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Excess winter deaths and illnesses associated with cold homes

About

What is covered

This pathway covers excess winter deaths and morbidity and the health risks associated with cold homes. It makes recommendations on how to reduce the risk of death and ill health associated with living in a cold home. The aim is to help meet a range of public health and other goals. These include:
  • Reducing preventable excess winter death rates.
  • Improving health and wellbeing among vulnerable groups.
  • Reducing pressure on health and social care services.
  • Reducing 'fuel poverty' and the risk of fuel debt or being disconnected from gas and electricity supplies (including self-disconnection).
  • Improving the energy efficiency of homes.
Improvements to make homes warmer may also help reduce unnecessary fuel consumption (although where people are living in cold homes because of fuel poverty their fuel use may increase). In addition, such improvements may reduce absences from work and school that result from illnesses caused by living in a cold home.
The health problems associated with cold homes are experienced during 'normal' winter temperatures, not just during extremely cold weather. (An increase in death rates due to a drop in temperature varies across England but can happen when temperatures drop below about 6°C.)
Year-round planning and action by many sectors is needed to combat these problems. The pathway outlines a role for health and other practitioners in:
  • prioritising which homes are tackled first
  • shaping and influencing decisions about how homes are improved
  • highlighting the importance of research, implementation and evaluation.
A wide range of people are vulnerable to the cold. This is either because of: a medical condition, such as heart disease; a disability that, for instance, stops people moving around to keep warm, or makes them more likely to develop chest infections; or personal circumstances, such as being unable to afford to keep warm enough.
In this pathway, the term vulnerable refers to a number of groups including:
  • people with cardiovascular conditions
  • people with respiratory conditions (in particular, chronic obstructive pulmonary disease and childhood asthma)
  • people with mental health conditions
  • people with disabilities
  • older people (65 and older)
  • households with young children (from new-born to school age)
  • pregnant women
  • people on a low income.
The pathway is for commissioners, managers and health, social care and voluntary sector practitioners who deal with vulnerable people who may have health problems caused, or exacerbated, by living in a cold home. It will also be of interest to clinicians and others involved with at-risk groups, housing and energy suppliers. In addition, it may be of interest to members of the public.

Updates

Updates to this pathway

3 March 2016 Preventing excess winter deaths and illness associated with cold homes (NICE quality standard 117) added.
3 November 2015 Link to NICE pathway on social care for older people with multiple long-term conditions added.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on reducing the risk of excess winter deaths and illness associated with cold homes in an interactive flowchart

What is covered

This pathway covers excess winter deaths and morbidity and the health risks associated with cold homes. It makes recommendations on how to reduce the risk of death and ill health associated with living in a cold home. The aim is to help meet a range of public health and other goals. These include:
  • Reducing preventable excess winter death rates.
  • Improving health and wellbeing among vulnerable groups.
  • Reducing pressure on health and social care services.
  • Reducing 'fuel poverty' and the risk of fuel debt or being disconnected from gas and electricity supplies (including self-disconnection).
  • Improving the energy efficiency of homes.
Improvements to make homes warmer may also help reduce unnecessary fuel consumption (although where people are living in cold homes because of fuel poverty their fuel use may increase). In addition, such improvements may reduce absences from work and school that result from illnesses caused by living in a cold home.
The health problems associated with cold homes are experienced during 'normal' winter temperatures, not just during extremely cold weather. (An increase in death rates due to a drop in temperature varies across England but can happen when temperatures drop below about 6°C.)
Year-round planning and action by many sectors is needed to combat these problems. The pathway outlines a role for health and other practitioners in:
  • prioritising which homes are tackled first
  • shaping and influencing decisions about how homes are improved
  • highlighting the importance of research, implementation and evaluation.
A wide range of people are vulnerable to the cold. This is either because of: a medical condition, such as heart disease; a disability that, for instance, stops people moving around to keep warm, or makes them more likely to develop chest infections; or personal circumstances, such as being unable to afford to keep warm enough.
In this pathway, the term vulnerable refers to a number of groups including:
  • people with cardiovascular conditions
  • people with respiratory conditions (in particular, chronic obstructive pulmonary disease and childhood asthma)
  • people with mental health conditions
  • people with disabilities
  • older people (65 and older)
  • households with young children (from new-born to school age)
  • pregnant women
  • people on a low income.
The pathway is for commissioners, managers and health, social care and voluntary sector practitioners who deal with vulnerable people who may have health problems caused, or exacerbated, by living in a cold home. It will also be of interest to clinicians and others involved with at-risk groups, housing and energy suppliers. In addition, it may be of interest to members of the public.

