Overview of NICE guidance on excess winter deaths and illness and the health risks associated with cold homes

Dr David Sloan, formerly chair of NICE Public Health Advisory Committee ESRC seminar. Doncaster 27 June 2016

Overview

• Context

• A little about the NICE process

• The evidence about the impact of cold weather on health

• The NICE guidance and quality standard

Context

• Poverty and inequity are health issues (Marmot etc.)

• Cold weather causes an increase in illness and death

• Fuel poverty causes double jeopardy

• Policy and initiatives on carbon saving, public health,

housing and poverty do not always align at national or

local level

It was in this context that NICE was asked to look at

Excess Winter Death and Illness.

Referral from the Department of Health

NICE was asked to produce: “Guidance for commissioners and practitioners working in local authorities and health services on effective implementation and delivery of approaches for prevention of excess winter deaths and morbidity and the health risks associated with cold homes. Focus specifically on vulnerable children and older people to promote and protect their health and wellbeing both in the short and longer term.

The guidance would aim to define the systems required for an integrated approach to identification of risk and vulnerability and the provision of effective interventions (including insulation, fuel tariffs, uptake of benefits, and heating improvements)… it would also be helpful if you could consider including the specific issue of excess winter deaths in rural areas.”

The NICE process

• Defined “scope” based on referral and consultation

• Reviews of evidence of effectiveness and economics

(London School of Hygiene and UCL)

• Best available evidence, wide trawl

• Public Health Advisory Committee discussions

• 3 month public consultation on draft guidance

• Open process; public meetings and stakeholders able to

comment at each stage

• Final guidance launched 5 March 2015

The evidence

• The nature of evidence – research literature; testimony

• Clear link between cold weather and increase in illness

and death from all causes

• Greatest burden cardiovascular and respiratory disease

but also other groups – mental health, disability etc.

• Greatest impact in coldest homes (Joseph Rowntree)

• UK has greater problem than e.g. Scandinavia

• Therefore strong inference that tackling cold homes and

fuel poverty will reduce excess deaths and illness

Evidence (2)

• Death rate rises when Temp drops to 5-8 Deg C

• Time lag – effect continues for weeks

• For every death, 8 admissions and unmeasured illness

at home

• Cost to NHS alone £1.36 billion (Age UK)

• Variation in practice, with many examples of innovation

and good practice and coordinated local initiatives

Daily deaths vs. temperature

Source: Excess winter mortality in England and Wales. Nov 2015. National Statistics

Excess winter mortality in England

Source: Excess winter mortality in England and Wales. Nov 2015. National Statistics

International comparisons

Limitations of the evidence

• Mostly time series studies at population level and based

on external temperature

• Few studies on individuals or using internal temperature

• While evidence of link with cold is clear, evidence of

what interventions work is more limited

• Reliance on modeling for economic evidence

• Little evidence on behaviour – trade offs, self disconnect

etc.

• Inequalities exist but little evidence about solutions

The NICE recommendations; the

headlines of NG6

• A key public health issue requiring whole year planning

• Single point of contact for tailored health and housing

advice

• Identify and focus on those most at risk

• Make every contact count

• Plan for discharge; never to a cold home

• Training; raise awareness of public and practitioners

about the impact of the cold on health

• Make use of the non health and social care workforce

• Compliance with building regs – e.g ventilation

• Research recommendations

Recommendation 7

“Discharge vulnerable people from health or social

care setting to a warm home”

–Early assessment of vulnerability and risks

–Planned discharge to include consideration of heating

–Referral to single point of contact health and housing service if

necessary

NICE Quality standards QS117

• Describe high priority areas for quality improvement in

specific aspect of public health, health or social care

• Quality improvement tool for use by NHS and others

• Seven quality statements. No 6 says:

“People who are vulnerable to the health problems

associated with a cold home who will be discharged to

their own home from hospital, or a mental health or

social care setting have a discharge plan that includes

ensuring that their home is warm enough.”

Using the Guidance and Quality

Standard

• Useful when negotiating locally and nationally – has

NICE stamp

• Helps others (e.g. NHS orgs) meet performance targets

• Helps focus on where action is likely to help (evidence)

• Some practical ideas

www.nice.org.uk/guidance and look for NG6

Conclusions

• There is much that can be done

• Several potentially congruent policy initiatives which

could be catalysts for coordinated local action:

– Cold weather plan, environmental policies to reduce fuel use,

drive for energy efficiency and the reduction of fuel poverty,

benefits programmes

• National policy provides framework but effective action

depends on good local coordination

• We need better evidence, especially of interventions so

please get your evaluations published!

References and further reading

1. The NICE Guidance, associated evidence reviews and Quality

Standard can be found at www.nice.org

2. National Statistics. Excess winter mortality in England and Wales:

2014/15 (provisional) and 2013/14 (final). Nov 2015

3. Paul Wilkinson, Megan Landon, Ben Armstrong, et al. Cold comfort.

The social and environmental determinants of excess winter deaths

in England, 1986-96. Joseph Rowntree Foundation and Policy

Press. 2001

4. The cost of cold: Why we need to protect the health of older people

in winter.. 2009. Age UK

5. Public Health England’s Cold Weather Plan is at

https://www.gov.uk/government/collections/cold-weather-plan-for-

england