Excess winter deaths and illnessess: call for evidence


NICE is issuing a call for evidence to support the development of public health guidance on ‘Excess winter deaths and morbidity and the health risks associated with cold homes’. A series of evidence reviews and an economic analysis are being conducted to address the key questions that are set out in the scope. We are particularly interested in any relevant unpublished, commercial or other information that we would not be able to identify through a search of databases and that can contribute to the key questions and outcomes in the scope for this work (for published data, we are interested in data published from 2000 onwards). For example:

  • reports about local systems or strategies to identify risk and vulnerability;
  • material about the uptake, acceptability, delivery and implementation of interventions and approaches in this area;
  • local policy approaches to deal with ill health related to cold weather.

The questions in the scope are as follows[1]:

Question 1:

Which subpopulations are more vulnerable to cold temperatures and poorly heated or expensive-to-heat homes? What factors contribute to vulnerability and how do these factors interact with each other?

Question 2:

How effective and cost effective are interventions and approaches to reduce excess winter deaths and morbidity and the negative health consequences of cold weather and cold homes?

How effective are these interventions?

How does effectiveness vary according to demographic, geographic, health, housing and socioeconomic characteristics?

What impact do these interventions have on health inequalities?

What impact do these interventions have on the wider determinants of health (for example, carbon dioxide emissions)?

What adverse effects are associated with changes to energy efficiency or the cost of heating? (For example, reduced ventilation may be associated with increased levels of indoor air pollution, including radon, and overheating may be associated with an increased risk of cot death.)

Question 3:

What systems and strategies have been used to identify vulnerable and at-risk populations and what impact do they have? 

What activities and interventions support effective delivery and implementation of approaches to reduce excess winter deaths and the negative health consequences of cold weather?

What influences the effectiveness of an integrated approach to addressing risk and vulnerability?

What are the most effective methods for reaching at-risk and vulnerable subpopulations?

What approaches increase uptake and enhance the acceptability of effective interventions?

What facilitators and barriers influence delivery and implementation?

Instructions relating to published and unpublished data; data in confidence, and commercially or academically sensitive information appears below.

The closing date for submissions is the 27 August 2013.


Cold weather and cold housing is linked to an increase in deaths and illness. In 2011/12 there were 22,700 excess winter deaths in England. A 5-year moving average shows a sharp decrease between 1960/61 and 1973/74, followed by a more gradual decrease up to 1998/99. Since then, there have been an average 26,700 excess winter deaths a year in England and Wales (Office for National Statistics 2012).

In 2009, it cost the NHS an estimated £859 million annually to treat winter-related disease due to cold housing in the private sector (DH 2009). Using 2011/12 prices, Age Concern estimated that this figure had risen to £1.36b (Age Concern, undated). Liddell (undated) estimates that for every £1 spent on energy efficiency measures, the NHS makes a saving of 42p. There are also likely to be significant social care costs.

Circulatory (37%) and respiratory diseases (32%) are the 2 major conditions linked to excess winter deaths. Respiratory diseases have the largest seasonal effect, partly due to influenza. Deaths from dementia and Alzheimer’s disease are also more frequent in the winter, possibly partly because people with these conditions are vulnerable to respiratory diseases. Only a small proportion of excess winter deaths are caused by accidents (Office for National Statistics 2011).

It is important to ensure housing is energy-efficient because heating a house that is not energy-efficient adds to carbon dioxide emissions. This, in turn, impacts on health through global climate change.

In many countries, more people die in the winter than in the summer. However, in some countries where extreme winter weather is common, the rates of excess winter deaths are lower. This is probably because they are more prepared for the cold than warmer countries. (For example, the housing stock in warmer countries is more likely to be poorly insulated.) Evidence also shows that the number of deaths could be more closely related to the number of cold days experienced, rather than the average temperature (Wilkinson et al. 2004).

Living in fuel poverty or cold housing can adversely affect the health and development of children, the mental health of adolescents and the physical health and wellbeing of adults. (A household is currently defined as being ‘fuel poor’ if it needs to spend more than 10% of its income on fuel for adequate heating[2].) It also increases the risk of death and physical or mental ill health among older people (Marmot review team 2011). For infants, after taking other factors into account, living in fuel poor homes is associated with a 30% greater risk of admission to hospital or attendance at primary care facilities. For children, it is associated with a significantly greater risk of health problems, especially respiratory problems.

