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Reducing the Impact of Fuel Poverty on the

Health Services

Prepared for the Welsh Assembly Government

by NEA Cymru

February 2011

Foreword 3

Effects of Fuel Poverty on Health 4

Health impacts and cost to the health services 4

Recommendations 7

Develop robust evidence 7

Support referral by frontline workers 7

Improve awareness among health professionals 9

Education for the public 10

Integration of fuel poverty within health 10

Appendix A: Acknowledgements 12

Fuel poverty is suffered by anyone who would need to spend 10% or more of their
income on energy in order to heat their home to an adequate level. The most recent
statistics, for 2008, show that over 1 in 4 Welsh households are in this situation, with
1 in 5 of these suffering severe fuel poverty, needing to spend over 20% of their
income on energy. A further 50% of non-fuel poor households - 530,000 households
- currently need to spend between 5-10% of their income on fuel, putting them at
immediate risk of sinking into fuel poverty if fuel prices rise or their incomes reduce.
For many fuel poor, their bills will not equal 10% of their income because they will
instead turn their heating off and sit shivering in a cold home in order to keep the
bills down so they can spend limited budgets on other essentials, like food. The
impact this can have on health is great, particularly among those who are vulnerable
due to age (young children as well as older people) or pre-existing health conditions.
As well as physical health, mental health can also suffer, either through the misery
caused by living in a cold, damp home or the stress of being in debt due to keeping
the heating on, or a combination of the two.

Despite the clear connections between health and fuel poverty, the responsibility for
fuel poverty has tended to sit within teams primarily concerned about the
environment and carbon reduction, in both national and local government. When the
health message is often to turn the heating up, this can contradict an energy
efficiency message to click the thermostat down. That said, energy efficiency
messages such as the importance of insulation and efficient heating systems can
serve both agendas. Therefore it is vital that the health services and governmental
departments concerned with health are fully engaged with this agenda.

The Welsh Assembly Government has set itself targets to eradicate fuel poverty in all
vulnerable households by 2010, in all social housing by 2012 and throughout Wales
by 2018. The 2010 target, one which would have particularly benefited the health
agenda, has been missed already, with no indication of when it will be achieved. The
most recent data shows that in 2008, 29% of vulnerable households were in fuel
poverty, including nearly a third of households containing someone with a long term
illness or disability.

This report sets out the health case for tackling fuel poverty and makes some clear
recommendations on how fuel poverty can be addressed as a health issue and how
different agendas can work together to make Welsh homes warmer and their
occupants healthier. The findings were particularly influenced by a roundtable
discussion, chaired by Mark Drakeford (Cardiff University School of Social Sciences),
which was attended by representatives from a range of organisations interested in
this issue. Acknowledgements of those who contributed to this discussion and
otherwise commented on the report are in Appendix A. Their comments and
contributions have been invaluable in shaping this report.
Effects of Fuel Poverty on Health

Living in a cold damp home can have a significant detrimental affect on the health
and wellbeing of the occupants and may

• Make an existing illness/condition worse;

• Increase the risk of heart attack, stroke or other circulatory illness;
• Increase the risk of developing a respiratory condition e.g. asthma or bronchitis
• Weaken the immune system
• Cause misery and anxiety and mental health problems
• Cause mobility problems, often resulting in accidents or falls
• Cause or worsen allergies (rhinitis, alveolitis, itching, sneezing, wheezing,
conjunctivitis, etc.)
• Contribute to Wales’ excess winter mortality rate of 1700 cold-related deaths in
the winter of 2009-10.

By creating better linkages between the health services and help available for people
in fuel poverty, the following outcomes could be achieved:

• Saved lives
• Prevention of the onset of illness
• Reduced GP visits
• Prevention of falls
• Reduced prescription use
• Reduced need for in-patient care and reduced length of hospital stays
• Prevention of the re-occurrence of a condition when returning from hospital and
subsequent re-admission
• Reduction of the wider burden on other health and social care services
• Improved living conditions
• Improved sense of wellbeing and mental health.

