1. Update from NEA’s internal health working group
02/03/17
Working across sectors to tackle fuel poverty and cold-related ill health
Update from NEA’s internal health working group
Hi, many thanks for inviting me to speak today. I’d like to start by going over some of the health impacts that arise from living in a cold home, and give some examples of health-based affordable warmth schemes that we are delivering. I’ll then move on to discuss a new BEIS-DHSC working group that has been established around the need to tackle cold-related ill health through actions that cross sectors and departments, before touching upon some of the opportunities for health and housing partnerships within the new NHS long term plan.
NEA 2017

2. The reality of fuel poverty
02/03/17
The reality of fuel poverty
I’d like to give an update as to the range of work that NEA is currently undertaking around addressing the health impacts of cold homes.
As we know, the reality of fuel poverty means:
Living in a home which is insufferably cold
Not turning the heating on for fear of the cost
Washing with water from a kettle to avoid heating a water tank
Sleeping in damp bedrooms with walls covered in mould
Going without food or other essentials so that you can pay for your energy
Going to bed early to stay warm and/or to forget about the hunger
Living in the dark because you’re worried about turning on the lights
Using unsafe, old and un-serviced secondary heating appliances which put you at risk of burns or carbon monoxide poisoning
Being isolated because you’re too embarrassed to invite friends and families into a cold and damp home
And we know that these experiences have real life consequences for physical and mental health and wellbeing.
NEA 2017

3. Cold-related ill health
02/03/17
Possible direct impacts:
Heart attacks/ strokes
Respiratory disease
Influenza
Worsening of existing health condition/ slow recovery
Falls/ injuries
Hypothermia
Possible indirect impacts:
Mental ill health
Carbon monoxide poisoning
Malnutrition
Emergency (re)admissions
Delayed discharge from hospital
Cold-related ill health
For every 1°C drop in outdoor temperature below 19°C, those living in the coldest 10% of homes see a corresponding increase in mortality of 2.8%, whilst those living in the warmest 10% of homes see a rise of only 0.9%. Overall, those in the coldest quarter of homes have a 20% greater risk of dying during the winter than the warmest quarter
For every 1°C drop in temperature below 5°C, GP consultations for respiratory illness in older people increase by 19%. People suffering from Chronic Obstructive Pulmonary Disorder (COPD) are four times more likely to be admitted into hospital for respiratory complications during the winter months. Children who live in cold housing are more than twice as likely to suffer from chest and breathing problems. Those living in damp and mouldy conditions are up to three times more likely to suffer from them.
Living in a warm home heated to recommended temperature thresholds might act to mitigate an individual’s susceptibility to suffering from cardiovascular disease. Indeed, it’s estimated that 9% of hypertension in Scotland could be prevented by maintaining indoor temperatures above 18°C.
People reporting difficulties in paying their fuel bills are also four times more likely to suffer from mental ill health. And, inadequately heated homes where independently shown to be the only housing quality indicator associated with 4 or more negative mental health outcomes in young people.
Survival strategies employed by households trying to cope with cold homes and high energy costs can cause further knock-on effects on their health and well-being. Budgeting families may need to spend less on food, increasing the risk of malnutrition and poor infant weight gain. One study found that 65% of low income households that had cut back spending on energy had also done so for spending on food, and 59% of those reducing expenditure on food had done the same for spending on heating
NEA 2017

4. The health costs of cold homes
02/03/17
The health costs of cold homes
50,100 excess winter deaths in (15,030 of these attributable to cold homes)
UK experiences around 32,000 EWDS each year on average
For every cold-related death there are 8 non-fatal hospital admissions
Poor housing costs the NHS £1.4bn, and society more widely £18.6bn
Improving energy efficiency up to EPC Band E could save the NHS a minimum of £750 per year
Affordable Warmth schemes, such as the Warm At Home Programme, found that £4 in health benefits accrued for every £1 of funding received
In the 2017 to 2018 winter period, there were an estimated 50,100 excess winter deaths in England and Wales. 15,030 (30%) of these were attributable to cold homes (based on WHO calculations). The number of excess winter deaths in for last winter was the highest recorded since winter 1975 to On average, the UK experiences around 32,000 EWDs each year. However, The Department of Health in 2009 estimated that for every cold-related death there are eight non-fatal hospital admissions. This means that cold-related morbidity is eight times greater than cold-related mortality.
Research by the Buildings and Research Establishment has calculated that the overall cost to the NHS of poor housing containing category 1 hazards (which includes Excess Cold) is £1.4bn, with costs to society (including lost education and employment opportunities) of £18.6bn. They have also estimated that if all of the English housing stock with a SAP (energy efficiency score) below the historic average of 41 was to be brought up to at least the current average of 51 through heating and insulation improvements, the health cost-benefit to the NHS would be some £750 million per annum. .
NEA 2017

