A link restored for now

Originally written as a column for Inside Housing.

We routinely talk about the relationship between health and housing but have we forgotten just how close it once was?

That was the intriguing question posed by Al Story, professor of inclusion health at University College London, in the final session of this year’s Housing Studies Association conference.

As he traced how the relationship between public health, homelessness and housing developed from the 19th century to the present day, he outlined a sometimes surprising history with a striking contemporary relevance in the wake of Covid-19.

It’s a story that starts with the 19th century Vagrancy Act (now finally scheduled for repeal) but also the gradual realisation of the links between overcrowding, poor housing, contaminated water and disease.

A system of workhouses, poor law infirmaries and shelters developed with features such as the penny sit-up (a bench with no sleeping allowed), two penny hangover (a rope to lean on) and four penny coffin (a coffin-shaped box to sleep in).

Although the workhouse model was finally abolished in 1930, much of the concept and many of the buildings still survive: communal casual wards became modern day night shelters and cellular casual wards became hostels.

Public health concerns drove increased help for homeless people. Workhouse infirmaries were responsible for half of all deaths from TB but these were significantly reduced by segregation of consumptives even before treatments were available.

The contemporary relevance of all this is not just that homeless people still have the highest rates of TB even in the 21st century but also that the disease is spread via aerosol transmission – the same as with Covid-19.

The homelessness sector faced particular challenges when the pandemic arrived, with evidence from around the world of higher rates of disease and deaths in communal hostels, and one in four homeless people classed as clinically vulnerable.

Al Story said that Everyone In had been ‘an absolute saviour’ in reducing the risk of severe illness and death.

After decades in which the links between public health and housing and homelessness were lost, might one positive legacy of the pandemic be to bring them back together? This is about, as he put it, ‘not just rights – but why we have rights’.

However, there are big questions about what comes next now that we are ‘living with Covid’.

With no prospect of permanent immunity, the development of a novel variant a question of not if but when, and low vaccine uptake among people experiencing homelessness, we know that communal sleeping amplifies transmission of disease.

That leaves us with a stark question: ‘Can we do better than offering people a choice between a ventilator or hypothermia?’

Work to do better is perhaps furthest advanced in Scotland. Claire Frew of Homelessness Network Scotland explained plans to scale down night shelter and hotel room provision at the same time as rapid rehousing and Housing First are scaled up.

‘Pre-pandemic, health was not the first thing we were thinking about,’ she said. ‘There was broad support for moving away from night shelters…but the pandemic forced the change to hotel rooms. It forced to happen what everyone wanted to happen – what was just not possible became perfectly possible.’

But turning that possibility into something more permanent is still a challenge. Despite political commitment from the Scottish Government and a progressive legal framework that means almost everyone has a right to temporary accommodation, people still fall through the cracks.

Overnight Welcome Centres in hotels in Edinburgh and Glasgow have replaced night shelters over the last two winters. However, there are still problems for people with No Recourse to Public Funds, while rapid rehousing and Housing First are not scaling up as rapidly as needed and recent reports suggest issues with staffing and funding

For Al Story, it is vital to remember that link between public health and housing – ‘we need to understand why we lost it and how we got it back’ – but he fears that the progress of the last two years across the UK will fizzle out as funding is scaled back.

One of the strengths of the HSA conference is the way that it puts policy concerns like this into a wider context – and there were plenty more reminders of that this year.

Aimee Ambrose of Sheffield Hallam University gave a paper on the UK’s notoriously high levels of energy poverty. Even before soaring energy prices, our energy inefficient housing was driving thousands of excess winter deaths per year.

Meanwhile Alex Marsh and Dave Cowan of the University of Bristol looked at the way that ideas about the ‘housing crisis’ are affecting decisions by judges in homelessness cases.

In recent cases local authorities have argued that the housing crisis makes it impossible for them to find suitable accommodation and judges have accepted that it is not for the courts to say that more money ought to be spent.

Where does the boundary lie between law and policy – and is this now the frontline in the abrogation of legal rights?

That summary only scratches the surface of what was on offer at this year’s conference. Other sessions that I couldn’t make covered everything from Covid and mental health to housing and homelessness interventions and trauma-informed practice, to the prevention of youth homelessness.

And that is just the ones related to health and homelessness. Other plenaries covered equality, inclusion and discrimination in housing, the future of housing and professionalism, management and governance.

From a myriad of workshops, the other highlights for me were papers on mixing tenures in blocks of flats by Anna Clarke and Hannah Taylor of Peabody, the new legal threat to people living in vehicles by Rhiannon Craft and life in some of the last private landlord blocks with regulated tenancies by Sharda Rozena.

This was the first in-person HSA conference for two years, although it was a hybrid event with people able to attend online as well as in Sheffield and papers about housing in the UK and around the world. 

While this is mostly an academic conference, the housing practitioners who were there found plenty of ideas to take back to their workplaces. It is still easily the most eclectic housing conference out there and it never fails to get me thinking.


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