Dr Meredith JP Robertson
Consultant Respiratory Paediatrician, Evelina London Children’s Hospital

Throughout my medical training and practice there have been many families who have approached me and my colleagues for support with rehousing.  Like many others I had written letters, “To Whom It May Concern” saying something along the lines of, X lives in a house that is overcrowded or affected by damp and mould.  They suffer from asthma and I would be grateful for your support in tackling this, or re-banding them on the waiting list for a new home.  These letters often made no difference and I would warn families that I had no power to directly influence their situation.

Many times I would hear that an inspection had taken place, but most often the tenants were blamed for not opening windows enough, or for drying laundry indoors.  Sometimes surface mould treatments would be applied, but usually the change was only cosmetic and issues persisted.  Sometimes the photos we would be shown were truly appalling and I felt helpless, knowing that good quality affordable homes are in extremely short supply across the country and in London in particular.

About four years ago I was referred two new patients, both with frequent attacks and admissions (including one to intensive care). The social histories revealed some extremely concerning issues.  Both were living in hostels that were clearly impacting on their health including: damp and mould; poor ventilation; sleeping, living and cooking in the same room; secondhand smoke exposure from other residents; lack of private bathroom meaning eczema treatments could not easily be completed; lack of laundry facilities to ensure house dust mite control measures. There were also indirect effects – significant stress and distress for the parents, making it harder for them to be employed, to engage with health and education, to help their children to thrive socially. 

I referred one child to the Housing Officer at the Local Authority and at her next appointment a few weeks later I heard that a meeting had taken place but that the case had been closed without any housing solution being found.

I was angry and determined to help.  I wrote letters explaining exactly why the housing situation was unacceptable and should be treated as an emergency by the relevant non-health agencies.  I used key data from the National Review of Asthma Deaths, setting out one by one each potential risk factor for fatal asthma attacks and how these were influenced by housing for each child. I wrote that even though asthma medication is extremely effective and maximal medical and nursing support was being provided I felt that they were still at high risk of avoidable harm.  

The first child was moved from her hostel into a flat within a few weeks.  Asthma control and eczema improved and the treatment regimen was able to be simplified.  Subsequently care has been stepped down from tertiary respiratory and dermatology services to enhanced community services, delivered by specialist paediatric nurses in the community.

The social worker of the second child phoned me within hours of receiving my letter.  He thanked me for giving him the evidence he needed to move the family from “deplorable” circumstances.  Within 72 hours they were installed in accommodation with hard flooring, separate bedrooms for the children and parent, new beds and bedding had been provided and they were waiting for delivery of their own washing machine.  There was around 18 months of stability with no asthma attacks, and then the new landlord defaulted on the mortgage and the family were moved back into the previous hostel.  Almost immediately there was a severe asthma attack requiring IV therapy.

Over the next few months my colleagues used the same structure for their highest needs patients and there were several more families who were re-homed, had long-standing maintenance issues resolved or were re-banded on housing lists.  My amazing nursing colleagues simplified and generalised the letter and turned it into a template that could be used for children known to have severe allergic sensitisation to house dust mite, associated with poorly controlled asthma and living in chronically damp or mouldy properties.  We shared the idea in several forums and versions of it are being used by several teams across London and in one or two other areas as well.

I have reviewed the template with colleagues at Southwark Local Authority, who have added signposting and resources for families whether they live in Local Authority, Housing Association or privately rented accommodation.  We removed the emphasis on re-housing and now instead list what standards the child’s home should meet. We are now able to send our Southwark residents’ referrals directly to the Local Authority team, who arrange an inspection, provide a report and refer on to the relevant team for action.  We hope to make similar links at other Local Authorities across our integrated care system (ICS) and tertiary referral network.

Colleagues in other tertiary centres have used and adapted the letter, collaborating with lawyers who have added paragraphs detailing the responsibilities and legal obligations of landlords with regards to disrepair, hazards and fitness for habitation.   

I’m excited to share how my simple idea has grown and evolved.  I look forward to discussing it with you in our network and community of practice events.  Please get in touch if you’d like copies of the template or if you have ideas about how it could be adapted for other purposes.

Visit the 2023 #AskAboutAsthma webpage for more blogs, videos and podcasts about asthma care for children and young people.