address health
inequalities at community level.1,29 It is important
that community-based partnerships take a lead, as
if medics alone take control of strategy, there is a
risk that it will mobilize around quantifiable health
risk onlysuch as home accidents, fuel poverty,
etc. and wider socio-economic issues in regeneration may fail to be sustainably addressed.
The Environmental Health Commission30 recognized the need for: health inequalities and health
determinants to be sustainably addressed; policy
and its organizational delivery to be more closely
aligned to need through community development
and bottom-up participation mechanisms; a new
focus and re-integration of environment and health
policies; and a renewed emphasis on addressing the
needs of the most deprived communities through
active citizenship and partnership working. Much of
this is happening in social housing (although housing
officers may not see themselves as part of the
public health workforce), although the extent to
which it is happening in private sector housing is
notoriously more difficult to implement and assess,
J. Stewart
except in area renewal schemes which are gaining
increasing political favour.
Partnership approaches in health improvement
have moved apace.27,31 Local Delivery Planning
(previously Health Improvement Programme
(HImP), then Health Improvement and Modernisation (HIMP) is now concerned with identifying
local-needs and turning national contracts into
local action with a focus on schools, workplaces
and neighbourhoods. It has placed particular
emphasis on health inequality. The aim is to tackle
poverty, poor housing, pollution, low educational
standards, joblessness and low pay. This is to be
allied with other partnerships, including local
strategic partnerships (LSP) that align public,
private, business, voluntary and community initiatives and services, and seek to operate at the right
level for strategic decisions that are close to
communities. LSPs are seen as pivotal to finding
joined-up solutions to help tackle priority areas for
local people, notably in crime, jobs, health and
housing.
In addition, local authoritieswho oversee local
social and private sector housing, conditions and
needhave new duties for community strategies
under the Local Government Act 2000 and are
required to prepare a strategy for promoting or
improving the economic, social and environmental
wellbeing of their area and contributing to sustainable development across housing tenures. The
purpose is to enhance the quality of life locally
based on community need and participation, with a
long-term vision focusing on health improvement
outcomes. This is closely aligned to local authorities best value obligations, to ensure continued
service improvements. Public service agreements
(PSA) also offer opportunity for additional resource
that can be used to help address national and local
priority issues such as social exclusion, improving
education, housing and employment, and reducing
crime and health inequalities.
However, despite these major policy shifts, the
extent to which partnerships are being developed
and implemented as perceivedso that they have an
actual and sustained impact on health improvement
where it is most acuteis difficult to gauge. The
plethora of policy change leaves little time for
evaluation, aggravated by the fact that meaningful
improvements in housing and health status need to
be measured over a period of years, not months.
Meanwhile, however, there are many examples of
innovative practices being delivered by local authorities and their partners in promoting public health.
One example is that of the London Borough of
Newhams approach to tackling tuberculosis.9
Newham had one of the highest rates of
533
rating system; introduce mandatory Health Maintenance Organisation (HMO) licensing (but only for
those HMOs deemed higher risk); introduce
discretionary licensing of the private rented sector;
modernize the Right to Buy provisions; and to
improve the process of house selling and buying. All
this, of course, sits within a wider package of public
health reform aligned with national policy and
local-needs-based strategic partnerships to promote health where inequalities are most acute.
Partnerships alone cannot guarantee this, and there
is a real need for enough suitable accommodation
within health-promoting environments where housingwhether owner occupied or rentedis available, secure, of a decent standard and affordable.
However, despite these major steps forward, it is
the authors view that many of those involved in
housing still do not see themselves as public health
workers. Environmental health practitioners, who
mainly work in private sector housing, are trained in
public health, and therefore tend to recognize the
role they play in the public health agenda.
Conversely, social housing practitionerswhilst
dealing with housing and healthdo not normally
regard themselves as public health practitioners
(although they clearly are), despite the current
government agenda. There still remains a divide in
terminology in social and private sector housing,
which is not helpful. Such issues could be more
comprehensively addressed so that housing and
health policies are more closely integrated and the
new partnerships could offer a more tenure
neutral approach.
Conclusion
The public health movement has made enormous
progress since its inception in the mid Victorian era.
The post-war welfare state sought to ensure
equality, and remained in its largely top-down
structure for some 30 years. The post-1979 conservative government adopted a neoliberal agenda,
with a focus on ideology and health seen as a
commodity rather than a complex result of a
complex socio-economic society. The current
labour government has absorbed many political
systems into its Third Way, promoting public health
as a core policy, arguing for a new relationship
between individuals, communities and the government, and seeking to align policy with healthpromoting outcomes. Turning around a legacy of
health inequality is a large task and it will be some
years before the fruits of the current public health
534
agendaand, in particular, moves in health-promoting housing and communitiescan be realized.
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