Health starts at home. It’s central to where many of the building blocks for a good life are created, including safety, warmth, family connection, community, good education and work. But for some people, home is making them sick.
The UK’s housing crisis reflects decades of failure to take the long-term action required to ensure the nation’s housing stock is affordable, high quality and secure. Almost a fifth (19%) of families now live in the private rented sector, of which 36% are families with children. The long-awaited Renters (Reform) Bill presents an opportunity to begin to ensure tenancy conditions support healthy homes.
There is a welcome focus on housing security, with a proposed end to no-fault evictions, although a potentially lengthy wait until implementation is cause for concern. More recently, the commitment to passing legislation to apply the Decent Homes Standard to the private rented sector has finally been brought forward, through an amendment to the Bill.
The Decent Homes Standard was set almost two decades ago. It is currently being reviewed by the Department for Levelling Up, Housing and Communities. This must result in updated criteria, to ensure it meets modern standards and protects against future risks, if it is to support healthy homes.
Across all tenures there are still 3.7 million households in England classed as ‘non-decent’, causing avoidable ill health and inequalities. Failure to drive up standards means that hazards in the home are estimated to cost the NHS £1.1bn a year.
Overcrowding – which is linked to development issues for children as well as worse mental health – has been gradually rising since the early 2000s in the private and social rented sectors. The number of families with children living in temporary accommodation – often unsuitable bed and breakfast or hotel rooms – is also increasing. This reflects affordability issues driving families into unsuitable accommodation.
In this long read, we set out the health case for change, outline the principles to create healthy homes (including through the Decent Homes Standard) and call for a long-term strategy to ensure healthy homes for all.
What’s the connection between housing and health?
Unhealthy homes cause and worsen illness and can cut lives short. We were reminded of this by the tragic death of 2-year-old Awaab Ishak, from exposure to mould in his home. Housing issues are known to contribute to many avoidable deaths – for instance, more than a fifth of excess winter deaths are estimated to be due to cold homes.
Cold homes and mould contamination increase the risk of developing asthma and can exacerbate existing respiratory conditions. Mental health has also been shown to be negatively affected by the financial stress brought on by cold homes and fuel poverty. More directly, poor safety levels and hazards in the home can lead to injuries such as falls, or a lack of fire safety due to poor electrical installations. Poor air quality indoors also has a negative impact on health.
Many lower income older households own their own homes, but they live in non-decent housing as they do not have the necessary funds to spend on costly repairs and adaptations. This means that their homes do not meet their changing, and often deteriorating, health and mobility needs.
Overcrowding can put strain on family relationships, reduce privacy and limit the space for children to study or play. There is some evidence of it affecting health and respiratory conditions, as well as contributing to psychological distress.
Housing affordability matters for our health. Difficulty paying the rent or mortgage can cause stress, affecting our mental health, while spending a high proportion of our income on housing leaves less for other essentials that influence health, such as food and social participation. People on the lowest incomes are hit particularly hard – 26% of households with the lowest incomes spent more than a third of their income on housing costs in 2019/20, compared with only 3% for households with the highest incomes.
High costs and a shortage of affordable homes mean many people fall into debt because costs are too high, they have to move frequently, or may face repossessions or evictions. This all creates further instability and stress, with a significant impact on people’s health and wellbeing. Strong social networks and relationships are important to our health, but if we frequently have to move house, our engagement with local community and services (such as GPs and schools) is often weakened.
This long read focuses on housing quality – specifically, decent homes and overcrowding. Because housing is a devolved issue, and due to data availability, we analyse England only.
What is meant by ‘decent homes’?
The quality standards applied to different housing sectors vary, and it is a complicated landscape. Historically, the motivation for such standards was strongly linked to health, but more recently this rationale has tended to be overridden by a focus on quantity and lower costs of production.
The ‘Decent Homes Standard’ was introduced in 2000, partly to address the 43% of local authority properties failing to meet quality standards at that time. After significant improvements between 2006 and 2012, the rate of progress has slowed. In 2022, 14.6% of all homes in England (3.7 million homes) still don’t comply with the Decent Homes Standard.