Over 90% of excess winter deaths occur among the over-65s and, in particular, among the over-85s. In 2011/12, 10,700 males and 13,300 females in England and Wales were affected. (There was a larger proportion of women in the over-75s group, where the majority of these deaths occurred.) Much of this concentration of deaths in older age groups is due to seasonal distribution of causes of death, rather than greater sensitivity to seasonal change with age (Dinsdale et al. 2006). Cold housing and weather may also disproportionately effect people with disabilities and some long- term illnesses (Power et al. 2009).

Excess winter death rates are not necessarily linked to deprivation. This might be because a higher percentage of those in lower socioeconomic groups are living in social housing. This tends to be more energy efficient than housing in other sectors. The average standard assessment procedure (SAP) rating is a measure of a property’s energy efficiency (a higher rating indicating a more energy-efficient property). In 2009, it was 51.3 for owner-occupied properties, 51.9 for private rented, 59.6 for local authority and 62.4 for housing association properties (Department for Communities and Local Government 2011). Links to deprivation may be more likely in rural areas, depending on the measure used (Davie et al. 2007; Hajat et al. 2007; Lawlor et al. 2000; Shah and Peacock 1999).

Information of interest

We are interested in a broad range of different types of information, including local process and evaluation reports, measures of service reach and sustaining activity, finance reports, strategy/policy evaluations, along with more traditional quantitative evidence (such as pilots or observational studies) and qualitative evidence (such as those which consider participant satisfaction or reasons for drop out). We are also interested in any trials/ongoing research relevant to our questions which are in progress. We are particularly interested in evidence that may help to better promote equality of opportunity relating to age, disability, gender, gender identity, ethnicity, religion and belief sexual orientation or socio-economic status.

With finance data, we are interested in the cost to individuals, the local authority or NHS of taking part in an intervention, including discounts by volume and for longer contracts. We are unlikely to be interested in the profits or losses to a commercial company.

Submitting evidence

It would be helpful if you could identify which of the questions above the information you are submitting relates to.

Due to copyright restrictions please only forward the details of references for papers that are published in peer reviewed or other press. We are unable to accept paper or electronic versions of evidence if it is published in peer reviewed or other press. Electronic details and documents for this call for evidence can be found on the NICE website

Please note that the following material is not eligible for consideration:

  • Opinion/discussion pieces
  • Promotional material
  • Unsubstantiated or non-evidence based assertions of effectiveness
  • Forms with electronic attachments of published material (eg journal articles), or hard copies of published material. For copyright reasons, we cannot accept these copies. If you provide the full citation, we can obtain our own copy(ies). We are able to accept attachments of unpublished reports, local reports / documents.

Commercially or academically sensitive information

If you wish to submit commercially or academically sensitive information, unpublished information or research, please can you highlight which sections are confidential or sensitive by using a highlighter pen or the highlighter function in Word. Please see Annex 1 (below) and section 4.4.6 of the NICE CPH methods manual for information on submissions of confidential material.

Forwarding relevant evidence

Instructions for Published material

Please send full reference details (which are to include author/s, title, date, journal or publication details including volume and issue number and page numbers) - not a PDF/WORD attachment or hard copy - using this form by 5pm on 27 August 2013 to - excesswinterdeaths@nice.org.uk using the subject line ‘Excess winter deaths: call for evidence’

Instructions for Unpublished material

If you are aware of any trials/ongoing research relevant to our questions and focus populations which are in progress please could you help us to identify that information by providing relevant information such as a weblink to the project or other means of identifying the work as appropriate. Please use this form to send in details of any relevant evidence by 5pm on 27 August 2013 to - excesswinterdeaths@nice.org.uk using the subject line ‘Excess winter deaths: call for evidence’

Paper copies can be sent to:

Rukshana Begum
Centre for Public Health
National Institute for Health and Care Excellence
10 Spring Gardens
London SW1A 2BU

Please send any relevant evidence by 5.00pm on 27 August 2013

We look forward to receiving information on this and thank you in advance for your help.

