The National Institute for Health and Clinical Excellence (NICE) has published a draft guideline on preventing Excess Winter Deaths and Morbidity and Health Risks associated with cold homes. The document is designed for “commissioners and practitioners”, including health and social care professionals (particularly Health and Wellbeing Boards and those working directly with people at risk from the cold), local authorities, installers, the energy efficiency industry and the voluntary sector. It lays out a set of recommendations for all of these actors.
The business end first: the guideline is out for consultation, with a closing date of 25 July. You can download the draft guideline, a wealth of supporting evidence and the form for consultation responses at http://guidance.nice.org.uk/PHG/70/Consultation/Latest.
The guideline has some great background information about the impacts of living in cold homes, and is well worth a read if you’re looking to gather statistics or to make the case for warmth. It also makes a number of recommendations; these are listed in bold below, with some thoughts from a London-wide perspective:
Recommendation 1: Strategic planning
The guideline says that Health and Wellbeing Boards should establish strategies for tackling Excess Winter Deaths and illness by dealing with cold homes. This is a great recommendation as it places cold squarely in the health and social care space.
From a London perspective, there would be value in some sort of overview or scrutiny to help ensure the quality of the strategies that are produced, drive up levels of aspiration and ensure that some Boroughs aren’t being left behind. There is also scope (as we have seen already) for bringing Boroughs together into projects that cross local authority boundaries and in shared procurement.
There’s an interesting dynamic in terms of delivery. The role of the healthcare system is very much seen as signposting, with local authorities seen as the delivery organisations. This builds on local authority expertise and experience, but does rely on effective partnership building, a sustained focus on the issue and adequate levels of resourcing.
I wonder on this: who owns the issue? Who is accountable? How are improvements measured? And what happens if no improvements are made? Back in the days of National Indicators, there was a clear responsibility for local authorities around fuel poverty. I’m not convinced that the issue is owned in the same way here.
Recommendation 2: Referral service
Recommendations 2 and 3 are closely linked. 2 calls for referral services to be available, whilst 3 goes into more detail about the services that they should provide.
Thinking about London as a unit, I wonder if the focus on local authority led services means that we miss some opportunities. Would some services be better provided across LA borders, either jointly across a couple of Boroughs or actually with a more logical geographical split (eg a “Westway” referral service which stretches across multiple boroughs)?
There’s also the risk that communities of interest are lost. So, could there be scope for a London-wide support service for all cancer patients, addressing their specific needs (which may go beyond affordable warmth), and looks across boundaries. How might this emerge within the framework of the NICE guideline?
One positive about the health-led approach is that it is tenure-neutral. A lot of local authority fuel poverty services struggle to justify giving advice within the social housing sector. A health-commissioned service targeting based on medical risk helps to overcome some of these issues.
Recommendation 3: A one stop shop referral service
This recommendation provides more detail about the types of service that should be offered (eg, energy efficiency measures, income maximisation advice).
The phrase “One Stop Shop” is perhaps a red herring. It suggests one central hub per borough whereas some boroughs may need more than one shop (this may be semantics, but I think it’s worth raising). Whilst a well-coordinated service is essential, I also wonder whether a one-stop-shop approach just places too many eggs in one basket. Is there a more distributed model of knowledge and advice provision that might help to ensure that more people are reached? We have been centralising for a while and I’m just curious about whether more social, de-centralised models may have a different impact – perhaps another project for another day!
Recommendation 4: Use existing data to identify people at risk of ill health from living in a cold home
This recommendation helps to unlock health data so that GPs and others can identify people based on their medical conditions. That said, we don’t want to commission tons of new research when there are already some useful sources of information out there, so dialogue between the Health and Wellbeing Board, the CCG and the local authority (which holds most data) would be crucial. There are interesting opportunities to draw together medical data and housing data (eg, EPC records) to really target interventions.
One key issue here is that vulnerability is dynamic. The group of vulnerable households changes over time. So there’s some thinking that needs to be done about the points in time at which someone becomes vulnerable and could therefore be targeted – trigger points, to borrow a phrase from EST. So, how can we integrate questions about warmth into care for people in changing situations – eg, people who become house-bound following injury or new mothers?
