Since March 2020, most people in the UK have been spending a lot more time at home. Rarely has the nature of these homes been more important, as they are doubling up as workplaces, schools, gyms and the only place to spend time if working from home, furloughed or unemployed. This has highlighted stark inequalities in housing, with some residents enduring the lockdown in large homes with gardens and plenty of living space, while others struggle in overcrowded conditions with no outdoor space. COVID-19 has highlighted and intensified existing problems with housing in England.

Housing can contribute positively to people’s mental and physical health – but all too frequently it does not. In this long read we sets out the links between housing and health and explores the inequalities in housing across different groups and types of tenures. We then consider the impact of COVID-19 on housing so far, future risks and possible ways forward.

Although the COVID-19 pandemic has renewed interest in the influence of housing on people’s health, studies of housing and health have a long history. Joseph Rowntree wrote about the impacts of housing conditions on health in the UK at the beginning of the 20th century. More recent research on housing and health emphasises the importance of the psychosocial aspects of housing, such as affordability and security, as well as the physical components. Despite overall housing conditions having improved in the last 20 years, the pandemic and lockdown have highlighted the continued relevance of housing to health. 

The factors linking housing and health can be broadly described as follows:

• Quality and condition: relating to the physical characteristics of homes, such as damp. Studies have linked damp to a number of health problems, including respiratory issues, physical pain, and headaches, particularly affecting children. Quality and condition can also include the suitability of the home, such as whether it would be considered overcrowded for the household living there. Less obvious aspects include whether the home has access to a garden or outside space, an issue brought to the fore during the lockdown. A range of studies have found health benefits to improvements in home quality, for example, a recent longitudinal study found a reduction in hospital admissions following a range of home upgrades.
• Stability and security: relating to the extent to which people have control over how long they live in their homes, and how secure they feel. Owner occupiers can typically stay in their home as long as they keep up with payments (if they have any), whereas private renters typically have short tenancy agreements and can be evicted through factors beyond their control at short notice. Housing instability can act as a stressor harming health, while frequent moves can undermine engagement with health, other local services and weaken relationships in the local community.
• Affordability: relating to the financial pressure caused by housing payments – both for housing itself and for utilities and maintenance. The effects of poor housing affordability are both direct (causing stress and anxiety, for example) and indirect – particularly through reducing the disposable income that people have available to spend on other things which may promote good health (such as quality food and exercise). Affordability problems can also contribute to overcrowding, as households seek to share the fixed costs of accommodation across more individuals.

COVID-19 has been an intensifier for all three of these existing factors. The following sections consider each factor in turn, followed by a discussion of the role of housing in the spread and experience of the COVID-19 pandemic.

Quality and condition of housing

The quality or condition of a home is one of the more direct ways in which housing can affect health: a home could be cold or hard to heat, contain hazards such as fall risks or faulty wiring, or be damp and mouldy.

One way of measuring the quality of housing is through the ‘Decent Homes’ standard, a tool used to measure the improving standards of socially rented homes under the multi-billion-pound investment programme of the same name that started in 2000. The standard assesses the level of thermal comfort, state of repair, whether the facilities are sufficiently modern, and the presence of any hazards. If a home fails to meet any of these requirements, it is considered ‘non-decent’.

Figure 1 shows the association between this measure and self-rated health by tenure (controlling for age). For owner-occupiers and private renters, living in a poor-quality home goes hand-in-hand with worse self-rated health. The relationship is complicated, as it is influenced by other factors which affect health such as income, employment, and more. Causality may also be bidirectional, with those in poorer health more generally on lower incomes, which may impede access to quality housing. For social housing, allocation on the basis of need might explain the small and not statistically significant difference in health between decent and non-decent homes.

Figure 1

Boosting home ownership

Long-term trends in house prices have led to a focus by successive governments on increasing the supply of affordable housing as well as a series of subsidies and stamp duty changes to encourage first time buyers. This focus on increasing supply dates back to the mid-2000s and the Barker Review. Such interventions have so far had little success in creating a significant boost to supply – from Labour government targets for home building (in 2007), through to the coalition government’s financial incentives for councils to permit construction (in 2010) and the introduction of Help to Buy (in 2013). The latter – a subsidy for first-time buyers – has increased house prices as well as increasing supply.