5. Connecting Homes for Health
02/03/17
Connecting Homes for Health
County Durham and Sunderland
Test and measure health and environmental outcomes that can be achieved through the provision of free gas grid connections and gas central heating systems
Mapping exercise to inform targeting strategy
Eligibility designed to capture significant health outcomes with particular groups of vulnerable households, rather than measuring general population trends
Mainly monitoring self-reported improvements
Potential for quantitative monitoring of health and social care service use going forward
I’d now like to focus on an example of a health-related affordable warmth project that we are currently delivering. Connecting Homes for Health is a pilot scheme being delivered in County Durham and Sunderland. Through the project, we are looking to test and measure the health and environmental outcomes that can be achieved for vulnerable households who are in or at risk of fuel poverty through the provision of a free gas grid connection and free first time gas central heating system, alongside energy efficiency advice.
In Phase 1 of the project we carried out a literature review to identify the health impacts of living in a cold home, and the improvements that could be achieved through energy efficiency interventions. We are now in Phase 2, or the delivery phase, of the pilot.
We designed a mapping exercise in order to contain the pilot to an area in which the majority of households are low income, likely to be in or at risk of fuel poverty and living in energy inefficient housing. Targeting initially involved identifying GP practices within the two areas that were showing high prevalence of multiple cold-related health indicators according to the Quality Outcomes Framework. Areas were be given weighted rankings according to prevalence levels of cold-related morbidity across a number of metrics (like COPD, ischaemic heart disease, for example. These were then overlapped with the IMD rank and fuel poverty prevalence at Ward level in order to give each GP practice catchment area an overall health/deprivation/fuel poverty risk score. Postcodes falling within the catchment area were then given to NGN, who carried out an additional layer of mapping, in identify which addresses were off-gas.
Through the project, we will be measuring:
Self-reported changes to fuel poverty risk and energy affordability
Self-reported changes to energy rationing practices
Self-reported changes to physical or mental health, well-being, and ability to cope with illness, including how far households link ill health and poor well-being with living in a cold home, and how far they connect changes to health with increases in indoor temperatures at home
Self-reported changes to how often health and social care services are accessed before and after the intervention
We will also be looking to work with the local public health teams in approaching Durham and Sunderland CCGs and the North East Commissioning Service to assess the possibility of monitoring changes to actual health and social care services use, comparing the year prior to the intervention with the year following it
NEA 2017

6. 02/03/17
Under One Roof
Examines evidence and practice where health and social care bodies have worked in partnership with fuel poverty alleviation schemes
Role of local public health, but some NHS and CCG bodies bringing ill health prevention to the forefront of their strategies
Variations in evidence required through business cases
Challenges around outcomes measurement and data-sharing
Role of continuous and complementary cross-sector funding streams
I’d like to move straight on now to another project which we have recently completed, named Under One Roof. This was Commissioned by Liverpool City Council, funded by BEIS (Department for Business, Energy and Industrial Strategy). It examines evidence and practice where health and social care bodies have worked in partnership with fuel poverty alleviation schemes, and Identifies the types of evidence commissioners require. It is aimed at local programme delivery organisations as well as national policy and programme funding organisations.
Ultimately we found that local public health practitioners consider that tackling fuel poverty and cold-related ill health is a major aspect of being able to reduce health inequalities . When public health are engaged they can act as broker, coordinator and/or funder of actions that cross multiple sectors.
Generally, investment from CCGs and NHS bodies in fuel poverty interventions is not widespread. But, there are cases where health sector organisations have embraced new imperatives to bring health prevention to the forefront of their strategies and have been able to reinforce their new strategic commitments with financial assistance.
Overall, when presenting a business case for investment, we found that being able to tell stories across multiple narratives that use different strands of evidence works best.  
Evidence centres on identified local priorities and evidence of need within a local population, as well as feedback from ongoing or previous scheme delivery. Importantly, local public health teams or CCGs themselves have often had a significant role to play in the identification and collation of such data in the first place, prior to any funding being granted. They can help programme deliverers to understand their key priorities and analyse relevant local trends. There is also much that can be done with data that is already held by local authorities and some local health bodies – often the issue is being able to engage and identify the individuals who can access, interpret and present that data according to the interests of the various bodies involved.
However, challenges were often encountered in demonstrating improvements to physical health, or impact on local and national trends (such as excess winter mortality or morbidity). It could be argued that the move towards prevention and integration in the health sector may require it to shift its position and to consider alternative methods more appropriate to the measurement of social determinants of health, especially for interventions as complex as addressing poor housing and fuel poverty. Creating ‘budgetary space’ to allow for investment of resources in prevention, coupled with appropriately defined outcomes and associated methods for evaluation that will not jeopardise acute spending in the short- term could be one way of overcoming this problem
We also found that enabling greater data-sharing in a standardised and regulated fashion between health and local delivery bodies would facilitate monitoring of intervention outcomes as well as helping to identify households to target for support.
Case studies considered within the report suggest that the use of continuous and complementary cross-sector funding streams could provide a means of bringing together the targeting and strategic aims of sectors like energy, health and social care and local government. Addressing cold-related ill health then becomes more of an issue of improving energy efficiency across the board.
NEA 2017

