Health equity in housing: over-reliance on the private sector will not deliver healthy and affordable homes
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj.r446 (Published 05 March 2025) Cite this as: BMJ 2025;388:r446
- Isobel Braithwaite, housing and health research fellow1,
- Phillippa Howden-Chapman, distinguished professor2,
- Helen Pineo, research associate professor3,
- Giorgos Petrou, senior research fellow4
- 1Research Department of Population Health and Primary Care, University College London, London, UK
- 2He Kāinga Oranga Housing and Health Research Programme, Department of Public Health, University of Otago, Wellington, New Zealand (Aotearoa)
- 3Department of Urban Design and Planning, University of Washington, Seattle, WA, USA
- 4Institute for Environmental Design and Engineering, Bartlett School of Environment, Energy and Resources, University College London, London, UK
The quality and affordability of UK housing is poor relative to international comparators,12 and, alongside the wider built environment around people’s homes, directly affects physical and mental health.3 In this context, Michael Marmot and the UCL Institute of Health Equity have published a report Building Health Equity: The Role of the Property Sector in Improving Health that analysed the intersection between housing, neighbourhoods, and health equity in the UK.4 The report focuses on the role of investors, developers, and operators in the current housing crisis, drawing on interviews and a roundtable, and makes recommendations for wider reform to the sector.
Marmot and colleagues detail how quality issues such as cold, damp, mould, overheating, inaccessibility, and inadequate safety create avoidable illness and exacerbate health inequalities. Unaffordable housing also contributes to economic stress and socioeconomic inequities, with concomitant health impacts. Additionally, overcrowding and homelessness are highlighted as critical public health problems linked to housing supply. The report recognises the important role of integrated urban planning with community participation in the delivery of healthy places. Facilitates should be planned to be in close proximity of housing, public transport, community amenities, and wider infrastructure, ensuring that residents have opportunities for physical activity and access to essential services and employment.
Practical recommendations are offered in the report to better align the property sector with public health goals, including a need for stronger regulation and better integration of health equity into planning. This alignment could be achieved through national policy that requires health equity to be considered in planning decisions, greater collaboration between public health and planning, enforcement of more stringent building standards, incentivising retrofitting, and further prioritising the creation of more affordable housing. Recognising sustainable building design as a determinant of health equity is also important, which the UK property sector has been reluctant to pursue because of cost barriers; although, evidence does not support this claim.5
The report falls down, however, on its relatively limited historical perspective. For example, the UK’s scarcity of housing supply is emphasised but not the effects of historical political choices, such as the introduction in the 1980s of the “Right to Buy” scheme and assured shorthold tenancies (which provide renters with much less security than the earlier protected tenancies), or the increasing financialisation of the housing sector.67 These policies have had a wide range of adverse social and health consequences, including substantially reducing housing stock in the social rented sector and contributing to fast rising property prices and rents, leading to increasing overcrowding and homelessness.7 Another area the report does not tackle is how non-supply side policies can improve affordability. Welfare housing subsidies or rent control policies, for example, can mitigate inequalities related to housing if implemented carefully and alongside measures that also increase housing supply.8
More can also be said about the barriers to and opportunities for health equity that can be created by the development process. Research has repeatedly highlighted the commercial property sector’s use of “development viability” (ie, whether a development would still be adequately profitable for its investors) as justification for not integrating design measures that promote health, including provision of affordable units, sustainable carbon mitigation measures, design quality, and adequately sized homes.9101112 The UK’s over-reliance on private sector-driven housing provision hampers efforts to address social and health equity, emphasising the need for a larger public sector role in supplying quality affordable housing amid high demand. This larger role can be achieved through incentivisation, regulation, enforcement, and public sector housing development.
Far reaching consequences for communities
A key principle of healthy urban development theory that could have been usefully reinforced in this report is the importance of considering how a housing development can have far reaching consequences community’s health, both spatially and temporally. For instance, mixed use developments, which blend new housing with community facilities, can be socially inclusive in the mix of built housing and provide amenities for neighbouring low income communities if they are permitted to use those spaces and facilities. This type of development has, however, been discouraged by some property owners. Similarly, housing design and construction choices can also affect the health of more distant populations and future generations, whether negatively through environmental harms or positively through enhancing biodiversity and carbon mitigation measures.5
Concerns have also been raised about the negative health effects of housing and planning deregulation in the UK. Of note, in relation to the poor quality of some homes created under Permitted Development Regulations,131415 and risks such as those exposed by the Grenfell Tower disaster,16 although they are not a focus of this report.
The UK could usefully learn from international examples of alternative ways of working. In New Zealand, for example, the crown agency Kāinga Ora–Homes and Communities was mandated by the government to establish alliances with private infrastructure and building companies, as well as partnerships with councils and other government agencies. These alliances were to build sustainable housing that is close to accessible public transport and that supports community formation. As such, this approach has increased supply and has also increased tenant wellbeing.1718 Another example is Nightingale Housing, an Australian social enterprise model led by the private sector that aims to develop financially, socially, and environmentally sustainable housing projects.
Marmot and colleagues’ report highlights the UK’s housing related health inequities and makes a useful contribution to understanding the property sector’s contributing role; although, the findings perhaps understate the important roles of local and central government in promoting healthy housing. Over-reliance on the private sector for housing and other development creates a problematic gap between the financial cost and societal value of healthy places, which cannot be fixed by regulation or developers’ goodwill alone. New ways of working are needed to ensure that development models will benefit lower income populations. These methods can be achieved through greater public and private sector coordination that builds affordable healthy housing and places, and through adequate regulation and effective enforcement to protect residents from unhealthy housing and mitigate housing related health inequities.
Acknowledgments
IB’s has funding from National Institute of Health Research funding (fellowship no. 306120). PH-C’s has funding from a Ministry of Business, Innovation & Employment Endeavour Grant PHURP. GP’s has funding from the Wellcome Trust (227123/Z/23/Z).
Footnotes
Competing interests: PH-C has previously worked with Michael Marmot on a Balzan fellowship at University College London.
Provenance and peer review: Commissioned; not externally peer reviewed.