Compliance means a property:
- meets the current statutory minimum standard for housing
- is in a reasonable state of repair
- has reasonably modern facilities and services
- provides a reasonable degree of thermal comfort.
Figure 1 uses the English Housing Survey to track compliance with this standard since 2006. It shows that significant investment in the social rented sector, estimated to be £37bn between 2001 and 2011 from both the government and housing associations, led to the share of non-decent homes falling to 10% in England by 2022. There has been little progress in the last decade.
Private rented homes are most likely to be non-decent (21%), equating to 1 million non-decent homes in England. More than half of these have serious hazards. Private renters who receive housing benefit are more likely to live in a non-decent home.
In 2022, 14% (approximately 2.2 million homes) of owner-occupied properties were classed as non-decent. Although the Housing Health and Safety Rating System applies to owner-occupied properties, the standards are rarely enforced, and grant funding is currently only available to a small proportion of households.
Although the share of homes that are non-decent in the private rented sector has halved since 2006, the number has only fallen from 1.2 million to 1 million over the same period. The private rented sector has more than doubled in size since 2000, and now comprises more than 4.6 million households, which is 19% of housing stock in England. Tenants tend to be younger – almost a third (31.7%) of private renters were aged between 25 and 34 in 2019/20 – and have become more likely to be families with children – 36% of households having dependent children in 2019/20. It is estimated that £1.6bn a year in housing benefit is going to private landlords renting out non-decent homes.
What’s happening with overcrowding?
Figure 2 shows the proportion of households that are counted as overcrowded, by housing tenure over time in England. Overall, 2.9% of households in England were overcrowded in 2022/23, which amounts to 0.7 million households.
Overcrowding in private rented and social rented tenures peaked in 2019/20 (before the COVID-19 pandemic), following a rapid increase since 2016/17. In 2022/23, 8% of households in the social rented sector were overcrowded, compared with 5% of private rented households. These increasing trends reflect a lack of increase in social housing, an increase in families with children in the private rented sector, and affordability issues – which in part relate to reductions in the value of housing benefit over the period.
What about people experiencing multiple housing problems?
Housing issues linked to poor health do not affect the population equally. Lower income households are more likely to live in non-decent, overcrowded properties and are more likely to experience a higher housing cost burden, all of which negatively affect health.
This chart shows the proportion of households in each tenure that experienced one or more housing problems in England in 2018/19. Those households facing multiple housing problems are mostly in social and private rented homes. These two types of tenure are the only ones to experience all three problems of non-decent, overcrowded and unaffordable housing.
The current government aspires to reduce non-decent housing by 50% by 2030. It has now brought forward plans to apply the Decent Homes Standard to the private rented sector in the Renters (Reform) Bill. But with the current standard now two decades old, there is a risk that it no longer reflects the latest understanding of health hazards and environmental impact.
What would a ‘healthy home standard’ look like?
A healthy home should be a safe and accessible environment. It should also be a place that is free from hazards, able to be efficiently heated to a healthy temperature, provide a sense of security and have modern facilities.
A standard that has health at the heart of it would need to be ambitious. It would likely take some time and significant investment before the necessary improvements to housing can be implemented. But given the UK has the highest proportion of inadequate housing in Europe (and has more substandard homes than Hungary, Poland and Lithuania), significant action is clearly required.
Improving housing stock can require a big upfront investment. There are long-term rewards, but government intervention is likely needed to realise them. For instance, the Environmental Audit Committee estimated that to improve all UK properties to EPC (energy performance certificate) band C will cost between £35bn and £65bn and it could take 18 years to recoup upfront costs.
In addition, it has been estimated that removing the worst hazards in the home (category 1 hazards) would cost a one-off nearly £9bn, although around £6bn of this is taken up by addressing cold homes. The cost savings to the NHS are estimated at approximately £1.1bn per year. Households would also benefit through reduced energy bills, something that is currently putting a huge strain on individuals and families with the cost-of-living crisis far from over.