Updates

Updates to this pathway

3 March 2016 Preventing excess winter deaths and illness associated with cold homes (NICE quality standard 117) added.
3 November 2015 Link to NICE pathway on social care for older people with multiple long-term conditions added.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Quality statements

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Identifying people vulnerable to health problems associated with a cold home

This quality statement is taken from the preventing excess winter deaths and illness associated with cold homes quality standard. The quality standard defines clinical best practice in preventing excess winter deaths and illness associated with cold homes and should be read in full.

Quality statement

Local health and social care commissioners and providers share data to identify people who are vulnerable to the health problems associated with a cold home.

Rationale

Local coordination is needed to ensure that individual people who are vulnerable to the health problems associated with cold homes can be identified. Data sharing, for example using health and social care records, professional contacts and knowledge of people who use services, can help to identify people who are vulnerable to the health problems associated with cold homes. This will enable referral to the local single-point-of-contact health and housing referral service to address people’s needs.

Quality measures

Structure
a) Evidence of local arrangements for multi-stakeholder winter planning meetings for data sharing to identify people who are vulnerable to the health problems associated with a cold home.
Data source: Local data collection.
b) Evidence of local data-sharing arrangements and analysis to enable identification of people who are vulnerable to the health problems associated with a cold home.
Data source: Local data collection.
Outcome
Identification of people who are vulnerable to the health problems associated with a cold home.
Data source: Local data collection.

What the quality statement means for service providers, health, public health and social care practitioners, and commissioners

Service providers (such as local authority departments, local NHS providers, housing organisations and voluntary organisations) ensure that data-sharing arrangements are in place to identify people who are vulnerable to the health problems associated with a cold home. They should ensure that records can be appropriately shared and that there are local pathways in place to safely and appropriately share knowledge to identify people who are vulnerable.
Health, public health and social care practitioners (such as GPs, community nurses, health visitors and home care practitioners) ensure that they use existing information to identify people who may be vulnerable to the health problems associated with a cold home.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) should commission services that share data to identify people who may be vulnerable to the health problems associated with a cold home.

What the quality statement means for patients, people using services and carers

People who may be vulnerable to the health problems caused by living in a cold home are supported by local services working together and sharing information to identify people who may be vulnerable.

Source guidance

Definitions of terms used in this quality statement

People who are vulnerable to the health problems associated with a cold home
People living in cold homes who are vulnerable to the associated health problems include:
  • people with cardiovascular conditions
  • people with respiratory conditions (in particular, chronic obstructive pulmonary disease and childhood asthma)
  • people with mental health conditions
  • people with disabilities
  • older people (65 and older)
  • young children (under 5)
  • pregnant women
  • people on a low income
  • people who move in and out of homelessness
  • people with addictions
  • people who have attended hospital due to a fall
  • recent immigrants and asylum seekers.
[Adapted from Excess winter deaths and illness and the health risks associated with cold homes (NICE guideline NG6) and expert opinion]
Health problems associated with a cold home
Cold homes and poor housing conditions have been linked with a range of health problems in children and young people, including respiratory health, growth and long-term health. In older people, cold temperatures increase the risk of heart attack, stroke and circulatory problems, respiratory disease, flu and hospital admission. They also lower strength and dexterity, leading to an increase in the likelihood of falls and accidental injuries. Home temperatures also have implications for mental health because cold is linked with increased risk of depression and anxiety.