Recommendation 5: Health and social care professionals should make every contact count by assessing the heating needs of vulnerable people
You can’t really argue with this one, though it will be hard to implement all year round (issues around cold always see seasonal fluctuation – when it’s sunny outside, we tend to forget that it’ll be snowing again soon). It’ll be important to systematise this by fitting it into everyday systems and processes.
It will be important to manage residents’ expectations about what is available and for whom. It can be frustrating – for the householder and the practitioner – when there is a severe need but there is nothing on offer. A stagnant ECO market could compound this frustration.
Recommendation 6: Others visiting vulnerable people
This recommendation looks at capacity building among those visiting vulnerable people, raising the awareness of cold as a health issue and encouraging referrals. Again, hard to argue but also hard to implement. We need to think about why the person is visiting, what they are there to do, how a conversation about warmth fits with that visit and the level of trust that the resident has in that visitor (eg, think about the levels of trust you would have in a meter reader, a heating installer or a friend visiting socially). It’s also important to think about the quality of advice and information that people might provide, and the consequences – positive and negative – of that advice.
Recommendation 7: Use new technology to reduce risks from cold homes
A topical recommendation linked to the roll-out of smart meters and the opportunity to install temperature sensors alongside smart meters that would alert support services if temperatures fell below a certain point. Islington Council have done some interesting work with Telecare services around temperatures.
Recommendation 8: Discharge to a cold home
Discharge from hospital is often seen as one of the trigger points to have a conversation about warmth. Actually, the trigger point should be admission to hospital (if not earlier). Admission allows the chance for conversations about housing conditions, and potentially gives a window for energy efficiency improvements to be made.
There is a tension in this recommendation about making sure the home is warm enough without delaying discharge from hospital. It’ll be interesting to see how this happens in practice and to build up a roster of case studies and good practice so that discharge teams can learn from each other and create strong processes.
Recommendations 9, 10 and 11: Training
I’ve bundled these together because they all address the issue of training, whether of health and social care practitioners, housing professionals, voluntary sector workers, heating engineers and others.
I wonder if technology can be our friend here. One of the challenges of training is the cost of delivery, particularly at scale. Another challenge is accessing these groups of people when they already have a very full schedule. Perhaps some well-made short films, tailored for different audiences, could be produced; practitioners could watch these in team meetings or individually, with maybe some place for comments and questions. I sense an expensive iteration of the Fuel Poverty Hub coming along….
Recommendation 12: Raise awareness of how to keep warm at home (for professionals and public)
This is a very broad recommendation about general awareness raising and about making sure that information about local and national support services is available (this latter is the reason why the Fuel Poverty Hub exists).
Consideration needs to be given to the value of national messaging versus local and targeted messaging, what we are asking people to do in response, and who the messengers are. Sensible advice about keeping warm (eg, wearing appropriate clothing) often turns the national press into sarcastic mode.
When it comes to overcoming common misconceptions, a key issues is that of people using electric heating rather than (or alongside) their gas central heating. I read a great article recently where an energy adviser worked with a householder to look at energy consumption and the relative costs of electricity and gas; there was a revelatory moment when the true costs of having your central heating on were revealed. Suffice to say the householder isn’t using plug in electric heaters anymore and has a much more comfortable heating regime at a lower cost.
Recommendation 13: Ensuring buildings meet standards
Last but not least, there’s a recommendation about technical standards for buildings, whether identifying risks through HHSRS or ensuring that works are done to the correct standards (a Building Control issue). Again, there’s a tension here between commissioners of health services and levels of local authority resourcing. And there’s the elephant in the room – funding. Ensuring that problems are addressed is a lot easier said than done.
Overall, the guidance goes a long way. The fact that it places cold very firmly on the agenda of the health and social care sector is fantastic. It should give more power to the elbows of campaigners, local authority officers, housing officers and charities in continuing and even expanding the support they can offer to those at risk from the cold. Its focus on local delivery and its recommendations about the types of support on offer are helpful in defining responses to the issue of cold homes. However, with a London hat on, that very local focus means that some opportunities for coordination and collaboration may be missed. We’ll be responding in this vein to the consultation (which runs til 25th July). We’d encourage everyone with an interest in fuel poverty, the health impacts of cold, and improving housing conditions and energy efficiency to respond too.