A chilling effect

Cold homes are robbing patients of their health. Doctors tell Tim Tonkin why fuel poverty needs to be seen as a major public health issue – and how GPs are helping some with heating on prescription

In her two decades spent working in general practice, Becky Haines says she has never seen fuel poverty play as significant a factor in her patients’ health as she has in the past couple of months.

Speaking to The Doctor, the Gateshead GP says health issues relating to fuel poverty and cold homes were historically something she tended only to encounter among older or homeless patients, and rarely among those of working age in accommodation.

Since the beginning of this winter, however, Dr Haines says she now regularly encounters patients of all ages and backgrounds with complaints relating to physical and mental health that are being exacerbated by living in homes many admit they simply cannot afford to heat and keep warm.

‘I can’t previously remember ever having conversations where it [fuel poverty] was a primary focus of what we talk about, whereas it’s not uncommon now,’ she says.

‘In a deprived area, such as where I’m working, it’s now normal that people can’t afford to have adequate heating in their home, and that’s shocking to me. People are coming in and talking about being cold and how their bills and finances are the most stressful thing in their lives at the moment, so it is the biggest thing affecting their health.

‘I feel afraid. I think people are going to die because they’re cold. I know that every winter that does happen, and that’s shocking enough, but this winter it’s going to be worse, because of the number of people who are unable to keep themselves warm.’

Dr Haines is, unfortunately, far from alone in her experiences.

Soaring prices

Like many other parts of the world, the UK faces a ‘perfect storm’ of factors contributing to fuel impoverishment.

A surge in the cost of commodities such as gas, oil and coal following the peak of the COVID-19 pandemic was then further exacerbated by Russia’s invasion of Ukraine in February last year.

Coupled with record inflation and a broader cost-ofliving crisis, more people than ever are facing the stark reality they may not be able to afford to heat their homes.

The seriousness of the situation was made evident by figures published by fuel poverty charity National Energy Action, which warned that the number of UK households in fuel poverty could hit 8.4 million by April this year, almost double the 4.5 million in this position in October 2021.

The health implications of fuel poverty are varied, with a report published by University College London’s Institute of Health Equity warning that cold homes can cause or worsen a range of health issues including respiratory and cardiovascular illness, musculoskeletal and rheumatological conditions, diabetes, dementia, mental health and childhood development.

Published in August 2022, the institute’s report warned that with an estimated 63,000 excess winter deaths in England in 2020-21, around 10 per cent of these are believed to be directly attributed to fuel poverty.

Those most at risk of ill health resulting from the cold include infants and children, older people and those with pre-existing health problems.

Dr Haines says the effect of fuel poverty on those in her care is often most apparent during long-term condition reviews, in which patients with pre-existing health issues are citing cold and the struggle to keep warm as health concerns.

‘Although it sort of feels obvious that being cold is going to make you feel more unwell ... I’ve really noticed that patients, especially ones who are coming in for their longterm condition reviews, are mentioning how being cold is affecting them,’ she says.

‘People complain of the cold in their houses affecting their asthma or their chest, lots of people with chronic pain are saying how their pain is a lot worse at the moment because of not being able to afford to heat their homes.’

Fuel poverty

In Scotland, Wales and Northern Ireland a home is deemed to be in fuel poverty if more than 10 per cent of its household income is spent on heating, leading to an overall inadequate standard of living.

In England, fuel poverty is determined by a home having an energy efficiency rating of band D or below and if, after heating bills, remaining household income falls below the official national poverty line.

Alongside the human cost, the financial burden to health posed by fuel impoverishment is also considerable, with the NHS estimated to have spent £2.5bn on treating illness connected to damp and cold in 2019.

‘It’s really hard when someone says to me that their pain is a lot worse because their house is cold,’ says Dr Haines.

‘You don’t want to just increase people’s painkillers because that’s not going to help them in the long run. We’re lucky in my area in that we’ve got a really good social prescribing system and there are warm spaces in Gateshead that people can be referred to, and that can help.

