It was acknowledged from the very foundation of the NHS that safeguarding the nation’s health was the responsibility of the government as a whole. Restoring a sick person to health was a duty of the state (and of the person themselves) “prior to any other consideration”, William Beveridge wrote in his 1942 blueprint for the welfare state reforms that were to follow the end of the second world war.
In the early days of the NHS, it was run from the same Whitehall ministry as housing. Although setting up and bedding in the service at the same time as meeting the huge postwar housing needs proved too great a challenge even for the charismatic Nye Bevan, who was health and housing minister, many observers have ever since lamented the decision after three years to separate the two functions.
As Nicholas Timmins writes in The Five Giants, the definitive history of the welfare state: “Given the impact that housing can have on health, there was an intellectual logic to [their being put together]. After housing was removed by [Clement] Attlee and put in with local government in 1951, repeated arguments would be heard down the decades for reuniting the two.”
Any formal reuniting seems a distant dream today. But there is a resurgence of awareness of the key role of good housing in supporting health and, conversely, the burden that poor housing can pile on the NHS. According to a joint report by the King’s Fund health thinktank and the National Housing Federation, the NHS could save £2bn a year if poor-quality homes were brought up to standard.
One health and housing scheme in Wakefield, West Yorkshire, is said to have cut local NHS costs by £1.5m a year. Another, piloted in Blaby, Leicestershire, and now being extended across the county, is projected to save £2m annually. Such schemes, run jointly by social housing providers and local health commissioners, help people to live independently through home adaptations, telecare and emergency call systems and even mental health support, but also tackle any obstacles to discharge if the individual does need hospital admission.
New research [pdf] in Wales, conducted over 10 years and the first large-scale evaluation of its kind, suggests that older people living in council housing where regular improvements were made, experienced up to 39% fewer hospital admissions for conditions such as breathing problems or for falls or other injuries.
This goes to the heart of the argument advanced by public health experts that “social determinants” of health and wellbeing are critical. Sir Michael Marmot, professor of epidemiology and public health at University College, London, says that two of the most important of these determinants are income and work. But this is nothing new: in 1948, just as the NHS was opening for business, the World Health Organisation defined good health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”.
One recent and striking development in this context is the way many firefighters have become associate health workers as they undertake fire prevention visits to people’s homes and at the same time check on their wellbeing.
This new aspect of the firefighters’ role stemmed from a realisation that they are highly trusted by the public and almost always welcomed into their homes. There are also many fewer fires to fight these days. In 2015, NHS England formalised burgeoning local arrangements in a consensus statement[pdf] setting out the potential of the 670,000 home visits carried out annually by fire services. These fire prevention visits could all become “safe and well” visits, it said. By last year, 41 of the 46 English fire services were signed up to the idea.
In Greater Manchester, where the fire service is not only carrying out home checks but also starting to respond to emergency health calls, where appropriate, an evaluation has suggested it is saving the local NHS at least £635,000 a year.
It is social care, however, that is the closest working partner of the NHS. By supporting older and disabled people to live independently – ideally preventing them from going into hospital, but welcoming them back home or into care settings afterwards if they do – social care is umbilically linked to the health service. And in providing 1.8 million jobs across the UK, it is at least as big as the NHS.
Councils in England receive almost 5,000 requests for social care every day. Although numbers receiving state-funded care have fallen sharply, by more than a quarter since 2009, about 900,000 people are still supported by councils. Adult social services directors recently told ministers that for an extra £1bn annual funding they could support 50,000 older and disabled people to continue living at home.
It would be false to suggest that relations between the NHS and social care are always smooth, or indeed that the health service always works seamlessly with its various partners. The record of local health and wellbeing boards, statutory bodies introduced in England in 2012 to coordinate services across localities, has been patchy. Councils, like housing providers, have felt marginalised on many of the 44 sustainability and transformation partnerships set up in 2015 to take forward the integration agenda of NHS England’s Five Year Forward View. And social care still awaits a funding boost to set alongside the NHS’s 70th birthday present of an average 3.4% annual real-terms funding increase for the coming five years.
MPs on the Commons health and social care committee and the housing, communities and local government committee said in a recent joint reportthat it was clear how funding of health, social care and housing was interrelated “and that spending growth or restraint in one area had an impact on the others”. Future funding settlements, the MPs concluded, “should consider all these in the round”.
Bevan would approve.