Recent housing policies include the stamp duty holiday (a short-term stimulation of the market during the pandemic) and reductions in processes related to permitted development, which allow for conversion of buildings to residential uses. However, there are concerns that the stamp duty holiday has increased the prices that sellers can charge rather than reducing costs for buyers, and that permitted developments have led to poor quality and unsuitable homes.  

Housing affordability for renters

For renters, support for housing costs has largely been through housing benefit. In the last decade, this support (through the Local Housing Allowance) has been reduced. Where once a maximum of 50% of local rents were covered, from 2011 onwards benefits have failed to cover even 30% of local rents in most areas.

There have also been specific reductions in housing benefit for younger adults (the shared accommodation rate), in the social rented sector for under-occupying (the bedroom tax), and an overall cap on benefits. The initial rationale for reducing the proportion of rent covered by housing benefit was (in part) to prevent cost inflation in private rents. However, evaluation has found that the burden of these cuts was largely borne by tenants rather than landlords. The effects of high private rental costs and reduced support for low-income families have been exacerbated by insufficient supply of more affordable social housing.

Housing quality

The quality of homes in the social rented sector was improved through a major investment programme between 1997 and 2010. Government policy on housing supply has implications for the quality of owner-occupied housing: new homes are less likely to be classed as non-decent than older homes.

The increase in families (especially those with children) living in the private rented sector, and renting for longer, has also led to a focus on the quality of these rented homes. For instance, the 2016 Housing and Planning Act strengthened local authorities’ enforcement powers and the 2018 Homes (Fit for Human Habitation) Act enabled tenants to take legal action in the case of substandard accommodation. This focus on standards in the private rented sector reflects that 25% of properties in this tenure are classed as ‘non-decent’. However, as shown in Figure 2, most non-decent properties are found in the owner-occupied sector due to its larger size. Improving housing quality for owner-occupiers is harder given the individual responsibility and choice of homeowners. Some improvements have however been made through schemes such as the Green Homes Grant.

Housing security

Rises in homelessness have encouraged some recent policy developments on housing security. The Homelessness Reduction Act in 2017 introduced new broader, preventative duties on local authorities, while the government has also committed to abolish section 21 notices (sometimes called no-fault evictions). At the beginning of the pandemic, a temporary ban on evictions in England was introduced, followed by a slower eviction process. However, a necessary precondition for improving housing security is maintaining housing affordability. For instance, social security cuts have led to more people becoming homeless. Once short-term protections expire after the pandemic, evictions due to accumulated arrears are expected to increase.

The analysis presented above shows the housing situation prior to the onset of the COVID-19 pandemic. In March 2020, millions of households in England entered a period of increased time at home with at least one problem relating to non-decent, unaffordable, or overcrowded housing. The pandemic has further highlighted the role that housing plays in our health.

The spread of coronavirus

People’s housing environments have affected their ability to shield themselves and others from COVID-19. People have been encouraged to stay in their homes as much as possible, but within-household transmission has played a serious role in the spread of the virus. Overcrowding, which has been increasing in the years prior to the pandemic, makes it harder to self-isolate and shield, and may have contributed to higher death rates in poorer areas.

Similarly, policy which only allows for housing benefit for those in a shared home until the age of 35, compared to the previous entitlement that covered a one-bedroom flat from the age of 25, has led to more people living in shared accommodation. It is harder to effectively self-isolate in a home with shared kitchen and bathroom facilities. The nature of shared housing in London also sparked a mass exodus to other parts of the country to enable people to live in better quality housing during lockdown – this could also have contributed to spread. About 13% of Londoners are thought to have moved out of their usual home during lockdown.

The social impacts of lockdown

People’s housing situations will have affected their ability to weather the challenges of a prolonged lockdown. People in larger homes will have had more space to adapt to working from home (if their jobs permitted), as well as having greater privacy. Research exploring the link between housing and health prior to the pandemic found that people living in detached houses had lower levels of C-reactive protein, an indicator of infection and stress, than people in other types of homes.

Evidence from during the pandemic suggests that people were more comfortable in houses rather than flats, as well as in older rather than newer properties. At the more extreme end of the spectrum, many people, particularly private renters, spent lockdown in homes where they felt unsafe. While the lockdown created new challenges in arranging repairs, such safety issues were prevalent in the private rented sector before the pandemic. For those living alone, the pandemic has heightened problems such as loneliness, which can contribute to mental and physical health problems.

