Living in substandard housing linked to kids’ missed schooling and poor grades

Improving their living conditions may benefit both health and exam results, say researchers

BMJ Group

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Children living in substandard housing in England miss 15 more school days and achieve worse test scores in English and maths than their peers living in better quality housing, suggests research published online in the Journal of Epidemiology & Community Health.

 

Improving their living conditions—specifically reducing overcrowding and damp, and upgrading heating systems—may not only benefit their health, but also their grades,conclude the researchers.

 

One in 7 families in England live in homes that fail to meet the official decent homes standard, point out the researchers. Housing is a key determinant of child health, yet relatively little is known about how its quality may affect educational outcomes, particularly the number of missed school days and exam grades, they add.

 

To explore this further, the researchers drew on data for 8992 children, born between 2000 and 2002 participating in the nationally representative Millennium Cohort Study.

 

Housing quality at the age of 7 was calculated from 6 key indicators: accommodation type; floor level; lack of access to a garden; presence of damp; inadequate/no heating; and overcrowding.

 

Housing quality was linked to the percentage of missed school days and standardised test results in maths and English at the ages of 7, 11, and 16 in the National Pupil Database.

 

On average, children missed 5% (86 days) of compulsory schooling (years 1–11). And approximately 16% of them lived in poor quality housing, defined as meeting at least 2 of the 6 indicators.

 

After accounting for potentially influential factors, including parental educational attainment and ethnicity, analysis of the data showed that children living in poor quality housing missed more school days and achieved worse grades than children living in better quality housing.

 

These children missed nearly 1.5 more school days, on average, for each of the 11 years of compulsory schooling than their peers living in higher quality housing (based on 7272 children). Damp, overcrowding, and living in a flat were most strongly associated with missed schooling.

 

Test scores in maths and English during primary and secondary school were between 0.07 and 0.13 points (2-5%) lower for children living in poorer quality housing (based on 6741 children), mainly driven by overcrowding, and to a lesser extent, lack of central heating.

 

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect, added to which data on school absences or test results on at least one data collection point were missing for 10% of the participants.

 

Children exclusively in home schooling and attending private schools (7%) aren’t captured in the National Pupils Database. And housing conditions were subjectively assessed by parents rather than being objectively measured.

 

Nevertheless there are plausible explanations for the observed associations, suggest the researchers, with living in damp housing increasing the risk of respiratory illness.

 

“While study participants were not asked directly about the presence of mould, damp conditions are a major determinant of fungal growth which can in turn release hazardous spores, fragments, and microbial volatile organic compounds into indoor air,” they explain.

 

Overcrowding also creates an unfavourable environment for study, they add. “Crowded housing is linked to behavioural problems and to worse health in children…Living in crowded homes is linked to lower academic achievement due to noise, lack of study space, insufficient sleep, reduced concentration and added responsibilities (eg, childcare).”

 

They conclude: “Improving housing conditions, especially reducing damp and overcrowding, and updating heating systems and energy efficiency can have significant benefits.

 

“Given the magnitude of the problem in England, national and local public health and housing policies targeting these features of housing quality could improve children’s health and school outcomes across the country and narrow the health inequality gaps.”

 

The NHS could also save the £1.4 (€1.6, US$1.8) billion every year it spends on treatment associated with the effects of poor housing, they add.

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Journal

Journal of Epidemiology and Community Health

DOI

10.1136/jech-2025-224495 

Subject of Research

People

Article Title

Housing quality and school outcomes in England: a nationally representative linked cohort study

Article Publication Date

16-Dec-2025

 

U.S. Hospitals acquired by real estate investment trusts associated with greater risk of bankruptcy, closure

Harvard T.H. Chan School of Public Health

Key points:

• Real estate investment trust (REIT)-acquired hospitals were associated with a greater risk of bankruptcy or closure than non-REIT-acquired hospitals. REIT-acquisition of hospitals was not associated with any significant changes in quality of care or outcome indicators.

• The study is the first national examination of the consequences of REIT acquisitions of hospitals. According to the researchers, its findings suggest the need for greater regulatory oversight over these acquisitions. 

Boston, MA—Real estate investment trust (REIT)-acquired U.S. hospitals were associated with a greater risk of bankruptcy or closure than non-REIT-acquired hospitals, according to a new study led by researchers at Harvard T.H. Chan School of Public Health. The findings also showed that REIT acquisition of hospitals had no significant impact on quality of care or clinical outcomes.

The study will be published Thursday, Dec.18, 2025, in the BMJ.

When a hospital sells its real estate to a REIT, the REIT then functions as a landlord with the hospital as a tenant. This practice has become increasingly common among private equity- and corporate-owned hospitals in the U.S. Proponents argue that the profits from a hospital’s sale of its real estate to a REIT can be used to improve clinical care. But concern has grown that for-profit hospital owners are using REITs as a strategy to strip assets from hospitals to generate returns to investors.

