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Case study: Helping people stay warm at home in later life

Health risks for those living in cold homes

Keeping warm enough at home in cold weather is a challenge that many older people face every year in the UK. Cold weather can increase the risk of stroke, heart attack and hypothermia, particularly among older people with underlying health conditions, with more than 26,000 excess winter deaths recorded between December and March in England annually. 

Excess winter deaths are mainly preventable and many could be avoided by older people keeping warm enough at home. Finding ways to promote good health by keeping warm, and ensuring people can access the support they need to do so, is vital to reduce ill health and the burden on the NHS over winter. 

The Cold Weather Plan  was introduced by the Department of Health and Social Care in 2011 to reduce cold-related ill health and deaths amongst vulnerable people. Vulnerable older people who don’t already receive health and social care services can be difficult to identify and support, so the plan asks frontline NHS staff to identify those at risk from cold and direct them for advice on keeping warm at home. Most policies and interventions to address fuel poverty and the impact of cold weather focus on ways to increase household income or reduce the cost of fuel, so people in need who are unaware of or have difficulty accessing such initiatives could often miss out.

The need to understand the influences and decisions of vulnerable older people in relation to keeping warm led to the NIHR Research for Patient Benefit Programme  commissioning and funding the Keeping Warm in Later Life (KWILLT) project. Led by Professor Angela Tod, Professor of Older People and Care at the University of Sheffield (formerly at Sheffield Hallam University), the project team planned to use their findings to identify and target assistance for those most vulnerable to cold houses. They also wanted to clarify the role of NHS staff in directing people for support to improve access and uptake of interventions.

As a member of the KWILLT research team and project co-ordinator for National Energy Action (NEA, a charity helping people access grants and assistance to live in a warm home) across Yorkshire and Humber, Kath McDaid explained why the research team applied for NIHR funding, saying: “I used to constantly receive requests from a whole range of organisations asking for information, guidance and evidence relating to fuel poverty and affordable warmth.” 

There was a definite need for a trusted source that would enable people to access guidance, information and ideas for action to keep people warm.
- Kath McDaid, member of the KWILLT research team

Identifying those most at risk from the cold

Between 2009 and 2011, the KWILLT study recruited 50 people aged between 55 and 95 years from across Rotherham in South Yorkshire, which is an area with high levels of fuel poverty and excess winter deaths. 

Working in partnership with NHS Rotherham, Sheffield Hallam University, Rotherham Council and charitable organisations such as Age UK, the NIHR-funded researchers interviewed participants in their homes about their knowledge, beliefs and values around keeping warm at home, and recorded their room temperatures and humidity measurements. Twenty-five health and social care staff were also interviewed to gather their perceptions of older people’s cold-related behaviour.

KWILLT’s interview results challenged expectations about who was at risk from cold homes, showing that although some older people’s behaviour was affected by a limited income and fuel poverty, those who were not fuel poor were also at risk. For example, one participant commented: “If it gets cold I put more clothes on or wrap a fleece round me…. That is always my last resort, to turn the heating up. I was trained to be frugal.”

Past experiences, trust and social connection all played a part, alongside uncertainty about using heating technology, with one interviewee saying: “I don’t know the first thing about working that boiler but I’m not bothered in a way”. Many were unaware of or had no access to energy-saving initiatives or social tariffs, indicating that new approaches were needed to address their difficulties in keeping warm. 

The team analysed the information to identify key groups of older people who would benefit from targeted interventions to heat their homes. The six distinct groups were all considered vulnerable to having cold homes, with members of each group having similar characteristics, situations, needs, attitudes or behaviours. Three groups were in fuel poverty and struggled to afford to heat their homes, while the other groups could afford heating but different reasons prevented them from doing so effectively. 

This information was used to create kwillt, an online learning resource designed to help different sectors, such as health and social care, housing advisors and community groups, recognise and assess the most vulnerable older people in their regions. Training materials for staff, assessment and referral tools and materials for public awareness campaigns were also available to help them promote behaviour change and increase access to services. The project’s results were published in BMJ Open.

The study was adopted by the health inequalities theme of the NIHR South Yorkshire Collaboration for Leadership in Applied Health Research and Care (now the NIHR Applied Research Collaboration Yorkshire and Humber), which supported wider dissemination and impact of the project through its public health networks and partners.

Warmer homes, better health

Commenting on KWILLT’s role in supporting older people in cold weather, Professor Tod said: “Our study has provided evidence to illustrate how older vulnerable people face a number of barriers that prevent them keeping warm and accessing initiatives that may help them.”

KWILLT enabled the experiences of older people to be captured in such a way that it challenged assumptions that people had about older peoples’ behaviour regarding home heating.
- Professor Angela Tod, Professor of Older People and Care at the University of Sheffield and Chief Investigator of the KWILLT study

In 2013 the government’s Cold Weather Plan recommended the use of the KWILLT toolkit in practice by health and social care teams to identify older people needing more support to keep warm. KWILLT’s findings also informed the development of the Department of Health and Social Care-funded Winter Warmth England (WWE) website, launched to support the annual Cold Weather Plan’s aims by providing resources about how cold weather affects health and how to reduce those risks. 

KWILLT’s input ensured the WWE resources for both healthcare professionals and the public were clear, accurate and accessible, ultimately helping to alter practice and improve public health. An evaluation of the WWE website outlined how KWILLT’s contributions had benefited services, for example, helping public health managers develop action plans for winter and developing partnerships across sectors. The South Yorkshire Hotspots scheme is an example of this, whereby a partnership between NHS departments, local authorities and other public services enables frontline staff to assess and refer people to a range of services including home safety checks, pensions and benefits assessment and affordable warmth interventions.

The research team also contributed evidence to local and national strategy and policy discussions, highlighting the complex issues underlying older people’s living conditions in cold households. The Department of Energy and Climate Change, which identifies cold homes and householders who would benefit from energy efficiency measures, used the electronic KWILLT resources to consider ways to identify those people and how their difficulties in accessing help could be overcome. The project has also contributed evidence to national consultations such as the Hills Fuel Poverty review. 

Using their experience from KWILLT, Professor Tod’s team extended their fuel poverty outreach research into other vulnerable groups using an award of £150,000 joint funding from NIHR, NHS Rotherham, NHS Doncaster and Consumer Focus Energy to explore the barriers, attitudes and values of families living in cold homes. The resulting Warm Well Families resources were made available alongside those for older people on the WWE website. 

The study was also cited in Research Excellence Case Study 2014, recognising its impact in its field on understanding of the complex issues surrounding health and social care, housing, energy and welfare alongside digital knowledge amongst older people.  

This research has provided a unique understanding of the complex reasons contributing to older people’s living conditions in cold households. Conducted in a region with a history of health and social care inequalities, the study has brought previously less-heard voices and under-served communities to the forefront of the government’s planning for cold weather.