Spending lockdown in a home with outdoor space is likely to have been much more pleasant, especially at the height of lockdown when time outside was strictly limited. Analysis by the Health Foundation has found inequalities in access to outdoor space by age, with 21% of those aged 25–34 lacking any access at all. The National Housing Federation estimated 30,000 people lived in a home consisting of only one room during the pandemic. Home environment will have had a particularly increased impact on educational inequalities given the time children have spent learning at home rather than at school – children will have needed quiet, private space to study, as well as good internet access, which is more likely in more spacious homes.

Consequences of the economic crisis on housing affordability

The pandemic and associated lockdown measures have necessitated a large decline in economic activity, which will have potential consequences for meeting housing expenses. As in Figure 4, many were struggling with housing affordability before the pandemic. Research by the Resolution Foundation found that (both private and social) renters are more likely to have lost their job, more likely to be furloughed, and more anxious about struggling to meet their housing costs than homeowners.

The government acted quickly to protect people with a mortgage – ensuring a mortgage holiday was available, including for landlords. No such support was provided for renters, with renters reliant on the goodwill of landlords to pass on the benefit of any mortgage holiday. One estimate has 700,000 private and social renters in arrears in October 2020, an increase of 250,000 since just before the pandemic.

Renters do have access to the Local Housing Allowance (LHA) for support with housing costs, however the amount provided by the LHA is set at the 30th percentile of rents in a local area, meaning that it will cover entire rents for a small minority of households. For example, the shortfall between rents and LHA is £1,227 per month in London. The benefit cap has also undermined the increases in social security the government has authorised.

Following the end of the eviction ban, the government has increased the notice period of evictions and agreed no bailiff action before January 2021, although cases can still proceed through the courts. Given the accumulation of arrears, this risks a ‘time bomb’ of evictions, and one that is likely to get worse the longer that measures remain in place. Further support is likely to be needed. Devolved governments have provided renters in other parts of the UK with greater protection, while other countries in the OECD have generally instituted more protections for renters.

These issues are not experienced equally across the population. Before the pandemic, housing problems were more commonly experienced by black and minority ethnic communities, younger people, women, disabled people and single parents. Many of these characteristics overlap with greater risk of contracting COVID-19, experiencing job loss or being furloughed, and struggling with lockdown.

Given the significant influence of housing on people’s lives, housing is a policy area with potential to bring about substantial improvements to health and broader social benefit. In addition, the status quo is expensive. Aside from the human cost, the current situation perpetuates high levels of spending on housing benefit (more than £20bn in 2018/19) and homelessness. If the former is cut, the latter is likely to spike. However, successive governments have failed to make the long-term decisions necessary to improve the situation.

One overarching consideration is the housing tenure mix: England has moved from 31% of households in social rented accommodation in 1980 to 17% in 2018/19. With a small social rented sector, many of those on lower incomes are being housed in the private rented sector instead, which tends to be more expensive, less secure and lower quality. At the same time, this has led to the so-called ‘residualisation’ of social rent, meaning that this form of tenure houses those with the highest need rather than providing an affordable option to a cross-section of society.

Recent policy has been concerned with boosting home ownership and increasing private supply such as Help to Buy and Starter Homes. There is a group for whom this is likely the right policy: relatively high-income adults whose rent payments have slowed the accumulation of a deposit. However, these schemes have been criticised for high deadweight costs, meaning they are subsidising transactions that would have occurred anyway. To create a longer term reduction in social housing waiting lists or those in poverty in the private rented sector, an increased supply of good quality, secure and affordable social homes offers a much better policy option.

Increasing the social share of housing stock through direct government intervention is a policy response that can contribute to the three main housing problems outlined here. Social housing has lifetime tenancies, is more affordable, and is more amenable to policy interventions to improve standards (such as the Decent Homes Programme) due to the relatively few ‘owners’ of the stock.

A key stumbling block is the dual investment needed to support those in need today and to simultaneously build new homes for the future. However, social housing is an economically, as well as socially, appropriate investment. Research for Shelter shows that a mass social housing programme would pay for itself over 40 years simply by reducing the cost of housing benefit. Greater investment also means reversing longer term trends of disinvestment. The coalition government reduced capital spend on social homes by 63%, a trend which continues with the current government and their focus on alternative forms of ‘affordable’ housing.

