Debate 1 - Paper 1

Decent Homes: Housing and Health

Dr Peter Ambrose, Director, Centre for Urban & Regional Research
University of Sussex

A fairy story?

Once upon a time there was a Minister of Housing who argued that there is a clear connection between poor housing conditions and the incidence of costly illnesses and related social pathologies. He referred to data from Glasgow and Birmingham which showed that mortality rates, especially for children, varied sharply depending on the degree of overcrowding. This also affected the sufficiency and quality of children’s sleep which, in turn, affects both general health and educational achievement. Such conditions often mean stuffiness and stagnant air. This is conducive to a number of disorders including chest and throat infections. These can lead to ear disorders which may affect employment chances in later life. The quality of food preparation facilities also, argued the Minister, affects health and well-being. Poor cooking and food storage facilities can lead to an over-dependence on ready-cooked foods which are more likely to cause digestive disorders.

It was important to consider the effects on the economic efficiency of the nation. Growing up in poor and overcrowded conditions, and suffering from under-nourishment, limits a person’s capability to work to her or his full potential and helps to contribute to the fourteen million weeks of work lost per year due to sickness. A recent Official Report had concluded that most sickness was due not to infectious diseases but to poor conditions that were easily preventable. But unfortunately:

‘…the data are not available whereby we can assess the national loss arising

out of the misery and sorrow, the discontent and the bad habits that assail…

the lives of those who have to spend their lives in… gloomy and unhealthy places.’

Much concerned, the Minister directed the Registrar-General to try to work out the costs of one particular disease which was obviously housing-related. The Registrar-General beavered away, seeking to assess costs such as state benefits payable, employment time lost through the disease, the cost to the economy of premature deaths and the cost to public funds of treating the disease. The answer came to £14.25 million. A number of local authorities reported that local annual expenditure on treating the disease was ten times more than the funds they received annually for housing improvements which would have reduced its incidence. The Report drew attention to the cost of treating other conditions whose incidence would similarly be much reduced by improved housing conditions. The Minister concluded that it was not yet possible to separate out the true cost of poor housing conditions but that the capital sum currently devoted to improving poor housing was very small compared to the ‘…millions …vainly poured out in dealing with the results’.

By now astute readers will be smelling several rats. Housing Ministers in the 1990s don’t have this kind of vision.

Is it all a fairy story? Who was this wise Minister? What is this mystery disease? And anyway what date are we talking about because £14.25 million wouldn’t even refurbish the NHS Trust executive suite these days?

The answers to these four questions are: No, Dr Christopher Addison, tuberculosis and 1919. All the foregoing is taken from Chapters VI and VII of Addison’s book The Betrayal of the Slums, (Herbert Jenkins, 1922) published soon after his Treasury-provoked dismissal as Minister. The matter can be pursued in various works (for example Ambrose, 1994,Ch. 6).

On re-inventing the wheel

Recent informed discussion suggests that Britain is spending more money - as much as £2 billion per annum has been estimated (see The Guardian and The Times, 8 November 1994) - on treating illnesses closely correlated with poor housing conditions than is being spent by local housing authorities on providing extra housing stock. Plus ça change…
Cold, damp, overcrowded, polluted, infested, insecure and in other ways inadequate housing has been shown by a large number of studies to be related to the increased incidence of a wide range of conditions including asthma and other respiratory problems, colds and flu, hypothermia, lung cancers, gastrointestinal upsets, aches and pains, fatigue and accelerated mortality rates. Similarly overcrowding, lack of security and high-rise living have been shown repeatedly to be associated with depression, insomnia, domestic violence, nervousness, ‘stress’ and a range of other manifestations of anxiety and unease (for a review of the research literature see Ambrose et al., 1996).

Apart from the costs related to the provision of health services, further additional sums, considerable but as yet uncalculated, are required annually in the form of extra expenditure on social services, law and order, emergency services, child protection and education in order to deal with some of the ‘fall out’ social conditions that regularly correlate with poor housing environments. In addition an immense amount of money is being wasted on providing heat for housing that has poor energy conservation qualities.

In total this represents a massive diversion of scarce public, private and voluntary sector resources to dealing with a set of inter-related problems whose cost impact could be significantly reduced by investment in better initial build and design quality and by better resourced management and maintenance programmes.

The condition of the housing stock

It cannot be denied that there is a problem of disrepair in Britain’s housing stock. Almost 50 per cent of the stock was built before 1939 and a quarter dates from before 1914. Furthermore, the output of new housing has declined persistently since the 1960s (for data see for example Newton, 1994) and is now lower on a per capita basis than almost all other European Union countries. The level of new construction is not enough to prevent the overall decline in quality and the ageing of the total housing stock.