Health impacts and cost to the health services

The cost benefits of improving the warmth of homes are well documented. BRE have
used information about the costs of mitigation works in homes and the costs to the
NHS of treating condition caused by cold and damp homes to calculate that poor
housing costs the NHS in excess of £600 million a year in England alone. The BRE
suggest that this cost is around 40% of the total cost to society, giving a total cost
figure of £1.5 billion a year.1 The National Housing Federation carried out a slightly
different calculation, considering factors like the costs of GP consultations, associated
treatments, hospital in-days and hospital out-day referrals where it was assessed
that a prime causative factor for the ailment was housing related. Their assessed
cost to society totalled nearly £2.5 billion in England.2 A report by Shelter Cymru in
2000 estimated substandard housing cost the NHS in Wales at least £50m annually3.
This data is currently being revisited by Shelter Cymru, who will be producing new
figures later this year.

The Real Cost of Poor Housing, BRE, February 2010
Social impact of poor housing, NHF, March 2010
Somewhere to call home?, Shelter Cymru, July 2000
The National Housing Federation has found that children in substandard or temporary
accommodation are particularly vulnerable. It reported that homeless children were
four times more likely to suffer from respiratory infections, while they suffered five
times as many stomach infections and made twice as many emergency hospital visits
as children with permanent homes. They were also six times more likely to suffer
speech and stammering problems and four times more likely to have asthma.
Children living in temporary accommodation were also more likely to miss school on
a frequent basis, taking off an average of 55 school days a year.4

Shelter produced supportive figures that poor housing conditions increase the risk of
severe ill-health or disability by up to 25 per cent during childhood and early
adulthood”.5 In addition, people with asthma are twice as likely to be living in damp
homes and one in 12 children in Britain are more likely to develop diseases such as
bronchitis, TB, or asthma, because of bad housing”.6

Analysis of trends suggests there is a correlation between increased excess deaths

and cold snaps: heart attack after 2 days, strokes after 5 days and respiratory
disease after 12 days7. A recent article in the British Medical Journal reported on a
study that found that each 1°C drop in temperature is associated with an extra 200
people having a heart attack within 28 days. The study looked at the records of
84,010 patients who were admitted to hospital with a heart attack in 15 places in
England and Wales during 2003-2006, factoring in the daily temperatures and other
factors which could potentially affect the figures. In addition, it is known that over
half of Excess Winter Deaths are from cardiovascular disease and a third from
respiratory disease.

A survey of 699 households by CSE found that nearly half (47%) of the low-income
households who experienced cold homes said the cold had made them feel anxious
or depressed while 30% said an existing health problem had got worse and 17% did
not feel able to invite friends or family to the house8.

BRE have produced a calculator to help demonstrate the value of an intervention by

producing a baseline of likely numbers of incidences within local authority areas,
together with the health costs and costs of mitigating the hazard. It shows that
every £1 spent improving heating in 100,000 homes, where residents are likely to
require treatment due to excess cold, saves the NHS £34.19 over 10 years.9

In a further study by BRE for 4NW, six local authorities in England were asked for
data around HHSRS hazard assessments and costs of mitigation works.10 Using
these figures, BRE calculated the notional annual cost savings to the NHS and pay-
back periods. The highest one-off cost to deal with Excess Cold was £3,015, giving
an annual benefit of £312 to the NHS - a payback period of over 9.5 years - and the
lowest one-off cost to deal with Excess Cold was £1,011, giving an annual benefit of
£512 to the NHS; a payback of just 2 years.

Social impact of poor housing, NHF, March 2010
Chance of a lifetime – The impact of bad housing on children’s lives’ Shelter, 2006
Taken from
Eurowinter Group, 1997
Coping with low incomes and cold homes, CSE, June 2010
Available at
Linking Housing Conditions and Health – a pilot study into the Health benefits of housing interventions,
study by Warwick Law School and BRE , January 2010
European research has found that for every euro invested in tackling fuel poverty, 12
cents is returned in savings from health expenditure on children, a further 42 cents
is returned in savings from health expenditure on all householders and the rest is
returned in savings associated with carbon reduction, making expenditure on fuel
poverty cost-neutral.11

Stats quoted by Christine Liddell, University of Ulster at the EPEE European Conference, October 2009.