Annex 1

The use of 'commercial in confidence' and 'academic in confidence' data in the development of public health guidance: statement of principle

1. NICE promotes transparency and fairness with all stakeholders in the development of its guidance.

2. The rights of the owners of the data provided to NICE must be respected.


3. Commercial in confidence information is information provided in confidence relating to the commercial interests of any person.

4. Academic in confidence information is information provided in confidence in circumstances where disclosure could prejudice the academic interests of any person. It is assumed that any information marked as academic in confidence is going to be published at some stage and that a timeline for publication can be given.

Submission of data

5. The amount of information submitted on an 'in confidence' basis should be kept to a minimum.

6. Only information that is genuinely confidential should be marked as in confidence. Information will not be treated as confidential where the information:

(a)  at or after the time of disclosure or acquisition is in the public domain in the form supplied otherwise than through a breach of any confidential undertaking; or

(b)  disclosure is required by any court of competent jurisdiction or any government agency lawfully requesting the same; or

(c)  is approved for release by the owner of the information.

7. Documents containing confidential material should be protectively marked ‘CONFIDENTIAL’ in the centre of the header for each page. Specific confidential data in sentences and paragraphs within the document should be highlighted. Organisations should indicate if this status will apply at the time NICE anticipates publication/presentation of the data. The last opportunity for organisations to review the confidential status of information is during the consultation on the draft guidance and its supporting evidence.

8. For all unpublished data submitted as 'academic or commercial in confidence' the minimum that should be made available for release is that which normally would be included in a CONSORT (or PRISMA) compliant abstract (http://www.consort-statement.org/?o=1011) and be suitable for public disclosure. An equivalent approach is required for all data and studies which underpin and are included in economic evidence,  models and analyses and for the economic model included in the submission if that is marked 'academic or commercial in confidence'.  Where confidential data need to be removed ensure they are removed completely from the submitted model.  If required for model functionality replace with ‘dummy’ data.

Presentation of data at PHAC or PDG meetings

9. Data that contributes to evidence of effectiveness and cost effectiveness can be presented to a PDG meeting or to a PHAC meeting provided the information is factual, accurate and not misleading.

10. 'Academic in confidence' information presented during PDG and PHAC meetings conducted in public can no longer be regarded as confidential.

11. The person submitting the data is responsible for identifying 'commercial in confidence' information. NICE retains the right to make a final decision in relation to the release of confidential information into the public domain on which they may consult the data owner.

Economic models

12. NICE will treat full economic models provided by manufacturers/sponsors to NICE as confidential and they will only be disclosed to stakeholders on a need to know basis.

Disclosure of confidential data

13. In circumstances where NICE wishes to publish data regarded by the data owner as academic or commercial in confidence, that is not subject to a freedom of information request, both NICE and the data owner will negotiate in good faith to seek to find a mutually acceptable solution, recognising the need for NICE to support its recommendations with evidence and the data owner’s rights.

14. NICE does not intend to make repeated requests for a prima facie tenable claim of confidentiality to be abandoned or modified, and it will accept the data owner’s judgement in that regard.

15. NICE cannot 'second guess' the motives of a data owner. If a data owner would not agree to the specific request for disclosure made, but would agree to some more limited disclosure (for example to a "confidentiality club"), then it is asked itself to suggest the disclosure it would find acceptable, rather than wait for NICE to propose the specific formula it may have in mind and discuss and agree a potential solution with NICE.

16. If disclosure is not possible the data owner must submit evidence giving the justification for maintaining confidentiality in defence of NICE's maintenance of that confidentiality.

Freedom of Information Act 2000

17. Nothing in this process shall restrict any disclosure of information by NICE that is required by law (including in particular, but without limitation, the Freedom of Information Act 2000).

[1] Please refer to the final scope for details of the expected outcome/s.

[2] The Hills review suggests moving to a ‘low income high cost’ indicator. This would mean a household is considered ‘fuel poor’ when its fuel costs are above average and its income is below the poverty line (once housing and fuel costs have been taken into account). It also proposed a new indicator, the ‘fuel poverty gap’. This would be calculated by working out how much the assessed energy needs of fuel-poor households exceed the threshold for reasonable costs.

This page was last updated: 26 July 2013