The remaining sections look at alternative and more immediate policy options for these housing problems.

Improving the quality and condition of homes

The focus on increasing private supply of housing can neglect the quality of these new homes. A stark example of this is homes provided through permitted development rights, which allow developers to bypass many aspects of planning permission when converting buildings from business to residential use. These homes have been described as the ‘slums of the future' and found by the government’s own review to be small – only 22% of these homes meet national space standards. Despite this, the government is currently planning to expand permitted development rights.

As discussed previously, tackling non-decent homes means intervening in the 61% of non-decent homes which are currently owner-occupied (Figure 6). This points towards grant incentives as a way to improve standards, as noted by the Centre for Ageing Better and The King’s Fund. A recent proposal from IPPR North suggested a programme of investment in decarbonising homes as an economic stimulus, which could also contribute to improving health outcomes by improving home quality through insulation and energy efficiency measures. This represents a considerable challenge, as it involves designing schemes which would require take-up from millions of households, and wrestling with the right of home-owners to not improve their properties.

Increasing the affordability of housing

Research suggests that affordability problems are less to do with the need to build more overall, and more to do with changes in the nature of the housing stock – problems such as erosion of social stock and housing benefit cuts. Longer term, this problem could be tackled by providing more affordable social homes as discussed above. But more immediately, affordability issues could be eased by reinstating support through housing benefit. The reductions in Local Housing Allowance from 2011 onwards, designed partially to try and depress rent increases (but failing in this regard), have instead contributed to increased homelessness. Short-sighted changes such as these – originally designed to reduce benefit spend – can often increase costs elsewhere in the public sector.

Prioritising security of tenancies

Housing security is largely a problem for the private rented sector, given long social tenancies and changes around mortgage forbearance since the financial crisis in 2008. The regulations around private renting come from a time when relatively few households lived in the sector, and those who did were primarily university students and young adults making the transition to owner occupation. These regulations are therefore unsuitable for the private rented sector as it functions today – as an increasingly permanent home to significant numbers of households, including households with dependent children.

This is in part due to the shrinking of the social rented sector – many of these households would likely have lived in a social home in years gone by. Increasing the amount of social housing will improve housing in the long-term, but not quickly enough for the people living in the private rented sector today. Housing costs in the private rented sector are the highest of any tenure, while quality and security are generally poorest. Regulation in the private rented sector is light-touch, and while some progress has been made in England, such as the as-yet unfulfilled promise to end ‘no-fault’ (section 21) evictions, there is still a long way to go. The government does not have to look far to see examples of successful intervention – Scotland for example has introduced more secure tenancies (although these still have some loopholes), while countries such as Germany have successful private rental markets designed around long-term tenancies.

While the COVID-19 pandemic has served to highlight the role housing plays in health, it is a critical wider determinant of health at all times – not just this year. Housing problems are likely a significant component of the ‘syndemic’ that has led to greater risks of COVID-19 infection and serious complications for certain social groups. As discussed in this piece, problems such as overcrowding, poor quality and unaffordable homes are a threat to health.

There are a range of short-term measures to help tackle risks to health. Intervening to improve housing’s impact on health will offer opportunities to address other interrelated environmental and economic challenges. These include:

• needing to reduce carbon emissions and be resilient towards more extreme climates (incorporating temperature management rather than simply retaining heat)
• catering for the likely shift in the type and size of accommodation required, resulting from the demographic shift towards an ageing population
• investing in more housebuilding and home improvements (supporting economic recovery as well as developing housing stock)
• adapting relevant policies and provisions to enable people to use their homes (and local transport and services) in different ways, with more people working from home as a long-term consequence of the pandemic.

The COVID-19 pandemic has highlighted the importance of homes, both the good and the bad. For many people, the nature of the housing stock and housing system meant that the experience of the pandemic since March 2020 has been even worse than it needed to be. The challenge is to ensure that housing starts to make a positive contribution to health for more people. Even if the beginning of the end of the pandemic leads to homes taking a less prominent role in our lives, guaranteeing housing that is affordable, high quality and secure will still offer great dividends for health and wellbeing.