Develop robust evidence

Although the benefits to the health services of tackling fuel poverty are well known,
there is a need for more strong evidence, including randomised controlled trials and
systematic reviews, as well as a clear health economics argument, to demonstrate to
the health services the benefits of investing time and resources into helping people
out of fuel poverty. The ‘Exercise on Prescription’ scheme is one example of where a
localised project had produced sufficient evidence for it to be rolled out on a national
scale across Wales. Particularly needed are statistics on the effects of fuel poverty
amelioration on hospital and GP admission rates and to cost the long term payback
against initial one-off investment, to encourage the health services to recognise their
important role in this agenda and to see how investment in fuel poverty prevention
can financially benefit the NHS.

Carmarthenshire county council is currently working with Cardiff and Swansea

Universities to monitor the health impact of improvements to council owned housing.
Every year for four years, starting in winter 2009/10, 2500 council tenants will be
asked by Cardiff University to report any difference to their health they notice,
following installation of new windows, cavity wall insulation and boilers by
Carmarthenshire council. Swansea University is comparing the results already
received with data from A&E departments and GP practices and has found that the
self-reported results are reflected in health statistics, noting reductions in respiratory
illnesses and GP visits and improvements in mental health.

Support referral by frontline workers

In the Fuel Poverty Strategy for Wales 2010, the Welsh Assembly Government
proposed to establish a two-way referral network centred around the new All Wales
Fuel Poverty Scheme. The referral network should ensure that whichever
organisation or service a householder accesses first, they can be referred to the full
range of advice and support services they require to meet their needs. The central
co-ordination point for the All Wales Fuel Poverty Scheme should work in partnership
with existing frontline services. Key to establishing a successful network will be
ensuring that existing services have the information they need to refer people. It is
proposed that the referral network will include energy saving advice providers, local
support agencies, local authorities, national and local third sector organisations,
health and social service organisations, energy companies and the new scheme

For the Welsh Assembly Government’s fuel poverty referral hub to be effective,
rather than attempting to duplicate existing networks, it should provide a central co-
ordination point which existing networks and services can use and are aware of, for
example NHS Direct, Macmillan’s helpline, local financial advice services and
databases used by health professionals. Two way referral must be proactively
pursued by the scheme managers to ensure that anyone put in touch with the hub
receives the full range of help they need, including face to face support with health
professionals where appropriate.
Although frontline workers are very busy and limited in the amount they can do
while at a client’s house, they are incredibly important to engage with, as trusted
people with direct access to those who are most vulnerable. A simple application
process is vital to ensure participation. This should be accompanied by some easy
questions for a frontline worker to consider when visiting a client’s house to enable
them to identify if action relating to heating and energy efficiency is necessary
without having to engage in a long conversation or assessment with the client in
addition to other duties. There are several models that can be followed. The NEA
Hotspots referral project enables busy frontline workers to make a referral in a quick
and easy way. Hotspots is a multi-agency affordable warmth cross-referral initiative
involving partners from a range of agencies including the NHS. Training is delivered
to front-line staff to help them identify people who may be in, or at risk of, fuel
poverty. These staff then complete a simple ‘Hotspots’ referral card for each client
and send the card to the energy efficiency advice centre, who then contact the client
and manage their referral as required. As a further model, NEA gave Coventry
Community Nursing Teams a diary sized card of questions to consider when visiting a
patient’s home, which could then lead to asking the patient’s consent for referral to
agencies that could help. NEA also approached other private nursing agencies,
health visitors, social workers, GP surgeries and early learning centres. One final
example is provided by Salford and Greater Manchester Fuel Poverty Initiative, who
developed referral schemes, using a single local clearing house model, including a
paid referral system to energy suppliers from GPs12.

The best judge of whether a patient’s health condition is being exacerbated by a cold
home and the urgency of attention needed, is likely to be a health professional
working with that patient. A system which allowed GPs and other health
professionals to flag up a patient as a priority case when applying for help such as
the all Wales Fuel Poverty Scheme, would enable these patients to be brought to the
front of the queue, thereby reducing burden on the health services quickly and
efficiently. This kind of system was used in Easington PCT in the ‘Warmer Homes on
Prescription’ scheme, whereby GPs and other medical professionals could make
referrals for patients suffering from cold-related problems to have their homes
insulated by Easington Council as a priority. In addition, the PCT contributed funding
for insulation to be fitted13.