Single-point-of-contact health and housing referral service

This quality statement is taken from the preventing excess winter deaths and illness associated with cold homes quality standard. The quality standard defines clinical best practice in preventing excess winter deaths and illness associated with cold homes and should be read in full.

Quality statement

People who are vulnerable to the health problems associated with a cold home receive tailored support with help from a local single-point-of-contact health and housing referral service.

Rationale

Many socioeconomic factors can cause people to be vulnerable to health problems associated with cold homes, and there may be a range of potential solutions depending on personal circumstances. A single-point-of-contact health and housing referral service can ensure people receive the help that they need effectively, with knowledge of services available and links with relevant national and local agencies, including health and social care providers, local housing providers, advice agencies (such as Citizens Advice and money advice organisations), health and social care charities, voluntary organisations and home improvement agencies.

Quality measures

Structure
Evidence of local arrangements to ensure that people who are vulnerable to the health problems associated with a cold home receive tailored support with help from a local single-point-of-contact health and housing referral service.
Data source: Local data collection.
Process
a) Proportion of people identified as being vulnerable to the health problems associated with a cold home who are referred to the local single-point-of-contact health and housing referral service.
Numerator – the number in the denominator who are referred to the single-point-of-contact health and housing referral service.
Denominator – the number of people identified as being vulnerable to the health problems associated with a cold home.
Data source: Local data collection.
b) Proportion of people identified as being vulnerable to the health problems associated with a cold home and referred to the single-point-of-contact health and housing referral service whose tailored support needs are agreed.
Numerator – the number in the denominator whose tailored support needs are agreed.
Denominator – the number of people identified as being vulnerable to the health problems associated with a cold home and referred to the single-point-of-contact health and housing referral service.
Data source: Local data collection.
c) Proportion of people identified as being vulnerable to the health problems associated with a cold home with tailored support needs agreed with the single-point-of-contact health and housing referral service whose needs were met.
Numerator – the number in the denominator whose needs were met.
Denominator – the number of people identified as being vulnerable to the health problems associated with a cold home whose tailored support needs were agreed with the single-point-of-contact health and housing referral service.
Data source: Local data collection, which could include a breakdown of achievement by type of support needed.
d) Proportion of people identified as being vulnerable to the health problems associated with a cold home and referred to the single-point-of-contact health and housing referral service who are no longer vulnerable to the health problems associated with a cold home.
Numerator – the number in the denominator no longer considered vulnerable to the health problems associated with a cold home.
Denominator – the number of people identified as being vulnerable to the health problems associated with a cold home and referred to the single-point-of-contact health and housing referral service.
Data source: Local data collection.
Outcome
a) People who used the local single-point-of-contact health and housing referral service who feel able to manage their home heating needs.
Data source: Local data collection.
b) The number of people living in fuel poverty.
Data source: Local data collection.

What the quality statement means for service providers, health, public health, social care and third sector practitioners, and commissioners

Service providers (such as local authority departments, local NHS organisations, fire and rescue services, housing providers, energy companies and voluntary organisations) ensure that processes are in place to enable referral or self-referral to the local single-point-of-contact health and housing referral service for people who are identified as being vulnerable to the health problems associated with a cold home. The local single-point-of-contact service should ensure that people living in cold homes using the service receive tailored support by assessing the person’s needs and working with identified partners (local organisations providing relevant interventions and services) to help them.
Health, public health, social care and third sector practitioners (such as GPs, community nurses, health visitors, home care practitioners and housing association officers) ensure they are aware of the local single-point-of-contact health and housing referral service and refer people who are identified as being vulnerable to the health problems associated with a cold home to the service. Anyone, such as gas and electricity engineers and fire and rescue officers, whose employment requires them to visit people vulnerable to the health problems associated with a cold home at their home should consider their heating needs and refer them to the single-point-of-contact health and housing referral service if needed.
Commissioners (such as clinical commissioning groups and local authorities) jointly commission a local single-point-of-contact health and housing referral service that helps people who are identified as being vulnerable to the health problems associated with a cold home to receive tailored support.

