Recently a Local Authority public health team invited me to tender for some work to develop a bone health campaign.
The objective of the campaign was to encourage people to take steps and adopt habits (calcium consumption, getting enough vitamin D, weight bearing exercise) to protect their bones. Due to a higher risk of falling and sustaining a bone injury, one of the key target audiences of this campaign was to be people over 65.
As we work across both public health and fuel poverty, this brief begged the question – is it better for the Local Authority to invest resources in a campaign to encourage lifestyle changes amongst older people in general or a project to ensure elderly people at high risk of falls are living in warmer homes?
The issue of cold homes was not mentioned in the public health brief despite the fact that a cold house increases the risk of falls in the elderly[i] and these falls often cause significant injuries resulting in a stay in hospital.
Using warmer homes as a preventative solution to reducing the impact of falls, rather than a single-issue bone health campaign, would result in other health benefits for elderly people such as reduced risk of death from cardiovascular or respiratory illness. In addition, a more energy efficient home may resolve “heat or eat” choices amongst the most vulnerable.
On a wider scale, Age Concern estimates the cost to the NHS of treating the illnesses caused by cold homes was £1.36 billion a year.[ii] The Department of Health’s Public Health Outcomes Framework includes indicators for fuel poverty, excess winter deaths and reducing falls and injuries in the over 65s, however few Health and Well-being Boards are prioritising fuel poverty.
So why isn’t addressing fuel poverty being seen as a solution to health issues?
With public health now sitting in Local Authorities there should be tremendous opportunities for health teams to work collaboratively with other departments to jointly tackle the wider, social determinants of health such as housing. Maybe more time is needed for these benefits to be realised but, as revealed by the bone health brief, public health teams may be too culturally entrenched in lifestyle changes as a means of preventing ill-health to the exclusion of environmental improvements.
There are also significant barriers to engaging other healthcare professionals in initiatives to make people’s homes warmer and reduce illness.
The SHINE project is an award winning “one stop shop” referral network established to tackle fuel poverty and reduce seasonal deaths and hospital admissions in Islington. Working in partnership across the borough, SHINE helps residents access energy efficiency measures and advice as well as other services including fire safety checks, benefits checks, medication reviews, medicine use reviews, flu jabs, NHS Health Checks, falls assessments, eye tests and befriending services.
SHINE received over 2,800 referrals in 2013/14 – but despite considerable effort to engage GPs and others only 4-5% of their referrals are from health professionals.
SHINE’s experience was echoed in the evaluation of the Warm Homes, Healthy People Fund[iii] which identified lack of engagement by healthcare professionals as “a major barrier to reaching those most vulnerable to the effects of cold”.
So what stops GPs from referring people to a service that could make their home warmer and improve their health?
There is undoubtedly an underlying cultural issue. GPs focus on a medical model of diagnosis and treatment – so non-medical solutions to the wider determinants of health may not occur to them.
There may also be a confidence issue – can GPs be sure that their patient will receive the home energy improvements they need if they do refer them? A GP could refer an elderly person in a cold home in the expectation that they will be assisted by ECO – The Energy Company Obligation whereby major energy companies are obliged to fund energy efficiency measures to meet carbon reduction targets and help vulnerable householders. However ECO eligibility criteria may not apply to that person’s property – it may be hard to treat or in a conservation area, so the works will not be done.
Maybe GPs need more evidence for the effectiveness of these non-medical interventions? Or at least the evidence that exists presented in medical “currency” such as reduced hospital admissions, rather than energy efficiency and carbon outcomes?
What is needed to encourage more health professionals to engage with fuel poverty interventions?
There are clearly no easy answers. However I feel there must be a solution to more effectively engage health – both public health and primary care – in fuel poverty interventions, and target resources more effectively than broad public health campaigns on bone health. If you have any observations, I would welcome your comments.
[i] Marmot Review Team, The Health Impacts of Cold Homes and Fuel Poverty, 2011
[ii] Age Concern, The Cost of Cold, 2012
[iii] Public Health England, Evaluation Report Warm Homes Healthy People Fund 2012 to 2013