Measurably reducing excess winter deaths, illness and fuel

poverty in populations

CLAHRCFor South Yorkshire

Unique selling point (USP) Strong multi-disciplinary team, combining scientific and

economic expertise with experience working on the front line and strategically for the NHS, Department of Health, local

government and the World Health Organization.

Abacus team. 

Prof. Chris Bentley • Prof. Geoff Green • Jan Gilbertson • Catherine Homer • Dr. Paul Redgrave • Dr. Bernard Stafford • Prof. Angela Tod

In winter2010/11 there were around 23,700 ‘excess winter deaths’, or

1,300 more people dying per week in the winter than the rest of the year

Average of 144 Excess Winter Deaths per year 1990-2010 in Rotherham, for example

The Threat of Winter

DEATH

Illne

ssDEPRESSION

Anxiety

Hypothermia

Misery

Accidents

Dis

abili

ty

Loneliness

ResultsSocial Cost of Cold Homes e.g. in Sheffield 2011/12

£Million

PrematureDeath

Cardio Vascular Illness

Respiratory Illness

Falls at Home

Common Mental Disorders

Total Cost

Loss of Well-Being £1.856

£1.894

£1.083

£0.845

£9.638

£15.316

NHS Primary Secondary and Tertiary Cost plus Social Care Cost

-

£0.462

£0.497

£0.250

£2.112

£3.321

GDP Loss

-

-

-

-

£0.934

£0.934

Number of Cases

58

148

114

88

1 369

-

Total Social Cost per Case

£0.0320

£0.0159

£0.0139

£0.0124

£0.0093

-

Total Social Cost

£1.856

£2.356

£1.580

£1.095

£12.684

£19.571

Producing Percentage Change at Population Level C. Bentley2007

Producing Percentage Change at Population Level C. Bentley2007

Intervention Through Services

An Abacus proposal for an integrated programme of local action to pro-

actively and systematically protect identifiable vulnerable people from

avoidable illness and premature death

Abacus excess winter deaths and illness: capability and resilience model

The Challenge:

To bring access to all the key 9 evidence-based interventions to as many vulnerable people as possible, in a systematic, rather than patchy process.

a) Coronary Heart Disease (Harison et al. 2006)

Have the problem

Aware of problem

Eligible forintervention

Optimalinput

Active use of systems

AB C D

b) Generic ‘Decay’ model (not to scale)

It is clear that, in trying to address the ‘decay’ in a population’s appropriate access to, and use of services, the role of individual services (such as medical GPs or Energy Sector companies) is essential, but not sufficient.The service will have a responsibility to decide which people identified as being at risk can benefit from which intervention, and then make that intervention available.They also contribute to drawing people at risk into their services, and helping them to use the interventions properly when they have access.

Have the problem

Aware of problem

Eligible forintervention

Optimalintervention

Benefit from evidence based interventions across populations(not to scale)

AB C D

Chris Bentley 2012

Active use of systems

However, in order to address the whole ‘decay’ pathway, it will be necessary to recruit other

partners.

This might include community based organisations, and other parts of the Third

Sector as well as other public sector organisations with frontline staff in

communities.

Have the problem

Aware of problem

Eligible forintervention

Optimalintervention

Benefit from evidence based interventions across populations(not to scale)

AB C D

Chris Bentley 2012

Active use of systems

A. Defining and reaching out to the vulnerablecreating a ‘list-of-lists’ virtual register of most at risk

List-of lists

• In order to systematise access to the 9 key interventions, a register of the identified most vulnerable people will be needed

• This can be a ‘virtual’ register, whereby:– frontline staff identify the most vulnerable on

their own caseloads, and establish their own list

– A (Cold Weather Plan) co-ordinator compiles a register of staff across the agencies keeping such a list (but doesn’t need the patient/client names)

– This ‘list-of-lists’ constitutes the virtual register

Constructing the ‘List-of-lists’

B.Screening for risk and the ability to benefitsystematic checklist of uptake on the 9 key interventions

Vulnerable Resident

Prim

ary

Care

Com

mun

ity C

are

Soci

al C

are

Hou

sing

Bene

fits

Agen

cy

Fire

and

Res

cue

Age

UK

Snow

Ang

els

Stro

ke A

ssoc

iatio

n

Commissioning Organisations

However, the potential is for …….

