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Changing practice 

Identifying people at risk of fuel poverty to prevent excess winter deaths

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Improving the energy efficiency of houses may reduce winter deaths. A trust developed an algorithm to assess eligibility for winter warmth initiatives


Andrew Bull is assistant director health improvement; Hashum Mahmood is public health epidemiologist; both at NHS Birmingham East and North; Nikki Cush is area partnership manager at npower Health Through Warmth.


Bull A et al (2010) Identifying people at risk of fuel poverty to prevent excess winter deaths. Nursing Times; 106: 49, early online publication.

An analysis of excess winter deaths across the West Midlands found higher levels at in the NHS Birmingham East and North area than in the rest of the region.

The trust created an algorithm to identify those at risk of excess winter death and fuel poverty.

This article describes the development of the algorithm and how it can be used by nurses to help initiate winter warmth interventions.

Keywords: Fuel poverty, Excess winter deaths, Algorithm, Care of older people

  • This article has been double-blind peer reviewed


Practice points

  • People move in and out of fuel poverty - it is a dynamic process.
  • Anyone who spends more than 10% of their income on keeping warm is in fuel poverty.
  • Energy efficiency measures can help reduce the risk of fuel poverty.
  • The algorithm can be used to help nurses identify individuals who could benefit from winter warmth interventions.


Case study: ‘The new boiler has made a world of difference to my arthritis’

William Clegg (not his real name), aged 72, lives in Birmingham with his wife Mary. He has arthritis and bronchitis. The central heating in their home had a history of breaking down and it eventually stopped working altogether. The cold temperatures in the home were exacerbating his health problems.

Mr Clegg’s local council neighbourhood office referred him to npower’s Health Through Warmth scheme to see if he could receive any help towards replacing his boiler. As a result, he had a new boiler installed. This cost £2,532, and payment was split equally between Mr Clegg and the npower Health Through Warmth crisis fund.

Mr Clegg said: “I’m extremely grateful for the help I have received. When the old boiler was condemned, it was very difficult for my wife and me.

“The new boiler has made a world of difference to my arthritis; the rooms heat up really quickly and the house is much more comfortable now it’s warm.

“The new boiler is really reliable and I now have the peace of mind that I can keep my home warm, particularly in the cold winter months when my arthritis is at its worst.”



According to government estimates, around 3.5 million UK households suffer from fuel poverty, leaving people in homes that can seriously damage health or even cause death (Department for Environment, Food and Rural Affairs, 2008). Press (2003) defined fuel poverty as spending more than 10% of income on all fuel use. When income is below £10,000, households will face fuel poverty regardless of other determinants (Yorkshire and Humber Public Health Observatory, 2006), and it is estimated that every 1% increase in energy prices takes 40,000 people into fuel poverty (House of Commons Business and Enterprise Committee, 2008).

Eighty five per cent of households in fuel poverty consist of single people or couples, and 50% of people in fuel poverty are aged 60 and over (YHPHO, 2006). Vulnerable groups such as unemployed, older or disabled people are particularly at risk as they tend to spend longer periods at home.

Excess winter deaths

The UK has one of the highest numbers of excess winter deaths in Europe, accounting for around 40,000 deaths a year. Excess winter deaths are the number of deaths of people aged 65 and over in the four winter months (December to March), minus the average number over during the preceding four months (August to November) and subsequent four months (April to July).

According to Fowajuh and Smith (2009), excess winter deaths are generally associated with lower temperatures, with an extra 8,000 deaths for every degree Celsius the temperature falls below the winter average.

Wilkinson et al (2001) argued that improving the energy efficiency of UK houses could accomplish “significant public health benefits, including a reduction in winter deaths”.

People with specific conditions, such as respiratory and cardiovascular disease, are particularly at risk from morbidity related to low indoor temperatures (Press, 2003):

Asthma and COPD

People with asthma are two to three times more likely than the general population to live in damp homes (Williamson, 1997). Damp leads to growth of moulds and fungi which can cause allergies and respiratory infections; 15% of homes report mould (Office of the Deputy Prime Minister, 1998).

The cold impairs lung function and is an important trigger of bronchoconstriction in asthma and chronic obstructive pulmonary disease (Collins, 2000). Temperatures below 16ºC are thought to lower resistance to respiratory infection.