While prior studies have examined the consequences of private equity and corporate ownership of hospitals, none have evaluated the consequences specifically of REIT acquisition of hospitals. For this study, the researchers compared the clinical and financial outcomes of 87 hospitals that had been acquired by REITs from 2005-2019 with 337 non-REIT acquired hospitals. They assessed at a variety of data, including Medicare claims, financial performance, patients’ experiences at hospitals, hospital staffing levels, and clinical outcomes and quality, indicated by 30-day mortality and readmission rates for patients with heart attacks, congestive heart failure, and pneumonia.

The findings showed that REIT acquisition had no significant impacts on quality of clinical care or patient outcomes—but had a significant negative impact on a hospital’s finances. REIT-acquired hospitals had a 5.7-fold higher risk of closure or bankruptcy compared with non-REIT acquired hospitals.

“In REIT-acquired hospitals, there don’t seem to be any systematic reinvestments into clinical services, which is one of the arguments employed by private equity or corporate owners of hospitals as to why a REIT transaction may be beneficial,” said corresponding author Thomas Tsai, associate professor in the Department of Health Policy and Management, co-director of the Healthcare Quality and Outcomes Lab, and a surgeon at Brigham and Women’s Hospital. “What we see instead is that these hospitals are less likely to survive. As more and more financial resources are stripped away, it’s death by a thousand cuts.”

The researchers say the findings highlight the need for greater oversight over REIT acquisitions of hospital real estate. 

“REIT acquisition of hospitals has the potential to help hospitals and the communities they serve, or to seriously damage them,” Tsai said. “The real-world evidence generated by our study can inform federal and state regulatory efforts to more closely monitor hospital ownership and transactions, to ensure that patients and communities are not being harmed.”

Article information

“Changes in hospital finance performance and quality of care after real estate investment trust acquisition; quasi-experimental difference-in-differences study,” Joseph Doc Bruch, Tarum Ramesh, Eric Boyang Yu, Jie Zheng, Jessica Phelan, E. John Orav, Thomas C. Tsai, The BMJ, December 18, 2025, doi: 10.1136/bmj-2025-086226

The study was supported by the Rx Foundation, the UM1TR004408 award through Harvard Catalyst 1, The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health), and financial contributions from Harvard University and its affiliated academic health care centers.

Visit the Harvard Chan School website for the latest news and events from our Studio.

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Harvard T.H. Chan School of Public Health is a community of innovative scientists, practitioners, educators, and students dedicated to improving health and advancing equity so all people can thrive. We research the many factors influencing health and collaborate widely to translate those insights into policies, programs, and practices that prevent disease and promote well-being for people around the world. We also educate thousands of public health leaders a year through our degree programs, postdoctoral training, fellowships, and continuing education courses. Founded in 1913 as America’s first professional training program in public health, the School continues to have an extraordinary impact in fields ranging from infectious disease to environmental justice to health systems and beyond.

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Journal

The BMJ

DOI

10.1136/bmj-2025-086226 

Method of Research

Observational study

Subject of Research

Not applicable

Article Title

Changes in hospital finance performance and quality of care after real estate investment trust acquisition; quasi-experimental difference-in-differences study

Article Publication Date

18-Dec-2025

Eight in 10 UK trusts caring for emergency department patients in corridors, finds BMJ investigation

Half a million patients being cared for in temporary spaces, which evidence suggests is becoming a permanent fixture in many hospitals

BMJ Group

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Most (79%) of NHS trusts in England are treating patients in corridors or makeshift areas in emergency departments including “fit to sit” rooms, x-ray waiting areas, and in one case a café, finds an investigation published by The BMJ today.

Data obtained by The BMJ show that such practices have resulted in at least half a million patients being cared for in temporary spaces and that in some trusts one in four patients in accident and emergency (A&E) departments were cared for in corridors last year.

Corridor care refers to the practice of providing care to patients in hospital corridors or other non-designated areas, owing to overwhelming demand.

Senior doctors say this is having a catastrophic effect on patient care, with end-of-life conversations being held in corridors. One describes the situation as “heartbreaking” and “undignified.”

Freedom of Information (FOI) requests by The BMJ show the extent to which A&E corridor care is becoming normalised, with examples of trusts installing portable sinks on corridors, along with heating, lighting, plug sockets, and toileting facilities to provide long term care to patients in these settings.

Some organisations have even created dedicated “corridor nurses” for shifts, with one trust hiring extra staff to help oversee patients in the “temporary escalation chairs.”

Wes Streeting, the health and social care secretary, promised in October 2024 to “consign corridor care to history where it belongs” and the government recently pledged to publish national data on the situation “shortly,” although NHS England first committed to this back in January.

Ian Higginson, vice president of the Royal College of Emergency Medicine, says: “We hear of persistent stories of patients having cardiac arrests on corridors or of an inability to get resuscitation equipment to patients because everything’s in the way.”