The voluntary sector has an important role to play in supporting the health sector,
and professionals like Macmillan’s Welfare Rights Officers and the Stroke
Association’s Family and Carer Support Co-ordinators visit people daily and could be
an excellent source of referrals to schemes like the new Fuel Poverty Scheme if
properly informed about help available and the referral process is made simple.
Voluntary organisation Menter Cwm Gwendraeth in Carmarthenshire offers a
particularly innovative model of how a hospital discharge service can help patients in
fuel poverty. The ‘Twilight’ scheme supports patients aged over 50 who have been
assessed as fit for discharge from hospital to their homes. The service carries out a
number of checks to link with the Local Health Board’s falls strategy and
commissions additional support from agencies like the British Red Cross, Careline,
Telecare and the Fire Service (for smoke detectors). From February 2011, all
Twilight staff will be trained to carry out home energy audits to support vulnerable
patients. This will include training in the use of thermal imaging cameras, to be

Examples taken from Alleviating Fuel Poverty in Order to Improve Health in the North East, NEA,
October 2009
provided to staff. The Twilight staff will then give the patient advice about energy
efficiency, fuel poverty and income maximisation and will signpost them to the
relevant department in Carmarthenshire county council for energy efficiency

Improve awareness among health professionals

Some health professionals may identify that a patient is struggling to afford their
energy bills or to keep their home warm but would not know what to do about the
situation. Even if they refer the patient to one kind of help, there is no guarantee
that patient will get all the help they would be eligible for, if the health professional
does not know what is available. For example, Macmillan Welfare Rights Officers
tend to refer patients struggling with energy debts for access to a Macmillan grant or
possibly to the DWP Social Fund. However, they do not necessarily know about trust
funds and social tariffs available from energy companies and grants like HEES, unless
they become aware of them through chance. A much more focussed approach to
training health workers is required to ensure either that they are aware of the
different types of help or they know a designated person or helpline which can
provide this, such as the Home Heat Helpline or a local authority officer with
responsibility for fuel poverty. The Health through Warmth project has taken this
kind of approach, giving health professionals basic training on the messages and
then providing them with contact details for a central person in the local authority
who can help further.

Training is not the only option and simply targeting information literature at different
voluntary organisations and health and social care teams would help to raise
awareness. Meetings such as team meetings of all practice staff in a GP practice
give this kind of opportunity to disperse information.

NEA Cymru is about to begin a programme named ‘Warm and Toasty’, whereby
health professionals and community workers would be trained, supported and
mentored so they can provide useful information on fuel poverty to their clients. We
hope this will provide a model of the sort of information health workers need on this

However, specific training may not always be necessary. Health professionals

receive a range of training opportunities, in which fuel poverty could be incorporated
without the need for a separate training course. Examples included the GP and
Practice Nurse protected learning system, the GP COPD programme, training for
social worker and discharge liaison staff and occupational therapist training on what
to consider when making an assessment. This could link with work recently carried
out by NLIAH on patient pathways. This should include raising awareness among the
statutory health services of the role of other sectors such as the voluntary sector and
housing providers so that links can be made. An audit to identify training needs may
be necessary. In addition, volunteer training should not be forgotten as volunteers
often have direct access to vulnerable people.

In writing this report, a wide number of health professionals were approached, many
of whom did not respond to requests for input. This indicates the difficulties in
engaging with this sector and the importance of raising awareness and
understanding in the health sector of how fuel poverty affects their work and the role
that the health sector can play.
Education for the public

Members of the public may not be fully aware of the range of serious health impacts
that living in a cold home could have on their wellbeing and see cold as a comfort
issue rather than a health issue. Publicity campaigns to increase awareness of fuel
poverty schemes should particularly target groups of people with an existing
condition or who are particularly vulnerable to the negative health effects of the cold.
This publicity should highlight the link between cold homes and poor health. One
way of reaching these groups is to work through voluntary and support groups
focussed on particular health conditions as well as through health and social care
services. Professionals and organisations like these are also well placed to ensure
their patients receive wider information that may help them.