Heart attacks and strokes

The risk of heart attacks and strokes increases with increasing blood pressure. According to Goodwin (2000), blood pressure rises in older people who are exposed to temperatures below 12ºC. In those aged 65-74, a 1ºC decrease in living room temperature below 12ºC is associated with a rise of 1.3mmHg systolic and 0.6 mmHg diastolic blood pressure (Woodhouse, 1993).

NHS Birmingham East and North

During routine health improvement monitoring in 2008, NHS Birmingham East and North (NHS BEN), was reported as having a high EWDI than other trusts in the West Midlands (Fig 1). An investigation was carried out to determine the cause of this variation.

EWDIs were calculated for specific age groups and specific disease categorised using the International Classification of Diseases (ICD 10). The analysis by Parsons (2009) showed:

  • The high level of excess winter deaths in NHS BEN were not because the catchment area had a large older population, as predicted;
  • EWDIs for many of the ICD 10 chapters  were considerably higher in NHS BEN than in the region as a whole;
  • In NHS BEN, neoplasms, nervous system, circulatory, respiratory and digestive ICD 10 codes accounted for 85%of excess winter deaths.

The algorithm

Following this analysis, the health improvement directorate of the PCT developed an algorithm of eligibility to help reduce fuel poverty and improve winter warmth (Fig 2), for use by a range of health and social care professionals within the PCT. Referral is third party only so the algorithm needed to be easy and quick to use by a range of busy practitioners.

The algorithm was to be used, in the first instance, by the trust’s telephone based long term condition care management service, Birmingham Own Health (BOH). This service offers a personalised, multilingual programme of healthcare support for people in Birmingham who have a range of long term conditions, such as diabetes, coronary heart disease and COPD.

BOH is delivered over the telephone by a team of care managers, who are principally nurses, physiotherapists and occupational therapists

The service helps patients, known as members,  to take better control of their condition and stay as fit and healthy as possible. Each care manager is dedicated to specific GP practices. They build and maintain ongoing relationships with members, providing motivation, support and information. As part of routine care, the algorithm is used to identify if there any issues with home heating.

The care manager helps individuals to:

  • Better understand their own medical condition;
  • Gain skills and knowledge to make positive lifestyle changes that can benefit their condition and health;
  • Correctly follow treatment as prescribed by their GP;
  • Understand how to engage and use local NHS services more appropriately and effectively.

The straightforward nature of the algorithm lends itself to use in a variety of settings and by a range of staff.  For example, practice nurses could use it during the flu vaccination season or opportunistically throughout the year.  It could also be used by community staff with vulnerable patients; and by nurses in acute settings as part of pre-discharge planning.

npower Health Through Warmth

The algorithm was developed in partnership with npower Health Through Warmth, a practical scheme that works in partnership with local, regional and national agencies (

npower Health Through Warmth operates in 15 areas of England and Wales. It aims to help vulnerable people whose health is adversely affected by cold and/or damp living conditions by assisting with installation of energy efficiency and heating measures. The case study illustrates how the scheme has helped one family.


Working with epidemiological data, EWDI was identified as a health issue within NHS BEN.

In partnership with npower Health Through Warmth, a simple algorithm was devised that identified individuals who are eligible for installation of energy efficiency and heating measures.

The algorithm has mostly been used by members of BOH for patients with long term conditions, but the plan this year is to extend its use in a targeted manner to include patients on GP COPD registers and other vulnerable adults.

Analysis of EWDI for NHS BEN in 2007-08 showed a significant reduction in excess winter deaths. It is not possible to say whether this is a direct result of introducing the algorithm, but it may have contributed to the improvements observed. Feedback from npower Health Through Warmth referrals and anecdotal accounts suggest initiatives like this are valued and do make a difference.  Day and Hutchings’ (2009) qualitative research demonstrates the importance and value placed on heating in both low and high income groups.  It suggested that in many cases older adults would sacrifice other expenditure in order to ensure that they could keep warm.


Living in warm, well aerated homes has the potential for many benefits, such as reductions in premature mortality, fewer emergency hospital admissions and earlier recovery from illness.

Ensuring warmth at home is a critical part of integrated care and could help lessen the winter pressure on the NHS, ultimately reducing costs.

From a patient centred nursing approach, working with partners to ensure patients live in safe and warm homes is a prerequisite of community nursing care.

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