It is crucial to make sure that the standards we are aiming for now do not leave people suffering the health consequences of poor quality homes in the 2040s and beyond. The ongoing review of the Decent Homes Standard, with proposed changes to the standard due to go out to consultation this winter, will be a key step in ensuing the standard supports good health.
The changes needed to the Decent Homes Standard that we propose as a starting point to move towards an improved standard in the longer term are:
- Thermal comfort: aligning with carbon targets, the energy efficiency of homes should be boosted to meet a minimum EPC of Band C. Increasing the EPC rating would improve insulation and make it cheaper to heat homes. This is an immediate priority given the cost-of-living crisis, and well-insulated homes are less likely to suffer condensation and mould growth. The World Health Organization recommends that in colder climates, houses should be heated to a minimum indoor temperature of 18oC, with warmer temperatures for more vulnerable people. Therefore homes should be able to maintain an indoor temperature in all seasons between 18 and 25°C, which may also require a means of cooling, either through natural ventilation or air conditioning (building alteration should be prioritised over air conditioning to reduce the carbon footprint).
- Hazards: standards should be updated to require homes to be free from vermin, dampness, cold and other hazards serious to health. The current requirement to be free from category 1 hazards is too narrow and tends to capture only the most serious levels of certain hazards (such as those with high levels of dampness, mould growth and noise). This leaves occupiers open to the negative health effects of homes in poor condition. Homes should be structurally sound and secure, be free from high category 2 hazards and have mains-wired smoke detection on every storey. To further protect against dampness and mould growth, intermittent extract ventilation should be a requirement for all bathrooms and kitchens.
- Modern facilities and services: all structural elements should be in good condition, with improved standards for space in kitchens and location of bathrooms. Building components (such as kitchen cabinets) should be assessed on their condition rather than their age. Adequate insulation to protect against external noise is required. In blocks of flats, common areas should be of adequate size and layout, and must be maintained, to support accessibility and escape routes.
- Connectivity: homes should have fast and reliable digital connectivity. Digital has become the default for accessing most essential utilities and government services, including health care. Such connectivity is also increasingly important for employment and social engagement, which are important determinants of health in themselves.
How to achieve healthy homes
Better housing standards can help reduce the risk to health of poor quality housing, but alone will not be enough to enable healthy homes. Also needed are the right policy structures to ensure standards are met, and consistent improvements across all types of tenure. Wider changes to other elements of housing, including addressing threats to health from insecurity and a lack of affordability, are important too.
Given the scale of investment needed, homeowners and landlords will require support to upgrade properties. Tax incentives, subsidised green loans, ‘warm rents' and increased ‘decent housing benefit’ rates to pay for improved quality could all be considered. An example of a scheme recently trialled in Scotland is an equity loan for energy efficiency improvements. Such schemes are a means of encouraging investment in energy efficiency, while also providing a means of recouping costs in the long term.
The largest number of non-decent homes are in the owner-occupied sector, so finding a way of improving standards here is essential. To drive this forward, properties in the owner-occupied sector could be inspected when they are listed for sale, allowing potential buyers the chance to see where a property passes or fails the healthy homes standard. The purchasing process could then include incentives for new owners to improve any property to meet the standard, potentially through low-interest loans or lower mortgage rates for compliant properties. A report by the Lenders Project showed that the idea of green mortgages and green loans were both appealing and likely to be taken up by homeowners.
There is an additional need to support an increasing number of older, more vulnerable homeowners with improvements and adaptations to their properties. This is important for the mental and physical health of occupants, but has the added benefit of reducing the burden on health and care services by enabling people to live at home for longer.
Enforcing housing standards
Social housing is regulated and controlled by councils and major landlords. Enforcement of housing standards is more stringent here, but is still not universal, and has been the subject of debate following the recent case of Awaab Ishak and investigations by the media into poor social housing. The government has responded by passing ‘Awaab’s Law’, which forces social landlords to fix damp and mould within strict time limits.