What the quality statement means for patients, people using services and carers

People who are vulnerable to the health problems associated with a cold home are referred (usually by health or social care professionals, or people from voluntary organisations, but sometimes by referring themselves) to a local health and housing referral service. Staff at the service can discuss the person’s needs and organise help so that they can keep their home warm.

Source guidance

Definitions of terms used in this quality statement

People who are vulnerable to the health problems associated with a cold home
People living in cold homes who are vulnerable to the associated health problems include:
  • people with cardiovascular conditions
  • people with respiratory conditions (in particular, chronic obstructive pulmonary disease and childhood asthma)
  • people with mental health conditions
  • people with disabilities
  • older people (65 and older)
  • young children (under 5)
  • pregnant women
  • people on a low income
  • people who move in and out of homelessness
  • people with addictions
  • people who have attended hospital due to a fall
  • recent immigrants and asylum seekers.
[Adapted from Excess winter deaths and illness and the health risks associated with cold homes (NICE guideline NG6) and expert opinion]
Health problems associated with a cold home
Cold homes and poor housing conditions have been linked with a range of health problems in children and young people, including respiratory health, growth and long-term health. In older people, cold temperatures increase the risk of heart attack, stroke and circulatory problems, respiratory disease, flu and hospital admission. They also lower strength and dexterity, leading to an increase in the likelihood of falls and accidental injuries. Home temperatures also have implications for mental health because cold is linked with increased risk of depression and anxiety.
Single-point-of-contact referral service
A local single-point-of-contact health and housing referral service provides access to interventions to address the needs of people living in cold homes. When setting up and monitoring the service, health and wellbeing boards should identify all local providers of interventions and services (such as relevant local authority departments, the health sector, utilities, housing organisations and organisations in the voluntary sector) to address health problems associated with a cold home and encourage their integration to create a single-point-of-contact for access to available assistance. The service should actively assist the people who self-refer or are referred to it by providing access to tailored interventions and services. It should not act as a signposting service.
[Adapted from Excess winter deaths and illness and the health risks associated with cold homes (NICE guideline NG6), recommendations 2 and 3 and expert opinion]
Tailored support
Tailored support is the delivery of interventions and services designed for vulnerable people living in cold homes to address their specific needs. This support takes into account the language and reading ability of the person, including any vision or hearing problems, and their ability to understand and act on information provided to them.
Support includes but is not limited to:
  • Housing insulation and heating improvement programmes and grants. Programmes are led, or endorsed, by the local authority and include those available from energy suppliers.
  • Advice on being energy efficient in the home and having the most appropriate fuel tariff and billing system (including collective purchasing schemes, if available).
  • Help to ensure all due benefits are being claimed, as people receiving certain benefits may be entitled to additional help with home improvements and may get help to manage their fuel bills and any debt.
  • Registration on priority services registers (for energy supply and distribution companies) to ensure households at risk get tailored support from these companies.
  • Advice on how to avoid the health risks of living in a cold home. This includes information about what these health risks are (see Public Health England’s Cold weather plan for England for further information).
  • Access to, and coordination of, services that address common barriers to tackling cold homes. For example, access to home improvement agencies that can fix a leaking roof, or to voluntary groups that can help clear a loft ready for insulation.
  • Short-term emergency support in times of crisis (for example, room heaters if the central heating breaks down or access to short-term credit).
[Adapted from Excess winter deaths and illness and the health risks associated with cold homes (NICE guideline NG6), recommendation 3]

Equality and diversity considerations

Good communication between the referral service and people who may be vulnerable to the health problems associated with a cold home is essential. Those at risk are likely to include people with communication needs, people who are frail or confused, and people who have difficulty understanding and acting on information provided to them. These people may have different support needs. The referral service should provide people with the level of support they need to ensure any needs identified can be acted on.

Asking people about keeping warm at home

This quality statement is taken from the preventing excess winter deaths and illness associated with cold homes quality standard. The quality standard defines clinical best practice in preventing excess winter deaths and illness associated with cold homes and should be read in full.