Problems of poor general quality are already widespread - well over 2 million homes suffer from severe dampness. The 1991 English House Condition Survey indicated that almost 1.4 million occupied homes in England were unfit. Over one fifth (20.5 per cent) of private rented dwellings fell into this category compared to 6.9 per cent of local authority, 6.7 per cent of housing association and 5.5 per cent of owner-occupied dwellings.

In Scotland, the 1991 Scottish House Condition Survey (which uses a slightly different definition of unfitness) indicated a total of 95,000 unfit dwellings. The proportions here were slightly lower than in England, with 16.5 per cent of private rented, 4.4 per cent of local authority, 3.6 per cent of owner-occupied and 3.3 per cent of housing association dwellings deemed unfit.

Why do we have so much poor quality housing?

Housing investment decisions are all too often taken in too ’short-termist’ a fashion. There is typically insufficient consideration both of the medium and longer term ‘cost-in-use’ implications and of the ‘cross-sectoral’ cost effects that poor quality housing has on other key areas of expenditure. As a result much British housing requires considerable refurbishment expenditure, perhaps within two or three decades of its construction, and provides living conditions that are so poor as to produce problems that require expensive solutions.

This under-investment in housing quality is systemic rather than surprising and it stems from a number of reasons. Four can be clearly identified - one technical, one administrative, one electoral and one political:

  1. No reliable and replicable procedures exist to relate the initial level of investment in a housing scheme to the level of cross-sectoral costs-in-use that it generates over its lifetime. It is therefore likely that cost-cutting imperatives at the point of initial investment will be more significant in determining standards than any projections of the subsequent cross-sectoral savings in costs-in-use that might be derived from investment in better quality.
  2. This is especially so in Britain where the definition of public expenditure is unhelpfully out of line with that in other European economies (Hawksworth and Wilcox, 1995). But it is also true of a number of other European Union countries seeking to meet the ‘Maastricht criteria’ in relation to their public expenditure programmes, especially borrowing-dependent programmes such as housing (consider, for example, the changes in Sweden’s housing policy since 1991).
  3. Elected administrations, both national and local, normally have a four or five year time horizon - until the next election, which may well be fought on grounds of saving public funds and thus minimising taxes. But decently constructed and maintained housing has a ‘life’ of 50-100 years. Thus the longer term savings deriving from better quality have a ‘pay-off’ period that is too long to give any short-term electoral advantage.
  4. Users of housing are weak and isolated ‘consumers’ in a complex market - and the more marketised housing provision becomes the more people are put at risk either through their own vulnerabilities in the labour market, or by changes in family circumstances, or by macro-economic episodes (such as sharp rises in interest rates) that have nothing to do with the individual, or by conscious policies by government aimed at reducing the availability of low rent property and the legal protection of tenants. There are no effective organisations within which one can mount collective opposition to builders, lenders, controllers of quality and setters of rents and prices.

The ‘cost-effectiveness in housing investment research programme’ (CEHI)

Given this general context a research project was initiated early in 1994 at the Centre for Urban and Regional Research at the University of Sussex. It seeks to explore the correlation between, on the one hand, variations in the local quality of housing environments and, on the other, two sets of costs that are likely to be strongly influenced by quality, and to some extent to correlate with each other:

  1. The costs generated for other expenditure programmes including health, social welfare, education, emergency programmes and crime prevention (mostly revenue costs)
  2. The rate of run-down of the capital value of housing assets (mostly capital costs).

The CEHI programme’s main objective is;

‘…to demonstrate and where possible to quantify these savings and financial effects and to seek to develop a replicable evaluative methodology so that longer term and more broadly based value for money criteria may supersede short term cost-cutting as a general principle underlying housing investment and support.’ (Ambrose, 1996).

An extensive review (Ambrose et al. 1996) was carried out of the literature linking housing conditions with the health characteristics of residents, (see especially Burridge and Ormandy, 1993, Carr-Hill and Coyle, 1993, Leather et al., 1994), with local rates of crime and other anti-social behaviour (see especially Wikström, 1991, Bottoms, 1994, Hope, 1994 and 1995) and with the educational development of local children (see especially HMI, 1990, Power, Whitty and Youdell, 1995). This literature review was funded and published by the Royal Institution of Chartered Surveyors.

Although the review indicated that there is a growing body of studies which analyse the relationship between housing quality, health standards and other social indicators, it is notoriously difficult to identify any simple ’cause/effect’ relationships and it is much safer to build up an understanding of the relationships in terms of correlations rather than ’causes’. Nor is the direction of influence always one-way. Many of the effects feed back on each other in a ‘reflexive’ fashion. In fact the complexity of the relationships is bewildering when the ‘holistic’ nature of everyday life is recognised.