• The HWB could establish a coordinating sub-group, or assign responsibility for this programme to an existing sub-group. In some areas this has been an expanded Affordable Warmth sub-group, in others the Seasonal Excess Deaths or Cold Weather Planning Group. In the latter cases, there have been strong links to the Local Resilience Forum

• In order to drive strong integrated actions, the sub-group might assign or appoint a dedicated programme coordinator

• Under the auspices of the HWB structure commissioning agreements to be reached whereby each vulnerable older person has a named key worker, out of those already involved

• This could be, for example:– a district nurse– a home care worker from social care or – a voluntary sector advocate

Health and Wellbeing Board

EWDTask Group

Vulnerable Resident

Key Worker

And, once established …….

• Each key worker would be empowered, supported and have the necessary arrangements to:– Carry out a simple screening assessment of

uptake on the 9 key interventions– Where appropriate, be able to make a

straightforward referral for more detailed assessment and delivery of any missing interventions

– Keep a simple record of progress against each of the 9 for his/her ‘list’

– Make a regular return to the co-ordinator/keeper of the list-of-lists

Assessment of vulnerable elderly against 9 interventions

Thermal efficiency

Household income

Falls assessment

Vaccinations Medication review

Nutrition hydration

Assistive technology

Contingency plan

Personal resilience

Patient A

GP

------------

Patient B

GP

------------

Patient C

GP

Patient D

GP

Patient E

GP

Assessed/No problem Referred/In process At risk

C. Quality service inputswhat good looks like for 8 of the interventions

Co-ordinating delivery

• Responsibility for delivery of each of the 9 key interventions would largely continue through specialty agencies as now

• Focus would need to be on the connectivity (‘wiring diagram’) amongst agencies

• Arrangements would need to be simple and efficient; e.g. single point to receive referral; minimalist referral mechanism; feedback updates to referrer at agreed points

• Referrals to other agencies requires patient agreement / consent

• Commissioners would need to agree target response times, as part of their quality specification

• Key workers could support communication with their vulnerable patient/client where necessary

D. Supporting good self managementthe 9th intervention – maximising personal assets

Situation or

contextual factors

Attitudinal factors Barriers

Money  Age  Social connections  Housing type and

tenure  Health

Making ends meet­ Thrift­ Competing

priorities­ Pride­ Struggling

I can manage­ Thrift­ Hardiness­ Stoicism

It's my business− Mistrust− Pride− Privacy I'm frightened

­ Privacy­ Personal safety/

vulnerability I'll stay as I am

­ Struggle with change

­ Like routine­ Fear­ Trust

Awareness­ Knowledge­ Information­ Experience

Technology­ Heating­ Information­ Banking

Disjointed systems­ Fragmentation or

services­ Local differences­ Lack of referral

systems Visibility

­ Fuel­ Money­ Information­ Older people

Factors influencing older people in keeping warm and well at home

KWILLT

Intermediate Outcomes

Summary• A strong case can and should be made to commissioners

that deaths, illness and misery of severe winters are largely preventable.

• There is a substantial financial case to also take into account, and this emphasises the key impact of mental ill health.

• It is proposed that a virtual register of the most vulnerable in an area be established, possibly as a ‘list-of-lists’

• A checklist of evidence-based key interventions should be established, and co-ordinated mechanisms set up to ensure those on the lists are systematically assessed for all

• ‘Organised efforts of society’ working together will be necessary to reduce ‘decay’ in access to and use of services by the most vulnerable. This will be necessary to achieve improvements in population level outcomes