Quality statement

People who are vulnerable to the health problems associated with a cold home are asked at least once a year whether they have difficulty keeping warm at home by their primary or community healthcare or home care practitioners.

Rationale

Primary or community healthcare and home care practitioners can make every contact count, by asking the person whether they or someone in their household is experiencing difficulties keeping warm at home. If keeping warm is a problem, the person can be referred for help to reduce any risks that are identified (for example through a single-point-of-contact health and housing referral service). People should be asked whenever appropriate, and at least annually. People who spend a lot of time at home may be particularly affected by living in a cold home. This may include some people with chronic conditions or disabilities who are likely to be in regular contact with primary healthcare and home care services.

Quality measures

Structure
a) Evidence of local protocols to define people who are vulnerable to the health problems associated with a cold home.
Data source: Local data collection.
b) Evidence of local protocols for primary healthcare professionals to ask people who are vulnerable to the health problems associated with a cold home at least once a year whether they have difficulty keeping warm at home.
Data source: Local data collection.
c) Evidence of local protocols for community healthcare practitioners to ask people who are vulnerable to the health problems associated with a cold home at least once a year whether they have difficulty keeping warm at home.
Data source: Local data collection.
d) Evidence of local protocols for home care practitioners to ask the people they visit at home who are vulnerable to the health problems associated with a cold home at least once a year whether they have difficulty keeping warm at home.
Data source: Local data collection.
Process
a) Proportion of people who are identified as being vulnerable to the health problems associated with a cold home who are asked at least once a year whether they have difficulty keeping warm at home by primary healthcare practitioners.
Numerator – the number in the denominator who are asked at least once a year whether they have difficulty keeping warm at home by primary healthcare practitioners.
Denominator – the number of people who are identified as vulnerable to the health problems associated with a cold home.
Data source: Local data collection.
b) Proportion of people who are identified as being vulnerable to the health problems associated with a cold home who are asked at least once a year whether they have difficulty keeping warm at home by community healthcare practitioners.
Numerator – the number in the denominator who are asked at least once a year whether they have difficulty keeping warm at home by community healthcare practitioners.
Denominator – the number of people who are identified as vulnerable to the health problems associated with a cold home.
Data source: Local data collection.
c) Proportion of people who are identified as being vulnerable to the health problems associated with a cold home who receive home care who are asked at least once a year whether they have difficulty keeping warm at home by home care practitioners.
Numerator – the number in the denominator who are asked at least once a year whether they have difficulty keeping warm at home by home care practitioners.
Denominator – the number of people who are identified as being vulnerable to the health problems associated with a cold home who receive home care.
Data source: Local data collection.
Outcome
Referral rates to a local single-point-of-contact health and housing referral service.
Data source: Local data collection.

What the quality statement means for service providers, primary and community healthcare and home care practitioners, and commissioners

Service providers (such as local authority departments, healthcare organisations and home care providers) ensure that local protocols are in place that define people vulnerable to the health problems associated with a cold home. The protocols should require primary and community healthcare and home care practitioners to ask vulnerable people, at least once a year, whether they have difficulty keeping warm at home. The protocols should ensure that primary and community healthcare and home care practitioners also take into account room temperature when they are making home visits and ensure good communication between agencies to ensure that any needs identified are addressed and avoid duplication.
Primary and community healthcare and home care practitioners (such as GPs, district nurses, health visitors, allied health professionals, outreach workers and social care practitioners) ask people who are vulnerable to the health problems associated with a cold home according to local protocols whether they have difficulty keeping warm at home. This can be done at least once a year when visiting the person’s home, when they should also be aware of the room temperature, or through discussions with the person during a primary care consultation. They should refer the person appropriately and communicate with the relevant agencies to ensure the person’s needs are addressed and avoid duplication.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that they commission primary and community healthcare and home care services that have protocols in place that provide a local definition of people who are vulnerable to the health problems associated with a cold home. The protocols should require primary and community healthcare and home care practitioners to ask such people at least once a year whether they have difficulty keeping warm at home.