As an example, an individual’s pre-existing standard of health, or perhaps disability, may well be a powerful conditioner of her/his position in the labour market hierarchy. This in turn, in a largely market-oriented housing system, is likely to condition the quality of housing that can be accessed. Housing location may influence the quality of education available locally and working conditions in the home may affect the qualifications achieved at school - which in turn may influence the chance of getting work and thus competing in the housing system. Not getting work may lead to personal stress, depression and possibly family break-up that will in turn impede access to housing. Poor housing situations, and especially poor domestic and area security arrangements, are demonstrably related to the local incidence of crime and other anti-social behaviour and this, in turn, may lead to higher stress levels and damage to self-esteem at both the personal and the generalised neighbourhood scale. Higher stress levels themselves impose extra health service costs. And so on.

Thus the ‘housing variable’ may sometimes be an influencing factor and sometimes a contingent one - sometimes more a ’cause’ and sometimes more an ‘effect’. Moreover the degree of association between observed conditions and observed behaviours is infinitely variable. Since the research seeks to identify not only firm correlations between measurable phenomena but also to illuminate the less tangible social processes that bring them about, a three-step methodology was agreed upon:

Step 1 - A household survey in at least two areas of widely contrasted housing quality to gain information on residents’ housing situations and their feelings about how their housing environment affects other areas of their lives

Step 2 - Discussions with local professionals in the fields of health and social welfare, education, emergency services, policing, etc. in order to throw additional light on the evidence gained in Step 1

Step 3 - A costing of the impact of those changes in health, welfare and other variables that can be reasonably related to housing quality differences

Step 1 - The household surveys in areas of contrasted quality

Early in 1995 funds became available as part of the Government’s Single Regeneration Programme in Central Stepney (east London) to carry out a ‘before and after’ Health Gain Survey on those parts of the Limehouse Fields and Ocean estates that are to be rebuilt or improved as part of the SRB programme. The population is ethnically well mixed and 60-70% of residents are of Bengali extraction.

A sample of 120 households was selected randomly for the survey. Almost all agreed to participate. The intensive interviewing procedure, carried out by bi-lingual pairs of interviewers, has involved three or four repeat visits to each household. It has produced rich and detailed material on residents’ experiences of the poor housing conditions and their views of the significance of these conditions to the lowering of health standards, the higher incidence of crime and other anti-social behaviour and the obstacles to progress experienced by children. There is a strong view amongst residents that much of these cost-incurring phenomena are closely related to the overcrowded, damp, insecure, run-down and often infested condition of much of the housing.

Work on a contrasting second case study (the Walterton and Elgin Community Homes improved housing in Paddington) is now well advanced. This study is already providing clear evidence that residents living at acceptable densities in warm, dry, secure conditions suffer from far fewer of the health problems and other difficulties that impose costs on a cross-sectoral range of budgets.

Steps 2 and 3 - Identifying and evaluating the costs

Funding has now been attracted from Riverside Housing Association (formerly Merseyside Improved Houses) to commence work on Steps 2 and 3 of the methodology.

Interviews are currently being arranged in the Central Stepney area with the providers of key services such as health, education and crime protection. The aims of this round of interviews are :

(a) to gather professional corroboration, or otherwise, of the links between

poor housing conditions and the other phenomena under examination

(b) to seek access to the cost databases of the provider services so as to identify the budgetary headings under which increased costs are incurred and, where feasible, to quantify them.

On what grounds should a campaign for better quality be mounted?

There are moral and ethical arguments that can be raised against the close juxtaposition of households of up to ten people living very unhealthy lives in a three bedroom flat in a damp and decaying block while half a mile away expensive new commercial buildings stand empty for years seeking tenants in a glutted market.

Arguments can also be raised around the issue of street homelessness - although it is unhelpful to reduce this country’s housing problem to this emotive, but marginalisable, issue. Homelessness is obviously a grievous matter for those involved but in terms of numbers there are probably fifty or one hundred times more people living stressed and unhealthy lives in totally inadequate conditions than are actually on the streets. But any campaign based on moral or ethical grounds, while it may make short-lived headlines, is unlikely to have serious policy effects in today’s political circumstances. Neo-liberalism is after all founded on the arguments of such as Hayek and Nozick who clearly and explicitly reject the desirability of ’social justice’ (see Nozick, 1974 and Hayek, 1976). If the maxim ‘good ethics make bad politics’ has not been invented maybe it should have been sometime in the 1980s.

Much stronger arguments, and ones that may attract many allies, can be made in terms of the need to make sensible and cost-effective use of scarce resources. The new commercial blocks referred to were promoted with massive state subsidy and tax breaks and they are now a financial liability for a number of institutions who are effectively trustees for our future pension and insurance rights. The homelessness problem is frequently dealt with by emergency ’solutions’ that are more expensive than building more housing units. Much of the bad housing in the survey area in Central Stepney now needs to be demolished and expensively rebuilt, in some cases after a life of only thirty years. None of these situations is remotely sensible or cost-effective.