‘Ultimately, however, if your house has not been heated at all, in this weather, then even if you go to a warm space for a few hours a day, you can come back to that cold house and sleep in that cold house. Which is a really terrible position to be in.’

The unprecedented rises in energy prices early last year prompted the Government to provide financial assistance to households, through a one-off scheme of incremental discounts to energy bills totalling £400 over a period of six months. But for those on low incomes it may simply not be enough.

Heating prescribed

This situation has in Gloucestershire led to an initiative that in a bygone era might have seemed inconceivable – that of domestic heating being made available on prescription.

Part of a joint project between One Gloucestershire, the county’s integrated care board, sustainability charity Severn Wye and non-profi t innovation fi rm Energy Systems Catapult, the Warm Homes Prescription aims to help clinically vulnerable people in the county keep their homes heated.

Under the terms of the scheme, fi nancial assistance with paying energy bills is available to those under the age of 60 who receive free

‘You don’t want to just increase people’s painkillers because that’s not going to help them in the long run’ prescriptions and have a chronic respiratory condition or to those over 60 who are struggling to meet their energy costs.

Gloucester GP Hein Le Roux has been closely involved in the initial piloting of the scheme in 2021 and with the prescription’s current iteration, which will see around 150 people have their heating bills met up until March this year through the Household Support Fund.

He says that while limited in its scope, the prescription is a good example of how primary care services can collaborate with other organisations to deliver public health management initiatives without adding drastically to GPs’ workloads.

‘Through social prescribing we’ve had [things like] art on prescription for people with depression and weight loss on prescription ... but this [heating on prescription] is a first,’ he says.

‘[In the 2021 pilot] we ended up getting 30 patients and based on the success of that pilot, we’ve now got funding for 150 people. Out of a population of 670,000 this is not huge but it’s a start, and if energy prices were low as they were last year, we would have actually been able to reach a lot more people.’ bma.org.uk/thedoctor

Rolling out the prescription involved first identifying patients known to have severe, chronic health conditions and then drawing on the knowledge of social prescribers working within general practices to determine which of this group was in, or at risk of, fuel poverty.

Reaching the vulnerable

Those meeting the criteria of being most at risk are contacted by social prescribers, rather than GPs themselves, and advised that they qualify for assistance with meeting their energy bills.

Dr Le Roux admits that while it is difficult to measure the extent to which the prescription has improved health or reduced hospital admissions of vulnerable patients, he believes engaging with patients on heating can often facilitate other health interventions.

‘In the public health medicine way of working it’s not just one magic bullet but it’s usually several different marginal gains [and] I think this [initiative] brings into play another concept – that of the care bundle,’ he says.

‘These are the people that we [general practice] aren’t very good at reaching. We discovered that lots of people in that severe segment hadn’t turned up for vaccination or annual review, and just a simple phone call had then got them to come to several different interventions that would help.’

BMA board of science chair David Strain says his committee is continuing to examine and lobby on issues such as the costof-living crisis and its impacts on individuals’ and communities’ health.

He says that while access to support with heating and access to warm spaces for vulnerable patients through social prescribing initiatives is to be commended, it is also important that providing such care did not overly add to the existing clinical burdens faced by many doctors.

He adds that, with coldrelated illness likely to present challenges to health for the foreseeable future, it is vital the Government does all it can to increase the support made available to those struggling with the cost of energy.

He says: ‘Fuel poverty and cold weather are going to be a major public health issue for the long term, particularly with the energy price cap set to be removed in April. Even with the war in Ukraine and with other situations that are driving the cost of energy, prices will inevitably continue to go up.

‘The BMA will be lobbying for the fuel cap to remain in place [until] next April [2024] as without it, the impacts of fuel poverty, both on individuals and households and the NHS, will be even worse than this year, irrespective of other support measures that are put in place.

‘Helping people to stay warm not only protects their health but helps to ease demands on hospitals and other services at a time when the NHS is facing unprecedented pressure and crisis.’

‘Fuel poverty and cold weather are going to be a major public health issue for the long term’

‘The BMA will be lobbying for the fuel cap to remain in place until April 2024’