What the quality statement means for patients, people using services and carers

People who are vulnerable to the health problems associated with a cold home are asked whether they have difficulty keeping warm at home. This can be done by healthcare or home care workers who visit their home, or when they visit their GP, and should happen at least once a year.

Source guidance

Definitions of terms used in this quality statement

People who are vulnerable to the health problems associated with a cold home
People living in cold homes who are vulnerable to the associated health problems include:
  • people with cardiovascular conditions
  • people with respiratory conditions (in particular, chronic obstructive pulmonary disease and childhood asthma)
  • people with mental health conditions
  • people with disabilities
  • older people (65 and older)
  • young children (under 5)
  • pregnant women
  • people on a low income
  • people who move in and out of homelessness
  • people with addictions
  • people who have attended hospital due to a fall
  • recent immigrants and asylum seekers.
[Adapted from Excess winter deaths and illness and the health risks associated with cold homes (NICE guideline NG6) and expert opinion]
Health problems associated with a cold home
Cold homes and poor housing conditions have been linked with a range of health problems in children and young people, including respiratory health, growth and long-term health. In older people, cold temperatures increase the risk of heart attack, stroke and circulatory problems, respiratory disease, flu and hospital admission. They also lower strength and dexterity, leading to an increase in the likelihood of falls and accidental injuries. Home temperatures also have implications for mental health because cold is linked with increased risk of depression and anxiety.
Difficulty keeping warm at home
Practitioners should take into account the needs of people who are vulnerable to the health problems associated with a cold home by asking whether they have, or are likely to have, difficulties keeping their home warm enough. This can be done either on home visits (by visiting health and home care practitioners) or elsewhere, for example during a routine consultation with a GP. The conversation should include, but not be limited to, the following considerations:
  • The amount of time the person spends at home.
  • How and when they use their heating.
  • If the cost of their heating makes them limit its use and risk being cold.
  • Any illnesses or temporary or long-term physical or mental health conditions they have, how their condition might be affected by being cold at home and how it might prevent the person from operating their heating system effectively.
[Adapted from Excess winter deaths and illness and the health risks associated with cold homes (NICE guideline NG6), recommendation 5 and expert consensus]
Primary and community healthcare and home care practitioners
These are practitioners who are likely to have regular contact with people who may be vulnerable to the health problems associated with a cold home and will, in many cases, visit these people at home. They include, but are not limited to, GPs, district nurses, health visitors, allied health professionals, outreach workers, dementia support workers, family support workers and other social care practitioners.
[Expert consensus]

Equality and diversity considerations

Good communication between primary and community care and home care practitioners and people who may be vulnerable to the health problems associated with a cold home is essential. Those at risk are likely to include people with communication needs, people who are frail or confused, and people who have difficulty understanding when asked about their home heating needs.

Identifying people vulnerable to health problems associated with cold homes on admission

This quality statement is taken from the preventing excess winter deaths and illness associated with cold homes quality standard. The quality standard defines clinical best practice in preventing excess winter deaths and illness associated with cold homes and should be read in full.

Quality statement

Hospitals, mental health services and social care services identify people who are vulnerable to health problems associated with a cold home as part of the admission process.

Rationale

Identifying people vulnerable to health problems associated with cold homes at the earliest opportunity (for example soon after admission or when planning a booked admission) based on their socioeconomic, demographic or clinical circumstances, allows care providers the opportunity to then carry out a more detailed assessment of needs that will inform discharge planning. This will help people in care settings who are vulnerable to health problems associated with cold homes to avoid the risks of discharge to a cold home.