Perhaps the ultimate aim of policy in any reasonably sane society should be to make optimal use of collective resources for collective benefit. Consistently to built too little housing, and especially to allow shortages at lower price and rent levels, is to fail to match the supply to the perfectly obvious needs of the society. Consistently to throw public money at demand side support such as Housing Benefit and Mortgage Interest Tax Relief is to inflate rents and prices when the same amount of support, applied to the supply process, could help to expand output, generate jobs and demand in the ‘feeder’ industries, modernise the stock and gradually relieve the shortage. Consistently to provide poor quality, poorly maintained housing is irrational in the face of all the mounting evidence that such conditions will predictably start to generate, and will continue to generate, heavy costs on a wide range of budgets for as long as the bad conditions prevail.

What to do?

We need to continue to press the case that housing is a central element of infrastructure which, because it safeguards the key resource of people, is more significant to the needs of the economy than any other infrastructural element.
We need to argue that the concept of ‘cost-in-use’ needs to be broadened to incorporate a wide range of revenue and capital effects on both housing and non-housing budgets.
We need to be ready with rigorous and convincing evidence about the order of magnitude of these cost effects.
We need to use this evidence to mount public arguments based on the hard logic of cost-effectiveness while reserving the moral and ethical arguments, should we so wish, as spurs to private action.
We need to draw the attention of all serious political parties to the need to think out and spell out the aims of their housing policies. If no aims are articulated there are no criteria against which to assess ’success’ or ‘failure’.
We need continually to expose the folly of making resource decisions about a product with long-term utility on the basis of short-term considerations.


Addison, C (1922) The Betrayal of the Slums, London, Herbert Jenkins

Ambrose, P. (1994) Urban Process and Power, London, Routledge

Ambrose, P. (1996) Bad Housing - Counting the Cost, University of Sussex Urban and Regional Studies Working Paper No. 90

Ambrose, P. et al. (1996) The Real Cost of Bad Homes, London, Royal Institution of Chartered Surveyors

Bottoms, A. (1994) ‘Environmental criminology’, in Maguire, M., Morgan, R. and Reiner, R. (eds.) The Oxford Handbook of Criminology. Oxford, Clarendon Press.

Bottoms, A., Mawby, R. and ‘A tale of two estates’, Chapter 3 in Downes, D. ed., Crime and the City: Xanthos, P. (1989) Essays in Memory of John Barron Mays. Basingstoke,Macmillan.

Burridge, R. and Unhealthy Housing: Research, Remedies and Reform, London, E. and F.N. Ormandy, D. eds. (1993) Spon

Carr-Hill, R. and Coyle, I. (1993) Poor Housing: Poor Health, Unpublished, Department of the Environment

Department of the Environment (1990) Handbook of Estate Improvement, London, HMSO

Hawksworth, J. and Wilcox, S. (1995) Challenging the Conventions: Public Borrowing Rules and Housing Investment, Coventry, Chartered Institute of Housing

Hayek, F. (1976) Law, Legislation and Liberty: Vol 2, The Mirage of Social Justice,

London, Routledge and Kegan Paul

HMI (1990) A Survey of the Education of Children Living in Temporary Accommodation. London, Her Majesty’s Inspectorate, Department of Education and Science

Hope, T. (1994) ‘Communities, crime and inequality in England and Wales’. Paper given at the 22nd Cropwood Round Table Conference on Preventing Crime and Disorder: Targeting Strategies and Community Responsibilities, Cambridge, 14-16 September

Hope, T. (1995) ‘The Flux of Victimisation’, in British Journal of Criminology, 35, 3, pp. 1-17, Summer.

Leather, P., Mackintosh, S. and Rolfe, S. (1994) Papering over the Cracks. Housing Conditions and the Nation’s Health, London, National Housing Forum

Martin, C., Platt, S. and Hunt, S. (1987) ‘Housing conditions and ill health’, British Medical Journal, 294, 1125-27

Newton, J. (1994) All in One Place: The British Housing Story 1973-1993, London, Catholic Housing Aid Society

Nozick, R. (1974) Anarchy, State and Utopia, London, Blackwell

Power, S., Whitty, G. and Youdell, D. (1995) No Place to Learn: Homelessness and Education, London, Shelter

Wikström, P-O (1991) Urban Crime, Criminals and Victims: The Swedish Experience in an Anglo- American Comparative Perspective, New York, Springer-Verlag

Dr Peter Ambrose is Reader in Social Policy and Director of the Centre for Urban and Regional Research at the University of Sussex where the CEHI project is based. Its progress so far has been written up in ‘Bad Housing: Counting the Cost’ published by the Centre.

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