Intended for healthcare professionals


Safer housing for better health

BMJ 2023; 380 doi: (Published 17 March 2023) Cite this as: BMJ 2023;380:p597

Linked Feature

The doctor forcing landlords to act on mouldy homes

  1. Tamara Joffe, GP
  1. London

GP housing letters are a crucial tool in patients’ struggle for improved health, writes Tamara Joffe

We must remember 2 year old Awaab Ishak. His death, the coroner concluded, was caused by exposure to mould in his home.1 We must talk about the health impacts of patients living in mouldy, damp housing.

In 2000, my experienced GP trainer told me that she had only ever written one housing medical assessment letter where the result was immediately effective. But, when we now know that so many illnesses are directly related to the conditions of patients’ homes, should we still aspire to such a selective approach, or do we need to re-think our response to the request for housing letters?

The estate, whose residents are our patients, consists of high rise, high density blocks of flats that stand on low lying ground. The tower blocks were rapidly built in the 1950s to meet post-war demand for housing. Recent regeneration work on this inner London estate discovered sewers just below surface level. But surrounding this area of generational poverty are areas of extreme affluence.

For over 150 years, this small patch has been home to series of immigrants, first Irish and Jewish refugees, then migrants and asylum seekers from war torn countries including Afghanistan, Algeria, Angola, Côte d’Ivoire, Eritrea, Iran, Iraq, Sierra Leone, Somalia, Sudan, Tunisia, and those fleeing the Balkan war. Many older citizens are the Windrush generation who came from the Caribbean in the 1950s, along with Ghanaians and Nigerians.

During home visits, the smell of damp and black mould clings to the communal areas and to most flats. Carpets and walls are dark with mould and, in winter, condensation collects over repeatedly applied paint. These are not isolated cases, it is like this in thousands of homes. For the tenants who plead with the local council, private landlords, and housing associations, it is degrading and humiliating at best. At worst, tenants live in fear for their family’s health.

Many repeated prescriptions are a direct result of these poor living conditions. For eczema, treatments include strong topical steroids and immunosuppressant creams, emollients, antibiotics for the consequent Staphylococcus aureus infections, and referrals to dermatologists. GPs are penalised for writing such prescriptions, but eczema exacts a harsh toll on children and families, who are woken nightly by the itching, tearing at skin, and pain. Allergic rhinitis results in further prescriptions for nasal sprays and stronger steroid drops, and decades on daily antihistamines. Surgical adenoidectomies, removing the adenoid after chronic infection, are rare elsewhere but more common here.

Asthma wreaks havoc, leaving families to manage terrifying attacks. Now the prescriptions are for bursts of oral steroids and regular “preventer” inhalers that are hugely expensive both to the NHS and the environment. Even with the best techniques, it’s a daily battle against mould spores and inner city pollution, deep in residents’ airways. GPs are criticised for prescribing repeated “reliever” inhalers on the assumption that asthma exacerbations are intermittent and control is achievable. This isn’t possible when your home is covered with mould and when you live with your triggers. I have had consultations with parents that sound like grotesque interior design discussions: can he sleep in the living room? Can you rotate their beds to the centre of their room?

Not to mention the effect of cold, damp homes on flare ups of rheumatoid arthritis or sickle cell anaemia. The result is patients regularly taking opioids and ending up in repeated admissions, with historically little belief or understanding from health services. Then there is the heightened infection risk for patients on immunosuppressive drugs and dialysis. This is exacerbated by covid-19, with low paid key workers experiencing high exposure, as well as overcrowding and poor ventilation at home.

All general practice is under pressure like never before, but practices in more deprived areas have been in an existential crisis for a decade already. The higher illness burden that poverty and marginalisation bring, without resources to mitigate it, was described over 50 years ago by Julian Tudor Hart’s inverse care law and later by the Marmot review.23

Was I right to have written hundreds of letters to private landlords, council housing officers, and managing associations? Advice has changed over time. Sometimes we are encouraged to write housing medical assessment letters, and other times discouraged. Social prescribers now say that this is not their role. Of course, for GPs it is “not our job” to write letters for what is obvious: inadequate housing creates and perpetuates poor health. One theme is consistent, however—residents believe it is necessary to get a letter from their GP despite it being the responsibility of housing associations and landlords to provide safe housing.

At national and council level, we need more suitable housing. Regeneration is coming slowly to our area, bringing anxiety and disruption with it, sadly. At the GP surgery, however, we have stopped seeing the families who were moved into the newly built flats that replace the tower blocks, as they have experienced a reduction or an end to atopic diseases, along with the stress and even domestic violence that can be concomitant.

Housing letters are a crucial tool. They tell a patient’s story, are tailored to their experience, validate their suffering, and explain why they are experiencing illness. For patients living in these conditions, fighting a faceless digitalised system is hard enough, but being refused a housing letter from their GP compounds the sense of invalidity and voicelessness. It may be a few lines long, but it is your interpretation of the hours of consultations over years, and publicly declares your belief in this person and understanding of their predicament. If GPs and their colleagues do not provide these statements on the impact of poor housing on health, case by case, who will?


  • This piece was edited on 27 March 2023 to change the title and standfirst and to make some minor formatting changes in the text.