It should be noted that where people with a health condition are targeted by
publicity campaigns and awareness raising, it is important that health professionals
are also aware, as in the previous recommendation, to ensure they can appropriately
refer or signpost patients who approach them after hearing about the links between
a cold home and a health condition.

Integration of fuel poverty with health

Fuel poverty is an issue which cuts across the work of many different departments,
organisations and personnel connected to health and social care. It is not an issue
for one team or department. Existing documents such as the Health, Social Care
and Wellbeing Strategies and the Children and Young People’s Plans within local
authorities have this kind of overarching remit but yet guidance for these documents
makes no mention of fuel poverty and those responsible for these strategies and
plans are often unaware of the impact of cold homes on people who use health
services, possibly seeing fuel poverty instead as an environmental issue. We
recommend that fuel poverty is highlighted in guidance for documents such as these
and also incorporated in other overarching approaches such as the unified
assessment process. However, we also believe WAG should go further in setting out
a programme of work for health and social care services to support the eradication of
fuel poverty.

Although fuel poverty should be a concern of everyone involved with a particular

patient or client’s wellbeing, having a nominated person with concern for fuel poverty
specifically written into their job description in every public health team or local
health board would ensure at least one person takes responsibility for putting this
issue at the forefront of the health sector’s awareness and can act as a contact
person to advise frontline workers who recognise fuel poverty as an issue for their
patient or client but are unsure what to do. This kind of approach has worked well in
a range of Primary Care Trusts, such as East Wakefield, where an energy champion
was appointed and North of Tyne PCT cluster where an identified public health officer
took the lead for excess winter deaths and fuel poverty across several PCTs within
the cluster.14 However different frontline workers may access different teams.
Therefore, where possible, it may be necessary to have key people in different

Example taken from Alleviating Fuel Poverty in Order to Improve Health in the North East, NEA,
October 2009
organisations to ensure they are accessed by health workers whose links with the
health and social care services may vary between contact with Social Services or the
LHB or another agency or local authority team. Where a key contact is placed within
the Local Health Board, it is important that a variety of relevant teams are put in
touch with that contact, such as the public health team, chronic conditions teams
and teams that link with social care.

There are other ways in which fuel poverty can be innovatively integrated in the
health services. For example, Newcastle Community Care Alarm Scheme put alarms
into vulnerable persons’ homes with temperature sensors which registered at an
alarm centre when the temperature fell below a certain pre-set15.

The Housing Health and Safety Rating System (HHSRS) requires local authorities to
act where a category 1 hazard is identified in a home. There are a total of 29
potential hazards, which can impact on the health and safety of a resident, including
some which relate to fuel poverty, such as excess cold, damp and mould growth and
falls. By implementing HHSRS, particularly among the private rental sector where
tenants have less control over their living conditions, health and safety hazards can
be removed from homes, improving the health of residents. NEA is currently
working on a toolkit to support increased use of HHSRS to tackle fuel poverty. This
will include case studies of use of HHSRS by local authorities, including some who
have linked it with reducing health inequalities in their local authority area. WAG
should support the increased use of HHSRS as a means of making homes healthier
places to live.

Examples taken from Alleviating Fuel Poverty in Order to Improve Health in the North East, NEA,
October 2009
Appendix A: Acknowledgements

Stuart Chadbourne, Arthritis Care

Mark Drakeford, School of Social Sciences, Cardiff University

Gary Ford, Health through Warmth

Gwenllian Griffiths, Macmillan Cancer Support

Lowri Griffiths, The Stroke Association

Lynne Hill, Policy Director, Children in Wales

Dyfed Huws, Department of Primary Care and Public Health, Cardiff University

Marie John, UK Public Health Alliance Cymru

Fiona Kinghorn, Public Health Wales

Jonathan Long, Macmillan Cancer Support

NEA staff

Rhian Pearce, Age Cymru

Andrew Roach, Fuel poverty and energy efficiency team, WAG

David Saywell, Menter Cwm Gwendraeth

Helen Scott, Citizens Advice Bureau

Martin Semple, Royal College of Nursing

Chris Tudor–Smith, Head of Health Improvement Division, WAG

Jonathan Willis, Home Improvement Manager, Carmarthenshire county council