Quality measures

Structure
Evidence that care settings (hospitals, mental health services and social care services) have arrangements to identify people who are vulnerable to the health problems associated with a cold home as part of the admission process.
Data source: Local data collection.
Outcome
The number of people vulnerable to the health problems associated with a cold home who are identified on admission.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as hospitals, mental health inpatient services and social care residential services) ensure that they have systems in place to identify people who are vulnerable to the health problems associated with a cold home at the earliest opportunity (for example soon after admission or when planning a booked admission) as part of the admission process. Subsequent discharge planning should take account of any issues identified.
Health and social care practitioners (such as occupational therapists, nurses and residential care managers) identify people who are vulnerable to the health problems associated with a cold home at the earliest opportunity (for example soon after admission or when planning a booked admission) as part of the admission process to hospital, a mental health service or social care service. Subsequent discharge planning should take account of any issues identified.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that they commission hospital, mental health inpatient and residential social care services that identify people who are vulnerable to the health problems associated with a cold home as part of the admission process.

What the quality statement means for patients, people using services and carers

People admitted to hospital, a mental health service or a social care service (for example a residential care home) are checked when they are being admitted to identify if they are vulnerable to health problems associated with a cold home.

Source guidance

Definitions of terms used in this quality statement

People who are vulnerable to the health problems associated with a cold home
People living in cold homes who are vulnerable to the associated health problems include:
  • people with cardiovascular conditions
  • people with respiratory conditions (in particular, chronic obstructive pulmonary disease and childhood asthma)
  • people with mental health conditions
  • people with disabilities
  • older people (65 and older)
  • young children (under 5)
  • pregnant women
  • people on a low income
  • people who move in and out of homelessness
  • people with addictions
  • people who have attended hospital due to a fall
  • recent immigrants and asylum seekers.
[Adapted from Excess winter deaths and illness and the health risks associated with cold homes (NICE guideline NG6) and expert opinion]
Health problems associated with a cold home
Cold homes and poor housing conditions have been linked with a range of health problems in children and young people, including respiratory health, growth and long-term health. In older people, cold temperatures increase the risk of heart attack, stroke and circulatory problems, respiratory disease, flu and hospital admission. They also lower strength and dexterity, leading to an increase in the likelihood of falls and accidental injuries. Home temperatures also have implications for mental health because cold is linked with increased risk of depression and anxiety.

Equality and diversity considerations

Good communication between health and social care practitioners and people who may be vulnerable to the health problems associated with a cold home is essential. Those at risk are likely to include people with communication needs, people who are frail or confused, and people who have difficulty understanding when asked about their home heating needs.
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Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

almost all causes of death show some variation with season. Overall, the death rate is higher during winter months and these deaths are referred to as 'excess winter deaths'. In the UK, these figures are based on death rates from December to the end of March
hard-to-heat homes include those with solid walls, those with no loft space, those in a state of disrepair, high rise blocks, those not connected to (and that cannot be connected to) the gas grid. Other factors, such as listed architectural features, accessibility or construction quality may make it difficult to significantly improve the standard assessment procedure (SAP) rating. Such properties are sometimes described as 'hard to treat'. While important, the major issue from a health perspective is to ensure properties are not 'hard to heat'
home improvement agencies are local organisations that help older people, people with disabilities and vulnerable people to live in safety and with dignity in their own homes. Services focus on ensuring existing housing is fit for purpose and that vulnerable people, predominantly homeowners, can live independently for as long as possible. Locally they may be known as 'care and repair' or 'staying put' agencies
the priority services registers are schemes offering extra free services to people who are of pensionable age, are registered disabled, have a hearing or visual impairment, or have a long term health problem. They are run by energy suppliers and distributors
self-disconnection occurs when a pre-payment meter is not topped-up (either accidentally or intentionally) before all the credit, including emergency credit, is used and the supply is cut off
'standard assessment procedure' (SAP) refers to an index that reflects the cost of heating a dwelling. The index depends on the rate of heat loss determined by: building fabric, degree of insulation, ventilation and the cost of the heating. This last factor is determined by heating efficiency, fuel price and solar gain. SAP ratings are frequently divided into 7 bands (A to G). A (most efficient) runs from 92–100, B from 81–92, C from 69–80, D from 55–68, E from 39–54, F from 21–38 and G from 1–20

Paths in this pathway

Pathway created: March 2015 Last updated: November 2016

© NICE 2017

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