Private housing is largely unregulated. The new Renters (Reform) Bill aims to address this, but currently does not apply Awaab’s Law to the private rented sector which would force faster action to fix housing quality problems in that sector. It proposes creating the first national register of landlords via a new national property portal. This will assist councils with the enforcement of standards and should allow renters to check whether a property meets basic requirements. However, such a scheme will only be successful if landlords engage positively. And for effective enforcement, financially stretched local authorities will require additional funding. Placing a duty on local authorities to provide this role will also require legislation – but this is not included in the Renters (Reform) Bill.
Making complaints and redress systems consistent
The complaints process should be standardised for all renters. Currently, as local authorities are not able to take legal action against themselves, social housing tenants are left with a lengthy process involving multiple organisations.
To increase the level of redress available to tenants, the Homes (Fitness for Human Habitation) Act came into force in 2019. The Act does not place any new obligations on landlords, but allows social and private tenants to take their landlord to court if their property (including common areas) is not fit for human habitation throughout the tenancy. The new Renters (Reform) Bill includes provision to create a new private rented sector ombudsman, intended to provide a quicker, cheaper and less adversarial way to resolve issues (rather than through the court system).
Allowing local environmental health teams to take enforcement action where necessary would also streamline the process, while making it consistent across rented tenures.
Improving security of tenure
An important element of the Renters (Reform) Bill is the ending of Section 21 evictions. This will allow tenants to voice any concerns about conditions within their property without fear of reprisal, protecting them from the strain of being under threat of no-fault evictions. Evictions can cause significant stress, along with affecting employment, education and social support. However, there is now likely to be considerable delay to the implementation because the government have stated it will be dependent on changes to court processes.
There has also been an increasing number of families moving into temporary accommodation in the last year, and more gradually since 2010. Figure 4 shows the number of households who have been placed in temporary accommodation in England since 2005 – people who have been classed by their local authority as being, or becoming, homeless and in need.
The data includes households with and without children, and households placed in unsuitable accommodation. Temporary accommodation is funded by local councils – typically it’s a private flat, a council or housing association flat, a room in a bed and breakfast establishment or a hostel.
In June 2023, there were 105,000 households in temporary accommodation – a high since 2005. 68,070 (64%) of those households had children.
The need for temporary accommodation has consequences for people’s health, and for local authority finances too (with such costs making up an increasing share of many council’s finances).
The increasing number of households in temporary accommodation since 2011 shows the impact of housing benefit and council funding both being cut over the last decade. The recent restoration of the Local Housing Allowance to cover 30% of local rents (from April 2024) will help with more immediate affordability pressures. However, it will not be uprated in line with private rents in future, which means pressure on low-income private renters (and therefore risk of eviction) will inevitably build up.
Longer term, there is a need to ensure that the types of homes available across the UK matches the needs of families living here. The increase in overcrowding partly reflects a mismatch between supply and demand. Part of the solution is to increase the supply of affordable and high quality housing, including social. But finding the funding to do so is also a challenge – the National Housing Federation have estimated this would require around £13bn a year of government investment for a decade.
Homes are an essential building block for our health, but for too many people – especially in private rented housing – they are making us sick. 3.7 million homes are still failing to meet the basic standards of 20 years ago, as successive governments have pushed more people into the private rented sector, while failing to invest in England’s housing stock.
As a result, we’re stuck with last century’s standards and a continuation of historic affordability and insecurity issues. These housing problems affect health, widen inequalities and lead to avoidable tragedies. They also create needless costs to the health and care system more through avoidable illness and lengthy hospital admissions. Outdated standards are becoming more apparent as more contemporary challenges – like climate change, the COVID-19 pandemic and the cost-of-living crisis – come to the fore.
There is growing consensus that housing quality must be addressed for health, environment and a more equal country. Taking actions upstream, such as creating new regulatory and market structures, alongside targeted investment and incentives for owners, can support housing improvements now to prevent crises and poorer health in the future.
Policymakers can address these issues together, including an updated set of standards for the next 20 years. Committing to improving the Decent Homes Standard and applying it to the private rented sector as part of the Renters (Reform) Bill are key initial steps in the long-term action required.