7. Cross-sector collabroation
02/03/17
Cross-sector collabroation
In October last year BEIS and DHSC jointly hosted a conference on “Preventing cold-related ill health, winter deaths and reducing health inequalities through joint working” as part of Green GB Week. At the event we launched the Under One Roof report, and highlighted how we can work to improve people’s lives and their resilience against the cold whilst narrowing the gap between the experience of the richest and the poorest in society.
Through a process of co-creation, the session aimed to bring health & social care, housing and energy professionals together to develop a series of practical propositions – grounded in real experience - for successfully delivering joint action on cold-related ill health and fuel poverty. Following the event, a Fuel Poverty and Cold-Related Ill Health Working Group has been established. Sitting on the group we have representatives from BEIS, DHSC, PHE and NHSE, as well as representatives from third sector organisations like NEA and Citizens Advice. The group aims to:
Influence relevant policies and strategic frameworks that will encourage and enable joint action on cold homes across sectors
Improve awareness of the links between poor housing and ill health across sectors to encourage and strengthen the development of new or existing affordable warmth support services
Support and enable the development and/or establishment of local Single Point of Contact (SPOC) referral services as outlined in the NICE NG6 guidance on excess winter deaths and the health impacts of living in a cold home
Monitor, provide scrutiny and challenge local bodies on the setting of public health priorities and commissioning of local services
NEA 2017

8. NHS Long Term Plan: opportunities for health and housing professionals
02/03/17
NHS Long Term Plan: opportunities for health and housing professionals
Social prescription services that include affordable warmth and damp-free homes
Training to identify fuel poverty risk
Fuel poverty strategy development
Single Point of Contact referrals
Discharge support
Frailty services
Overlap between target groups and conditions
Indeed, with the publication of the NHS Long Term Plan, we feel that the establishment of the new working group is particularly timely.
The establishment of Integrated Care Systems, the change in CCG mandates to support partnerships with local government and other community organisations, and the roll-out of personalised care models could represent a significant opportunity for health and housing professionals to feed in to the development of social prescription services that include and take into account the quality of someone’s housing and their ability to achieve affordable warmth and damp-free conditions at home
There is opportunity here for health and housing services to:
Offer training to primary and community networks to identify FP risk
Help local ICSs develop fuel poverty strategies, or to build in a fuel poverty perspective into their ill health prevention strategy
Help build a local social prescription service or act as a broker to bring those who can offer such a service locally together
Offer to act as the affordable warmth referral partner for a given ICS
The emphasis on local authority-supported delayed discharge support could provide an opportunity for health and housing professionals to advise and help build local discharge procedures and support services that include affordable warmth. Where acute frailty services are established, there could be role for health and housing professionals in helping to develop or even deliver affordable warmth actions under the theme of falls prevention. Also an opportunity to make the case for affordable warmth support in helping hospitals achieve the emergency admissions dividend through reduced emergency hospital admissions.
The plan looks to significantly improve mental health, and has an emphasis on supporting people to age well and giving a strong start in life for children and young people. It also particularly looks to targets cardiovascular disease and respiratory disease. These are all conditions that can be linked with living in a cold home, and target population groups are also those that are vulnerable to both fuel poverty and cold-related ill health. As such, there is quite a lot of overlap between the two agendas, which could result in improvements to population health if we are able to work together in partnership across sectors.
NEA 2017

9. Thank you jamie.ruse@nea.org.uk 0191 269 2912 02/03/17 NEA 2017
Ok, so after a bit of a whirlwind tour, that brings me to the end of my presentation. Should you be interested in linking with the work of NEA’s internal working group on cold-related ill health, do please get in touch as we’d be delighted to be able to bring such valuable perspectives into our work. Thank you.
NEA 2017