He added: “For staff it’s a real source of moral injury. If this was happening in any other place, in any other walk of life, there would be an absolute outcry. It’s a complete scandal.”

Yet despite the obvious harm corridor care causes to patients and the staff who treat them, evidence shows that temporary caring spaces are becoming a permanent fixture in many hospitals.

For example, Dorset County Hospital said that it had adapted a corridor by adding portable sinks, heating, lighting and plug sockets. University Hospitals of Liverpool told The BMJ it had converted a room on a corridor into an additional toileting facility for patients, and Dartford and Gravesham said it had “dedicated nursing staff to care for patients on corridors.”

The three trusts reporting the highest number of patients in corridor care were Liverpool University Hospitals (37,735, or 18.7% of attendances), Barking, Havering and Redbridge in east London (35,224, 24% of all attendances) and Northern Care Alliance in Greater Manchester (33,987, 11.3% of attendances), although they all cover two or more emergency departments within one organisation.

Lynn Woolsey, chief nursing officer at the Royal College of Nursing, says: “These figures reveal the tragic reality of the frontline, where patients are left in unsafe and undignified conditions and nursing staff are prevented from providing person centred care. The figures are shocking, yet they are the tip of the iceberg. We know that corridor care is not limited to emergency departments.”

“As we head into winter, this situation is only set to worsen,” she adds.

A spokesperson for the Department of Health and Social Care said: “No one should receive care in a corridor in a chair or trolley - it is unacceptable and undignified. We are determined to end this, which is why we’re publishing corridor waiting figures so we can take the steps needed to eradicate it from our health service.”

 

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Journal

The BMJ

DOI

10.1136/bmj.r2636 

Method of Research

News article

Subject of Research

People

Article Title

Eight in 10 trusts are caring for emergency department patients in corridors, BMJ investigation finds

Article Publication Date

17-Dec-2025

Chronic breathlessness emerging as a hidden strain on hospitals

Flinders University

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image: 

Professor David Currow, College of Medicine and Public Health, Flinders University

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Credit: Flinders University

Chronic breathlessness, a symptom often overlooked by healthcare systems, is associated with longer lengths of hospital stay on already overstretched healthcare resources, says new Flinders University research.

A new study, published in the Australian Health Review, highlights an urgent need for clinicians and policymakers to recognise chronic breathlessness as a major driver of hospital admissions and healthcare costs.

Historically, health systems have focused on sudden, short-term episodes of breathlessness (acute breathlessness), leaving millions of people living with recurring breathlessness (chronic breathlessness) underdiagnosed and undertreated, despite its profound impact on daily life.

Lead author, Professor David Currow, Strategic Professor at the Flinders Ageing Alliance, says at least one in 300 Australians is housebound or struggles with basic tasks such as dressing because of chronic breathlessness.

“Chronic breathlessness affects every aspect of life, contributing to disability, anxiety, depression, and reduced workforce participation,” says Professor Currow.

“People often adapt by avoiding exertion, which leads to further physical decline. Yet this symptom remains largely invisible in clinical consultations, often dismissed as an inevitable part of illness rather than a treatable condition.”

The study analysed data from nearly 12,000 patients and found that the severity of chronic breathlessness recorded in general practice predicts two critical outcomes: a shorter time to the next unplanned hospital admission; and longer length of stay once admitted

This helps explain some previously unexplained variations in length of hospital stays, even after accounting for demographic, clinical, and system factors.

“Longer hospital stays increase costs, reduce bed availability, and intensify emergency department pressures,” says Professor Currow.

“In Australia alone, chronic breathlessness is estimated to cost more than $12 billion annually in healthcare and societal expenses, a figure expected to rise with an ageing population and increasing rates of chronic illness.

“Chronic breathlessness is not just a symptom, it’s a major health challenge.  By recognising and managing it more effectively, we can improve quality of life. Understanding the drivers for these longer lengths of stay is a critical next step.”

The study outlines four priority actions:

1. Routine screening: Health professionals should ask about chronic breathlessness, not just acute symptoms, and consider making it the ‘sixth vital sign’ in emergency and inpatient settings.
2. Accurate reporting: Medical administrators should ensure chronic breathlessness is properly recorded for better data collection.
3. Early intervention research: Future studies should explore whether early management in primary care can reduce unplanned admissions.
4. Hospital process review: Investigate why patients with chronic breathlessness experience longer stays, including potential delays at admission or discharge.

The article, ‘Chronic breathlessness is associated with much longer lengths of hospital stay’ by David Currow, Slavica Kochovska, Rachael Evans (University of Leicester, UK), Janelle Yorke (The Hong Kong Polytechnic University, Hong Kong) and Patricia M. Davidson (University of New South Wales) was published in Australian Health Review. DOI: 10.1071/AH25253

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DOI

10.1071/AH25253 

Method of Research

Systematic review

Subject of Research

People

Article Title

Chronic breathlessness is associated with much longer lengths of hospital stay’